The nutritional recommendations widely adopted throughout the world and in France were inspired by the conclusions of American committees at the end of the 1970s. They did not prevent an increase in obesity, very often associated with type 2 diabetes. It is estimated that this “pandemic” will be responsible for a reduction in life expectancy due to an increase in the incidence of cardiovascular diseases, which the decline in smoking had nevertheless reduced.
The currently favored prevention approach focuses on the generalization of messages such as the famous “too fatty, too sweet, too salty” or “eat and move”, and especially on the extension of the Nutri-Score, acclaimed by patient associations. In the same way, Public Health France’s alcohol consumption guidelines “2 drinks per day maximum but not every day” are of course useful. However, these measures will remain insufficient to stop the current double pandemic.
This approach was influenced by a concept of prevention popularized in 1985 by Geoffrey Rose, an English epidemiologist from the University of Oxford. According to him, the application of prevention measures to the entire population, including people facing “low risks” of disease (for example low or moderate alcohol consumption and until then considered acceptable), would save more lives than just caring for people at “high risk” (for example excessive alcohol consumers). However, today we can only note the failure of strategies to prevent the pandemic of obesity and diabetes over a period which has also seen an explosion in the prescription of drugs for “metabolic syndrome” at the most advanced stage. as early as possible and for preventive purposes (hypertension, diabetes, cholesterol).
However, for “low risks”, statistical studies which serve to identify risk factors and determine desirable exposure levels are difficult to conduct and their results are often questionable and contested (this is also true for the criteria of prescription of certain medications for prevention). Drawing lots and comparing two populations is not possible or would be too difficult to carry out or considered unethical. John Ioannidis, an epidemiologist internationally recognized for his critical analysis of numerous medical publications, highlighted too much variability of the results of observational studies in “nutritional epidemiology” (thus for him, the relationship between a low alcohol consumption and breast cancer is not demonstrated).
The low level of evidence for positive results regarding the possible “correlation” between low exposure and disease risk does not prevent strong media coverage. It is often implicitly justified “morally” because it is likely to induce a reduction in consumption, even moderate or low, in agreement with the “population” strategy of Geoffrey Rose (and now in the name of the “precautionary principle” for certain exposures to low doses of pollutants). The same mechanisms could explain the decline in prescribing criteria for several classes of drugs in the prevention of diseases associated with metabolic syndrome (with the invention of “prediabetes” or “pre-hypertension” in the United States for example) . Paradoxically, even studies that have demonstrated a lack of impact have had no effect on current practices.
Recommendations established from biased studies
Recommendations can therefore be established based on the results of “low level of evidence” or even downright biased studies. Thus, the American recommendations of the 70s and 80s “demonized” “fat” as a risk factor for cardiovascular diseases on the basis biased studies and in particular the observational study of the seven countries of Ancel Keys. In 1991, the term “French paradox” was invented by journalists from 60 minutes from CBS to explain that thanks to wine (especially red) the French had a very low incidence of cardiovascular disease (with Japan) despite a diet that was too fatty from the American point of view. A politically correct explanation had to be found!
We know today that these recommendations have accelerated the opening of the market to ultra-processed foods (AUT), starting with “Low Fat” (Editor’s note: low-fat products) in the United States and elsewhere. They had the effect of significantly increasing the proportion of sugars and carbohydrates in the diet and reducing the proportion of “fat” (which was recommended by the American committees). Manufacturers have thus been able to reduce manufacturing costs, often by replacing “fat” with chemicals modifying the texture, palatability, taste and shelf life of the foods they have thus ultra-processed. However, it is above all sugars and carbohydrates which produce fat in our body. Excess sugar, especially in ultra-processed foods or excessive alcohol consumption, will cause “insulin resistance” which causes weight gain, diabetes and “metabolic syndrome”.
Another criticism of Geoffrey Rose’s population strategy is equally important. Favoring intervention on the entire population runs the risk of “invisibilization” of the most vulnerable or populations exposed to the highest doses. Measures applied to the entire population can lead to the stigmatization of certain groups and amount to neglecting the fundamental responsibility of social inequalities in exposure to risks and in the progression towards illness. However, whether it is the prevention of metabolic syndrome (obesity, diabetes) or the fight against excessive alcohol consumption, we can in reality observe a failure of approaches aimed at the general population and do not not addressing the root causes of current “pandemics”.
This does not mean that the introduction of consumption benchmarks (alcohol) or the generalization of a Nutri-Score are useless (provided that it identifies TUEs, the current Nutri-Score undoubtedly still remaining too aligned with the American nutritional recommendations from the 1980s). But they are especially effective among the better educated and economically advantaged population. To do him justice, Rose justified his approach by specifying that it would make it possible to attack the root causes of diseases that he thought he could better prevent thanks to his “population” strategy. This has not been the case and, given the economic context, a growing part of the population is exposed to high risks in the absence of measures aimed at reducing the supply of products harmful to health. Only smoking has been able to decline thanks in particular to communication campaigns and especially to the increase in the price of a pack of cigarettes.
For more effective targeted measures
TUEs now represent 70% of foods consumed in the USA and 30% in France. They remain less expensive than fresh food, which only households with a sufficient level of income can afford regularly. It is therefore time to question Geoffrey Rose’s population-based approach to complement it with more effective targeted measures. In the case of alcohol for example, the establishment of a minimum price per unit of alcohol would limit the sale of alcohol at low prices and in large quantities and would reduce the damage for the 10% of “invisible” French people. “who consume 80% of the alcohol sold in France, as well as the consequences of”binge drinking” among young people. Feedback from Scotland, which introduced this measure from 2018, shows that a minimum price of the unit at €0.50 had the effect of reducing mortality by 13.4%. For WHO says it is the most effective measure for preventing alcohol-related harm.
Drastically reducing the supply of very sugary foods, sodas, and ultra-processed foods should also be a public health priority. The addition of the NOVA classification in the French Nutri-Score is essential because the responsibility of TUEs is now better established and the Mediterranean diet has partly made it possible to rehabilitate “good fat”. We can also expect that this development, desired by the promoters of Nutri-Score, will be even more opposed by the lobbies of the agri-food industry.
Regarding the drift towards the overmedicalization of prevention, the use of medical or surgical treatments must be limited to cases where the benefit-risk balance is established by considering all-cause mortality and the quality of life of people. Thus, the current popularity of using new appetite suppressants, GLP-1 such as Wegovy, Ozempic or Mounjaro, in addition to dietary measures, should not serve to further delay the implementation of actions limiting access to products dangerous to health. If weight loss does reduce the risk of cardiovascular accidents in the short term in “high risk” patients, there is nothing to confirm that the benefit-risk balance will be maintained in the absence of continuation of hygienic rules. dietary supplements that have always been associated with these drugs in clinical trials.
Furthermore, under treatment, a diet in smaller quantities, but still unbalanced because it is too sweet, low in fiber and mostly ultra-processed, could cancel out the potential benefits of weight loss (“non-alcoholic” fatty cirrhosis is a risk even for non-obese people and an unbalanced diet can explain a diabetes in people of normal weight).
Only action on the root causes of the deterioration in the health of a large part of the population would be likely to halt the disastrous progression of chronic diseases such as diabetes and obesity. The dual mechanism of valorization on the market, both of harmful products and the extension of curative and preventive medical care, has been a preferred path until today. Without a paradigm shift, the progression of current pandemics and the widening of social inequalities remain inevitable.
Providing the means today for exposed populations to access quality food (fruits and vegetables, non-ultra-processed foods NOVA 1 to 3) also means avoiding a spectacular surge in medical care expenses. This is precisely what is demonstrated by the results of the initiatives taken by some North American insurers and healthcare providers who have chosen to open “fresh food pharmacies” in their hospitals in order to offer the right foods to obese and diabetic patients from the least advantaged categories and their families in order to improve their health, while considerably and quickly reducing healthcare and medication expenses.
* Jean-Pierre THIERRY. Medical advisor to France Assos Santé, member of the board of directors of Le Lien. User representative to the Transparency Commission of the High Authority of Health and to the ANSM Scientific Council. Co-author with Claude Rambaud of “Treating too much makes you sick”, Albin Michel, Prescrire Prize 2017. The author speaks in a personal capacity.