WHO’s Global Strategy for Diet, Physical Activity and Health, and America’s New Dietary Guidelines Require Multisectoral Commitment to Promote Public Health
by Derek Yach, MBChB, M.P.H., Professor and Head, Division of Global Health, Yale School of Public Health, New Haven, Connecticut

Chronic disease risks, especially tobacco, unhealthy diets and a lack of physical activity, threaten the health of people in all but the very poorest countries in the world. Globally, 1.3 billion individuals smoke, and 1 billion people are overweight or obese compared to the 800 million who are underweight. China alone is home to 360 million smokers, 200 million overweight adults and 60 million obese adults. Not surprisingly, this Asian nation annually records 1 million deaths from tobacco use and almost 3 million deaths from cardiovascular disease.

Today, obesity prevalence is increasing in most countries across the globe, with no national examples of a sustained decline outside of wars and famines. Meanwhile, the investment in public health and related research, interventions and policies to control these risks remains paltry compared to the burden of disease and economic hardship they cause.

In recent years, with the World Health Organization’s Framework Convention for Tobacco Control, the international community stepped up its determination to control tobacco dissemination and use. In parallel, the development of science-based guidelines for action and a global strategy for diet, physical activity and health (GSDPA) have now been completed (see Monitor, Vol. 11, Issue 1, 2003 at http://ceche.org/mol/Spring-03/index.html). How does this global strategy, endorsed by a World Health Organization (WHO) resolution in May 2004, differ from the “Dietary Guidelines for Americans” released earlier this year?

Comparing the Recommendations
Both the WHO and U.S. reports draw on the same scientific pool of knowledge. Both were subject to intense lobbying by groups representing products or commodities that science suggests should be consumed less, and together they heard little from the fruit, vegetable and grain sectors, which, sadly, are not well-organized to push for increased consumption as a public health goal. Both reports also came to the same major conclusions and issued the same messages for individuals:

• Achieve energy balance and a healthy weight.
• Limit energy intake from total fats and reduce intake of certain types of fats.
• Increase consumption of fruits, vegetables, whole grains and nuts.
• Limit intake of free sugars and salt.
• Increase levels of physical activity.

There are a few differences, however. The U.S. guidelines encourage increased consumption of dairy products — a response, according to some, to strong industry influence. The U.S. guidelines also provide separate, and helpful, advice about the levels of exercise required to stay fit and to reduce body fat. In addition, the language in the new American directives is less ambiguous on recommendations related to sugar than before. The fact that the WHO strategy preceded the completion of the U.S. guidelines may have helped ensure this, especially because, during drafting of the GSDPA, intense lobbying by the sugar industry, first through U.S. corporations and trade associations, and later through developing-country sugar associations, was exposed by many governments and international media as being purely self-serving and not a real effort to support health. By the time the United States was completing its new guidelines, many potential lobbyists, at the urging of leading food companies, backed away from past practices and initiated a debate about how they could, and should, be part of the solution.

Overall, the differences between the U.S. and WHO reports are minor, and both have made important progress in reducing the use of vague and confusing words such as “moderation” and “balance,” although the U.S. guidelines still state, “Use alcohol sensibly and in moderation.”

Going Beyond Diet
The WHO strategy had a remit to go further than merely listing optimal diets for individuals. It highlights, and encourages implementation of, sector-specific strategies to make adherence to the guidelines easier. These include:

• developing a cross-sectoral national plan of action that integrates diet and physical activity
• strengthening surveillance, monitoring and research
• addressing marketing within the context of a broad-based approach to promoting better health literacy at school, in the workplace and within the community at large
• introducing labeling that is understood and effective in influencing healthy food choices
• developing supportive agricultural, fiscal and urban design policies.

Many elements of implementation require strong, new partnerships among multiple sectors, including industry, academia and nongovernmental organizations. The WHO strategy specifies how best to optimize interaction among these groups to achieve the most desirable impact on health. Meanwhile, there is a compelling need to forge serious partnerships between the soft-spoken fruit, vegetable and grain groups and the public health community. At an international level, in 2004, the Food and Agriculture Organization (FAO) and WHO convened groups representing these sectors in Kobe, Japan to stimulate more public action. (To view the meeting report, visit http://www.who.int/dietphysicalactivity/publications/en/fruit_vegetables_report.pdf.)

WHO’s global strategy recognizes that many aspects of food and nutrition policy are influenced for good or bad by transnational forces. For that reason, the role of a strengthened Codex Alimentarius Commission, an FAO/WHO committee that develops food standards and guidelines to protect consumer health and ensure fair food trade practices, is highlighted in labeling and marketing, as is the importance of enhanced cooperation between WHO, FAO, the World Trade Organization, the World Food Programme and UNICEF to foster development of a more integrated approach to promoting optimal diets worldwide.

Ensuring Implementation
Importantly, the WHO and U.S. recommendations apply to under and over nutrition, and should be promoted as supporting the optimal diet for all. But, what will ensure execution of the guidelines? The same forces that call for clear guidelines will be advocates for their implementation! In addition, in such countries as the United States, failure to address the rising obesity epidemic and its associated economic and human costs may, over time, become an election issue that will expedite implementation.

The real test of the WHO and U.S. strategies and guidelines will be whether they have a measurable impact on obesity and the growing list of diseases it causes. For that to happen, both the public and the private sectors will need to make substantially greater investments in health promotion and disease prevention.