Dean Diez Roux reflects on the global links between our diets and the environment and what they mean for public health.

When I was growing up, we ate meat almost every day. One of my earliest memories is of eating bife de lomo (sirloin steak) with mashed potatoes for lunch on a white formica table in our kitchen in the small apartment we lived in right above my grandmother’s house.  We ate steak with mashed potatoes and a tomato, neatly sliced in half and sprinkled with salt and olive oil. My mother grilled the steaks on a black stovetop grill and opened the windows right above the stove to let out the smoke. And many of our neighbors did the same, you could smell it as you walked down the cobble-stoned streets of Buenos Aires at noon. Meat was cheap and popular then. Construction workers assigned a co-worker (“el asador”) to grill meat for them while they worked so it was ready for their lunch. That’s all they ate: meat and bread.

It was after all Argentina, a country known for its grass-fed beef even today. But I don’t think we were that unique, certainly not for Argentina, and not even for what is usually called the Western world. This I learned after participating in an eye-opening session on food systems and health at the recent meeting of the Association of Schools and Programs of Public Health.

The session was led by Juan Rivera, a renowned nutritional expert who currently directs the Instituto Nacional de Salud Publica (INSP) de México. Dr. Rivera reviewed the findings of a powerful report recently produced by the EAT Lancet Commission. The report highlights key global nutritional challenges today. It notes that although global food production of calories has kept pace with population growth, more than 800 million people have insufficient food and many consume diets that cause micronutrient deficiencies and place them at high risk of obesity and non-communicable diseases. The Commission advocates for a diet that largely consists of vegetables, fruits and whole grains, a low to moderate amount of seafood and poultry, and no or a low quantity of red meat or processed meat, added sugar, refined grains, and starchy vegetables. The authors estimate that worldwide adoption of this diet would result in major health improvements.

But the report goes beyond simply advocating for healthier diets. It shows how our dietary practices, the food we consume, and how we produce and distribute it, is having dramatic environmental consequences including effects on climate and biodiversity linked to greenhouse gas emissions, land use, and waste. The functioning of today’s food system is also characterized by pronounced inequities: there is enormous food waste and yet millions do not have enough to eat, and the consumption patterns of wealthier countries have environmental consequences that affect nearly everyone, especially the inhabitants of lower income countries. Thus, over-consumption by the rich has environmental consequences that are borne in greater proportion by the poor, by those who are consuming much less and who are consuming in ways that are much less destructive to our planet.

The report advocates for what it calls “The Great Food Transformation,” a radical change in the way food is produced, distributed, and consumed. It recognizes that this Great Food Transformation will need multiple actors and multiple changes, must be based on continuously evolving science and evidence, and will require the full range of policy levers, from soft to hard.

It was refreshing to see the committee recognize the magnitude and dimensions of the problem, recognize the major challenges, but also argue that radical transformations are possible. Its sweep gave me hope. But it also led me to pause: what are we doing in public health, and especially in schools of public health, to address this, a major health and environmental issue of today? I fear that we are not doing much.

We in public health have traditionally focused on the environment as an important determinant of health but not as a critical outcome in its own right. This is understandable to a certain extent because our prime objective is to improve population health. But as has become increasingly evident, our behaviors (including health related behaviors) have environmental consequences, and these environmental consequences in turn impact our health. Health and environmental outcomes need to be considered in unison. We can no longer be oblivious to the environmental consequences of what we do.

As part of the session where Dr. Rivera presented the report, I was asked to comment on what the report meant for schools of public health. Three things came to mind. The first is that we need to teach our students to think systemically. This means learning how to characterize and understand the functioning of systems, putting together and understanding the implications of what we know, broadening our conceptual and methodologic approaches to better capture the interrelatedness of health and the environment. Our students need to be familiar with the features of systems (multiple levels, feedbacks, dependencies, nonlinearities, effects distant in space and time) and what they imply for understanding a population health problem. What the Lancet food report shows (and what is true of most if not all public health problems) is that systems thinking is critical to both understanding and effective intervention.

The second is that we need to teach our students to think globally, but not only in the sense of having global experiences (enlightening as they may be), but in understanding how what we do in the United States today affects the rest of the world and vice versa. We also need to make visible the true magnitude of worldwide inequities in resources and consumption and what they mean for our health and our planet. We should teach them not to shy away from these macro-level questions and their policy implications.

And last but not least, we need to teach our students how to communicate and advocate effectively about these big societal problems and around the links between environment, health and equity. This means communicating in ways that are enlightening, insightful, forceful and that don’t shy away from assigning causation where it truly lies or calling for the difficult choices and major societal and economic changes that we need to make.

Argentina is still a meat-eating country, and when I go home, I can’t avoid the traditional “asado” at least once (although it must be said Argentina currently ranks third in meat consumption per capita, after the United States and Australia). But it is not as bad as it used to be. Recent developments suggest that patterns are changing: in a sign that economic recessions are not always bad for health or the environment, meat consumption dropped during the recent economic crisis.

But there is a long way to go and it’s not only about consuming less meat: it’s about changing the way we produce and distribute what we eat. This will not be easy. Similar challenges exist around how we organize transportation and our excessive and growing dependence on the automobile. Nothing short of radical transformation will really solve these problems. But recognizing the real magnitude of the problem and articulating its dimensions is the first step towards solving it. In this, the Lancet EAT commission has done public health a true service. As for me, from now on I will think twice before I order that bife de lomo…

Ana V. Diez Roux, MD, PhD, MPH
Dean and Distinguished Professor, Epidemiology, Dornsife School of Public Health