|Medicine: Changing a Nation's Diet|
Dorit Adler, Hadassah–Ein Kerem’s chief dietitian.
You are a week into your latest diet, which is based on sound nutritional principles. Or maybe you are following a fad diet that worked for a friend. You are doing it to fit into that new dress, or because your blood pressure has soared. No matter the specifics, everything seems to conspire against your success.
Rest assured, you may be overweight but you are not paranoid. It seems that way because it is that way.
“We live in an obesogenic environment,” says Dorit Adler, MPH, director of the Nutrition and Dietetic Department at the Hadassah–Hebrew University Medical Center at Ein Kerem. She cites the developed world’s prime culprits: calorie-dense processed foods eaten in portions three times bigger than 30 years ago; mass availability of fast foods; and sugary beverages low in essential nutrients—all aggressively marketed.
It’s this environment, she says, that has propelled Western societies into obesity—a condition rare in history that is now a global epidemic affecting an estimated 200 million men and 300 million women. This past June, it was upgraded by the American Medical Association from a “major public health problem” to a “disease requiring a range of medical interventions,” with all that implies for health insurance, research funding and public perception.
While many—including Adler and her team of 18 clinical dietitians at Hadassah Hospital—applaud the AMA move, it addresses effect, she says, rather than cause. “Obesity is the driver of much suffering...but it is a result of the environment we’ve created,” she says. And it is far from the only result: Over 60 percent of noncommunicable disease can be attributed to modern diet and lifestyle. They include not only type 2 diabetes, heart disease and stroke, but several cancers have strong environmental links, and even brain functioning is shaped by what we eat. The problematic Western diet is related to brain plaques associated with Alzheimer’s disease, and sugar (beyond that found naturally in foods) has a major role not only in overweight but also in poor memory formation, learning disorders and depression.
“Early man lived quite differently—continuously active and eating far less than we do,” says Rivki Harari, deputy director of the department. In the United States, people eat an average of 650 calories more a day than in 1970, and Israel is close behind. An excess 120 calories a day (a glass of Coke, for example) results in 11 extra pounds in a year, and approximately 110 in a decade. “Not only does a single portion of many foods meet our energy requirements for the entire day,” she adds, “but we live in a high-tech environment that gives us little reason to move.”
It is this view that has propelled Hadassah’s nutrition department, one of the largest and most developed of its kind in Israel, into the crafting of food policy—in Hadassah’s kitchens and at the national level.
The department became proactive two years ago when soaring food prices in Israel sparked public protests. “The cost of food was increasing at almost double the rate of that in other developed countries,” says Adler, “and it was clear to us that to preserve public health, the cost of nutritious foods had to be held to sane levels.”
Hadassah joined Rami Levy Shivuk HaShikma, one of Israel’s leading supermarket chains, to promote the sale of healthy foods by offering them at the supermarket at discounted prices, competitive with junk food. Adler adjusted the selection of healthy options every two weeks. She thought of it as a first step in bringing food manufacturers and chain stores on board and lobbying the government to stabilize the prices of nutritious basics (vegetables, fruit, low-fat dairy products, poultry, fish, legumes, whole grains, nuts, canola and olive oils).
“Poor nutrition is linked not only to obesity, heart disease, cancer and diabetes,” she says, “but also to damage down the generations—poorly nourished women bear poorly nourished babies or babies with gestational diabetes who are at higher risk for a range of illnesses.”
Within two years, this initiative evolved into the National Lobby for Nutritional Security in Israel, headed by Knesset minister Isaac Herzog. The lobby was established in collaboration with Hadassah and the Israel Movement for Reform and Progressive Judaism as well as major nongovernmental organizations such as Leket Israel, LATET, the Israel Center for Food Security, YEDID: the Association for Community Empowerment, SHATIL, Community Advocacy and the AJEEC-Negev Institute. At its first conference at the Knesset, in May, Israel’s Welfare and Social Services Minister Meir Cohen pledged over $50 million toward a “food security budget,” declaring it “a key for change.”
While lobby representatives describe the sum as a drop in the ocean, none doubt that changing eating habits is doable. The prime example is Finland, which, in 1975, was one of the world’s unhealthiest nations. “Diet was poor, people were inactive and heart disease raged at record levels,” says Adler. “Now it’s one of the fittest countries on earth.” A massive, government-led campaign motivated Finns to eat healthy, exercise and quit smoking, and Finland became one of only two countries to halt its downward health spiral. (The other is Canada.) Rates of lung cancer and heart disease plunged by 65 percent.
Initiatives like this, on a smaller scale, have been developed and led by Hadassah’s nutrition department for years. “We have developed a Hadassah Life Style program, whose path is not about calories or prohibitions but about healthy nutrition and weight that prevent development or recurrence of noncommunicable diseases,” says Adler. “It is based...on the proven Mediterranean Diet. Its weight loss results chiefly from restraining the food environment at home and at work—not from restraining the dieter.” The diet offers tools for daily eating habits, cooking workshops, healthy and sustainable food purchasing, support and motivation. The nutrition department has adapted the program for many forums—patients with colon cancer, women with breast cancer, hypertensives and diabetics. The department is beginning to teach the program over Skype for those who cannot get to regular sessions.
Six years ago, the department revised all menus for staff and patients at Hadassah–Ein Kerem. “Jello and sugary drinks were out, fresh fruit and water in,” says Adler. “Whole rice replaced white, and an option of whole grain or bulgur wheat is always served.... We set up a lecture program and demonstration counters showing, for example, ‘normal’ and healthy portion sizes. We went into the kitchens and found too much salt in use, and ran a 40-hour course—half theoretical, half practical—for Hadassah’s cooks. We want every dish served to staff and patients to have standard contents. We also got people walking the nature trail around the Ein Kerem campus.”
The health profile of Hadassah staff improved as people were given the opportunity and incentive to eat better and exercise more, but Harari and her team see this as only a step toward a holistic multidisciplinary vision. “Our aim is to make Hadassah–Ein Kerem, its schools and the surrounding community a place of healthy and sustainable nutrition and a national example,” she says.
Another outreach population for Hadassah is Israel’s children, of whom one in four has been reported as overweight or obese. Not only have cooking classes and agriculture disappeared from school curricula, but exercise and sports are very low priorities.
“We began three years ago in five junior high schools and have added five more each year since then,” says Adler. “We are aiming to make these youngsters into leaders who will help change the obese environment.” Part of the program is to produce a poster, performance or artwork. One group adapted the Snow White story, having her handsome prince bring her a healthy apple, while the wicked witch tried to palm off Nutella.
“No medicine in the world will counteract the damage caused by a combination of bad eating habits and insufficient exercise,” she sums up. “The good news is that obesity is a reaction to an abnormal environment, which makes type 2 diabetes, heart disease and hypertension preventable conditions—and makes healthy eating cost effective, in every sense.
“We want to establish a Center for Sustainable Nutrition and Ethics at Hadassah as a voice in Israel,” she continues. “With Israeli NGOs and interest groups, diaspora communities, schools, the media, it would work toward changing a situation in which the abnormal has become normal.... It would work toward changing the health profile of our society and saving lives.”