Nutritional change is not a simple answer to non-communicable diseasesBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5097 (Published 11 August 2011) Cite this as: BMJ 2011;343:d5097
All rapid responses
Public policy for nutritional change is proven and doable. Preventing
non-communicable diseases (NCDs) via nutritional changes is also not as
complex as Yach asserts in his BMJ personal paper . Firstly, he
completely ignores the use of taxes on unhealthy foods, which are both
effective and can raise revenue for financially strapped governments. Such
taxes have been successfully introduced in a number of high income
countries with some evidence for benefits (weight reductions and chronic
disease risk) . Countries such as Denmark, Finland, Norway and Hungary
all apply excise taxes on various high-sugar and high-fat foods .
Modelling work also suggests the likely cost-effectiveness of generalised
"unhealthy food" taxes . These moves are likely to be feasible in many
developing countries, especially those that successfully use tobacco and
alcohol taxes. Indeed, there is already evidence for the benefit of soft
drink taxes in some developing countries , and data from Egypt
suggesting the benefit of higher sugar prices on decreasing BMI .
Another deficit in Yach's paper is the marked lack of attention to
legislative measures. These can range from banning some ingredients
outright (eg, trans fats in Denmark), to limiting or banning food
advertising to children [6, 7]. These moves are also likely to be feasible
in many developing countries, especially those that have successfully
banned or restricted tobacco marketing and various hazardous products, eg,
asbestos and leaded petrol.
Finally, NCD problems for developing countries can be partly
prevented by attending to food exports from the rest of the world. As with
the successful Framework Convention on Tobacco Control, it is not
unrealistic to aim for an international treaty that prohibits food exports
of those products that don't meet minimal health standards. These
standards could require low levels of salt, sugar, saturated fat and trans
fat; in addition to easy to understand health-related labelling (eg,
"traffic-light" style ).
Perhaps after these key things are done by governments and
international agencies there is merit in addressing some of the complex
other issues that Yach raises. By why not go first for the proven and cost
-effective low-hanging fruit: taxes and smart regulation?
1. Yach D. Nutritional change is not a simple answer to non-
communicable diseases. BMJ 2011, 343:d5097.
2. Thow AM, Jan S, Leeder S, Swinburn B. The effect of fiscal policy
on diet, obesity and chronic disease: a systematic review. Bull World
Health Organ, 2010;88:609-614.
3. Holt E. Hungary to introduce broad range of fat taxes. Lancet,
4. Sacks G, Veerman JL, Moodie M, Swinburn B. 'Traffic-light'
nutrition labelling and 'junk-food' tax: a modelled comparison of cost-
effectiveness for obesity prevention. Int J Obes (Lond) 2010, [E-
publication 17 November].
5. Thow AM, Quested C, Juventin L, et al. Taxing soft drinks in the
Pacific: implementation lessons for improving health. Health Promot Int,
6. Handsley E, Mehta K, Coveney J, Nehmy C. Regulatory axes on food
advertising to children on television. Aust New Zealand Health Policy
7. Caraher M, Landon J, Dalmeny K. Television advertising and
children: lessons from policy development. Public Health Nutr 2006;9:596-
Competing interests: No competing interests
The article about Nutritional Change recommends the replacement of
saturated fat such as palm oil with unsaturated fat such as sunflower oil.
This is a serious mistake. Two recent meta analyses (1,2) show saturated
fat to be harmless. A paper in the BMJ (3) shows that replacing saturated
fat with unsaturated fat increases heart disease incidence.
Possible mechanisms by which unsaturated fats are harmful include the
* They create oxidative stress which overwhelms the body's
antioxidants. Free radicals oxidise LDL. Oxidised LDL damages arterial
walls resulting in plaque formation.
* The high ratio of omega 6 to omega 3 fatty acids in most
unsaturated vegetable oil causes increased inflammation and this leads to
the metabolic syndrome.
* Canola oil causes atherosclerosis. It contains erucic acid which is
toxic to humans.
It is true that unsaturated fats can reduce cholesterol levels but
this is of no benefit. A graph of total cholesterol against all cause
mortality is u-shaped with a low point at about 6.0 mmol/l. The reduction
in cholesterol is due to a reduction in large fluffy LDL particles which
are harmless. Small dense LDL particles are increased and these are
harmful. There are increasing rates of cancer as the cholesterol level
falls below 6.0 mmol/l.
Palm oil is widely used in Africa and South America. These regions
have low levels of heart disease. If they converted to sunflower oil as
recommended in this article, they would acquire the high rates of heart
disease seen in North America and Europe.
1. Fats and Fatty Acids in Human Nutrition. Annals of Nutrition and
Metabolism, 2009; 55 (1-3).
2. Siri-Tarino PW, et al. Meta-analysis of prospective cohort studies
evaluating the association of saturated fat with cardiovascular disease Am
J Clin Nutr 13 January 2010 [epub ahead of print].
3. Corn Oil in Treatment of Ischaemic Heart Disease, BMJ, 1965, 1,
Competing interests: No competing interests