Richard Smith on improving what the world eats

Richard SmithHigh blood pressure is the second main cause of disease burden in Australia and is only marginally behind tobacco, said Bruce Neal, senior director, research and development at the George Institute for International Health in Sydney, at a seminar organised by C3, Collaborating for Health. It’s the same in other developed countries and increasingly in developing countries. Yet Australia spends about $1 billion a year treating high blood pressure but makes little impact on the overall burden of disease resulting from high blood pressure. (Half the money goes on drugs and half on doctors and other health workers.) Why is there so little impact and how could Australia and other countries do better?

Many BMJ readers will know why the huge treatment effort, which is the same in other countries, has so little impact—but it’s worth reminding you.

Firstly, it’s people with “hypertension” who are being treated—above a systolic of about 140 mgHg. But the risk of developing a stroke, a heart attack, heart or kidney failure, or any of the other adverse effects of high blood pressure increases steadily from a systolic of about 115 mmHg. About half of the adverse effects happen in people who have “normal” blood pressure—because although they are at lower risk there are many more of them (the “prevention paradox.”)
 Secondly, only about half of those who are hypertensive are diagnosed and treated, and, thirdly, only about half of those who are treated have their blood pressure reduced to below 140 mmHg. This is the familiar “rule of halves.” But to abolish risk patients need to have their blood pressure reduced below 115 mmHg, and this happens with virtually nobody. So overall only about 9% of the burden of disease from high blood pressure is countered by drug treatment.

What may be less familiar to BMJ readers is that the same or greater benefit could be achieved by a “gold plated” salt reduction scheme, which would cost about $10-20m, 1-2% of the spend on treatment. Plus the benefit would be additional to that from drug treatment.

Similar highly cost effective benefits can be achieved by reducing fat, sugar, and energy density in the processed foods that we all eat, but doctors think a lot about drugs and little about nutrition. Like most medical students I spent hundreds of hours learning about drugs but almost nothing about nutrition—and what I did learn was mostly about scurvy and other vitamin deficiencies. Sadly, I don’t think that it’s any better now.

Of course, doctors can prescribe drugs, but it’s hard to get individuals, particularly those on low incomes, to eat less salt, fat, and sugar—because most of what we eat is in processed foods. Doing something about food thus means either legislating or working with the food industry.

Many public health people are reluctant to work with the food industry. They think of the tobacco industry and its corrupt ways and conclude that voluntary efforts will never work. Professor Neal and most of those at the seminar, several from the food industry, think differently, pointing out that food is essential whereas tobacco is not, companies will reduce (and have reduced) the unhealthy components of their foods, and legislating on food and enforcing the legislation are much more difficult than doing so for tobacco.

But what should be helpful—no matter whether the way forward is legislation, voluntary codes, or a combination—is global, publicly available data on the composition of processed foods—and that’s what Professor Neal wants to achieve. These data can then be used to make comparisons with benchmarks of what’s regarded as healthy, among countries and companies, and over time.

Such a database has already been achieved in Australia, and—to my surprise—it’s mostly a matter of collating existing data. This about 50% of the data is supplied directly from food companies. More can then be gathered from websites, and some comes from patrolling supermarkets and reading labels. Random chemical analyses can be conducted to keep everybody honest.

Gathering these data can, Professor Neal believes, have a big impact in improving the world’s food supply—a bigger and more cost effective impact than relying simply on drugs.

Richard Smith was the editor of the BMJ until 2004. He also works for UnitedHealthGroup.

  • BM Hegde

    Dear Richard,
    Your points are very well taken. One is what one eats. One of my friends, an internist in the USA, was telling me that in a small percentage of patients salt decreases blood pressure! I have no evidence. So this becomes anecdotal, at best. However, what worries me is that we do not have any evidence to show that anti-hypertensives are effective in WOMEN to the best of my information. If there is any study of women and hypertension, I would be too happy to study that one. That much for evidence based medicine. We also do not have a placebo controlled trial of anti-hypertensives.
    Another vital point to note is story of the dangerous anti-hypertensive drugs in use these days. An audit of a total of 17 anti-hypertensive drug trials showed that the trialists misled the medical community about the benefits of drugs by using relative risk reductions in place of the absolute risk reductions. Uffe Ravnskov did the analysis in 2002 and had published them in the BMJ rapid responses that year. It is quite educative. Since then we also hear about the possibility of the drugs, some of them at least, being quite dangerous in otherwise healthy individuals in the long run. Both POISE and ACCORD studies did give enough indications in that direction. (…/lancet/article/PIIS0140-6...) (
    Ravnskov’s analysis is here. (Uffe Ravnskov, 18 Jun 2002)
    Table. Benefits from treatment of high blood pressure and of high cholesterol BP
    lowering 4S WOSCOPS
    Relative risk reduction; % -20 -29 -21
    Absolute risk reduction; % -0.8 -3.3 -0.9
    Chance of surviving without treatment; % 96 88.5 90.6
    Chance of surviving with treatment; % 96.8 91.8 91.4

    I think we should spend more time with diet as also talking with the patients (listening to patients) before drugging them right away. That can not be done in seven minutes allotted to doctors these days with one patient! My own experience shows that a significant percentage of the so called primary hypertensives could be managed by undoing some of the knots at their emotional level. If one develops the capacity to forgive, share and care, one could get his/her BP levels down significantly. Good clinical psychotherapy helps a lot.
    I have also tried Yogic breathing which decidedly reduces the BP and in the long run normalizes it. Yogic breathing boils down to making our breath both deep and slow thus lowering the diaphragm each time we breathe in to increase oxygenation as also to reduce the cardiac pre-load and after load which together help bring down the heart rate and blood pressure. Regular practice keeps pressures at normal levels in addition to giving many other health benefits.

    This kind of multi-pronged approach brings down BP levels in more than half the number of patients with primary hypertension without the need for drugs. Drug trials also show us that a large number of apparently normal people will have to suffer drug side effects for no benefit to them. The MRC study of mild to moderate hypertension did show that to save one patient from stroke we have to treat 850 healthy people (NNT) with drugs for five years. Our science does not tell us who that ONE patient is! Just imagine the number of side effects in that scenario. If people undergo emergency surgery while on drugs like Beta blockers and ACE inhibitors the peri-operative mortality could go up significantly! (POISE an ACCORD) ADR s were the fourth leading cause of death in the USA, says the IOM report of 2000! (JAMA 2000; 284: 483)

    Except in hypertensive urgencies and emergencies, one has time to try all non-pharmacological methods enumerated above before committing the hapless patient to drugs for the rest of his/her life. Whether that prolongs his/her life is a moot point but, as Late Sir George Pickering rightly noted, anti-hypertensive drugs certainly take away all the rights enshrined in the American Constitution of 1772-“life, liberty and pursuit of happiness.” Happiness, he wrote, would be the thing of the past after one starts to take these drugs! “History cannot give us a program for the future, but it can give us a fuller understanding of ourselves, and of our common humanity, so that we can better face the future,” wrote Robert Penn Warren.
    Professor BM Hegde
    Mangalore, India

  • Deb Verran

    How to get modern medicine to focus on the essentials-ie the critical importance of appropriate nutrition[plus the public health issue of the ongoing security heading into the future of the important sources of good quality foodstfuffs] versus the current focus on pharmacologic management.?

  • Geof Rayner

    Richard is right that the public health movement should examine what the food industry is doing.. and very carefully.But as with companies in the energy field (witness BP) there is often a very large gap between promise and performance. At present parts of the food industry, PepsiCo is particularly prominent, are launching a full scale effort, including the funding of voluntary organisations, to convince the world that they have changed their spots.

    C3, Collaborating for Health, with which Richard's company (United Health) is associated, is part of this effort. That food giants like Pepsi are committed to supporting voluntary organising and improving the healthiness of their foods is very commendable but of course, most of their product offerings are not very healthy at all, so they start from a low base point. Added to that they spend billions of dollars on marketing snack foods and commercial alternatives to tapwater.

    What is really important therefore is that the global food companies are effectively monitored such that we might distinguish real improvement from 'healthwash' (the public health equivalent of 'greenwash'). And we should ensure that our 'PR detectors' are always switched on.

  • Richard Smith

    Somebody has emailed the BMJ to say that I should have added a competing interest statement to this blog, and I agree and apologise that I didn’t. I simply didn’t think of it, and my forgetting might be a result of my competing interests.

    Before I declare my many competing interests, I want to make the point that there was considerable discussion of conflict of interest at the meeting that led to my blog. Bruce Neal, the speaker, put up his standard competing interest statement that listed many drug companies and a few food companies, including Pepsico. He argued that it’s essential for some doctors to have links with drug companies otherwise trials could never be done and drugs never reach market. Similarly there needs to be links between researchers and food companies in order to get the data that are needed for the database he wants to build and to work with companies to reduce the amount of salt, fat, and sugar in their foods. Britain has done well with reducing salt in processed foods. But the challenge is to be credible to both public health practitioners and the industry, who are often highly suspicious of each other.

    My first competing interest is that I’m on the board of C3 Collaborating for Health which organized the meeting. Indeed, I suggested to C3 that Bruce, whom I know, be invited to speak. I’m not paid for being on the board. C3 distributes money from the UnitedHealth Group for the chronic disease initiative, which I direct. C3 has developed from the Oxford Health Alliance, which distributed money from the Pepsico Foundation for the Community Interventions for Health Programme. Derek Yach, the head of global health for Pepsico, is also on the board of C3, and I’m a friend of Derek’s and admire him as the leading strategic thinker on how to counter chronic disease. Part of the mission of C3 is to bring together everybody interested to counter chronic disease, including academics, policy makers, and people from business, including the food industry bit excluding the tobacco industry.

    I am employed by the UnitedHealth Group to run its chronic disease initiative, which is a philanthropic programme to create centres in low and middle income countries to counter chronic disease. In this we collaborate with the National Heart, Lung, and Blood Institute, one of the US National Institutes of Health. One of the centres we fund is the George Institute China, which is part of the George Institute, where Bruce Neal works—and he works closely with the China Centre.

    Working for the UnitedHealth Group probably makes me more sympathetic to for profit organisations than is the case for many in public health, and I have blogged for the Guardian on the case for profit:
    I’ve also blogged for the BMJ on what to say to food companies:

    I’m not sure how all these competing interests have affected what I’ve written, nor am I sure how the listing of my competing interests will influence how readers interpret my article—but that’s why competing interests need to be declared, so that readers can make up their own minds.

    I like the fact that when submitting an article to the BMJ or sending a rapid response the technology obliges you to remember to declare competing interests. I will try not to forget again, but it would be good to be prompted each time I write a blog.

  • Richard Smith

    The monitoring of food companies that Geoff Rayner mentions is the whole point of the database that Bruce Neal proposes. It will be able to answer questions like:

    1. How do the foods produced by companies compare with recommended standards?

    2. Are they decreasing the amount of fat, salt, and sugar in their foods?

    3. Does the amount of fat, salt, and sugar vary in the same branded products in different countries?

    I agree too that the advertising, lobbying, and public relations activities of the companies should be monitored.

  • Mary Cardy

    WOW! Firstly we know why modern 'allopathic' medicine has failed….because the doctors fail to treat the 'person' holistically, not the symptoms. In reading this post I am shocked it was by a former editor or BMJ, it is an unusual mind that thinks improving what the world eats should be controlled by?? government, think tanks and food manufacturers?! when it simply should start with EDUCATION. Like Smith points out, doctors get no training or education in nutrition, that is ok, as people come to understand this, and the smart one's seek out the services of a Nutritionist, and even better 'smart doctors' will refer onto Nutritionist or Dietician. What we need are more Jamie Olivers sponsored by governments to start with educating children about healthy eating, to promote good eating habits for life, as reality is the individual has will power to make the right choice, but they can only do this with basic a knowledge foundation developed from family and education.

  • Richard Smith

    I'm grateful for Mary Cardy's response to my blog, and I'm all for educating people on food and nutrition. But it's important to understand the limitations of what can be achieved through education. Thus it's very difficult for people to chose to reduce their salt intake–because most of the salt they eat is in processed foods, including bread, cheese, and almost anything in a tin, a jar, or a packet. Very few people have enough time, energy, money, and imagination to avoid processed foods altogether. So education alone cannot be enough, and–in the light of other comments–concentrating on education would let food companies off the hook.