Introduction
For some time, it was thought that the growing technical capacity of nutrition professionals, improved knowledge of the relationships between food consumption and disease, improved ability to treat food-related illnesses, increased public recognition of nutritionists, and the progressive increase in food production would be sufficient to gradually solve the world's food problems and diseases based on unbalanced food consumption. Unfortunately, reality deviates from this premise.
In 2023, 733 million people were suffering from hunger worldwide, or 1 in 11 people, and 1 in 5 people in Africa . This is 152 million more than in 2019. Considering projections for 2030, hunger figures have remained proportionally unchanged since 2015, when the United Nations launched the Sustainable Development Goals (SDGs), where eradicating hunger was a central objective for 2030. In 2023, it is estimated that more than 2.3 billion people will suffer from moderate or severe food insecurity, with this situation affecting almost 60% of the population in Africa. After a slight reduction in the number of people with chronic hunger during the 2010-2020 decade, this number has increased significantly again since 2017. This failure to eradicate hunger is even more significant when the planet has the capacity to produce food for the entire population. Data on global food production, while far from being of the desired quality , suggest that food insecurity is not directly related to food scarcity, but rather to structural issues of access to food.
The inability to access “healthy diets” or healthy eating patterns affects more than a third of the world’s population. It is estimated that in 2022 more than 2.8 billion people will lack the economic means to afford a “healthy diet.” This disparity is more pronounced in low-income countries, where 71.5 percent of the population cannot afford a “ healthy diet ,” compared to 6.3 percent in high-income countries. The United Nations’ reference to a “healthy diet” includes reference intakes in terms of energy for six food groups: starchy foods; foods of animal origin; legumes, nuts and seeds; vegetables; fruit; and oils and fats. Eleven foods from the six recommended food groups provide a total of 2330 kcal per day, representing the average energy needs of a young, active woman. Overall, access to a healthy “diet” appears to be more difficult in poor, rural populations and among women, suggesting a strong social gradient as a determinant of the possibility of achieving healthy eating. In Portugal, regarding mortality, inadequate dietary habits were the third leading risk factor contributing to total deaths in 2021 (8.3%). For dietary risk factors, data from the Global Burden of Disease show that, in Portugal, high consumption of sugary drinks (+37.13%), high consumption of red meat (+22.53%), high consumption of processed meat (+21.59%), and low consumption of vegetables (+21.51%) were the risk factors that saw the greatest increase in "years of life lost due to death or disability" between 2000 and 2021.
Dietary diseases continue to rise in Portugal and worldwide. New estimates of adult obesity reveal a steady increase over the last decade, from 12.1 percent (2012) to 15.8 percent (2022). Projections indicate that by 2030, the world will have more than 1.2 billion obese adults. The double impact of malnutrition – the coexistence of undernutrition with overweight – has also increased globally across all age groups. In Portugal, overweight, which includes pre-obesity and obesity, affects 67.6% of the adult population, and obesity has a prevalence of 28.7%. The prevalence of overweight is also high in children; in 2022, 31.9% of children aged 6 to 8 were overweight and 13.5% were obese . According to projections by the World Health Organization (WHO), Portugal, like other countries in the WHO European region, is following a trajectory that will make it difficult to meet the goal of halting the growth in the number of overweight and obese people by 2025. In addition to obesity, other diseases strongly influenced by diet, such as diabetes and hypertension, appear to have a strong social gradient. In Portugal , the prevalence of diabetes, hypertension, and obesity varied according to age, education level, and employment status, being systematically higher in the older population, those with lower levels of education, and those without paid employment.
Beyond inadequate nutrition and associated diseases with a strong social gradient that need to be understood more broadly, within a global food system from production to waste, food production and access are increasingly influenced by climate change. Based on these premises, the Lancet Commission on Obesity, led by Professor Swinburn, published the report " The Global Syndemic of Obesity, Undernutrition and Climate Change " in January 2019, introducing the concept of a Global Syndemic.
In a previous essay, we addressed the concept of Syndemic or “synergistic epidemic” to try to explain “the synergy between the epidemics of malnutrition (obesity and undernutrition) and climate change. Two global problems of a complex nature, with common social causes and determinants, and with consequences for human and planetary health.” Again, it seems important to us to understand the configuration of food systems in order to understand what shapes citizens' choices. “Food systems, due to their current configuration, which promotes intensive agriculture, animal protein production, or the massive transport of food via road systems, end up favoring the existence of processed foods with high energy density and low nutritional value at low cost. This fuels obesity and malnutrition pandemics, but also generates 25-30% of greenhouse gas (GHG) emissions. If this model of food production, consumption, and transport accelerates climate change, then these changes, should they occur, will ultimately increase the risk of malnutrition among the most vulnerable populations with the least resilience to extreme weather events such as droughts, floods, or sudden changes in the prices of basic food products.”
The continued failure to combat hunger, promote healthy and sustainable eating, and fight diet-related diseases such as obesity should compel nutrition professionals to reflect on the widespread model of practice and how to modify thinking and action for greater effectiveness. This reflection is fundamental for nutritionists and all health professionals working in the field of food, as they are, in a way, stakeholders in these processes. This is what we propose to reflect on in the next steps.
A – Models of action for nutritionists – Individual-based interventions
The work of nutritionists and most other health professions in dealing with food-related diseases and inadequate nutrition has focused on promoting healthy eating and on the prevention and treatment of disease, both for the consumer and the patient.
Food is thus considered the main agent of the disease, particularly foods with high energy density. Along with the consumption of this type of food, reduced physical activity and other environmental factors interact with the host's genetic susceptibility to produce a positive energy balance .
The most recurring assumption has been that inadequate consumption is a matter of individual choice and responsibility. However, given the continued growth of diet-related diseases, the failure to combat obesity, and the persistence of consumption of foods considered nutritionally inadequate—that is, given the inability to change the current dietary and disease paradigm—the idea (with some associated research) has been growing that weight gain and resistance to weight loss do not reside in conscious individual difficulties but are dependent on brain processes that are beyond conscious experience. Appetite regulation could thus be shaped by factors extrinsic to willpower . This is despite the fact that regulating energy intake and increasing physical activity continue to be tools that are successfully used in some people.
The perception that the treatment of food-related diseases, such as obesity, should be carried out using an individualized intervention that recommends lifestyle changes (better diet and more physical exercise) combined with pharmacological therapy and surgery, represents, for those who advocate this narrative, an alternative to the previous narrative of blame and moral judgment, which was highly conducive to stigma. In this new model, the aim is that the " medicalization " of obesity, like any other disease, such as hypertension, can remove it from the moral sphere, reducing stigma and patient blame. It should be noted that "' medicalization ' describes a process by which human problems come to be defined and treated as medical problems." Portugal is one of the countries that has already recognized obesity as a disease, although the medicalization of the disease is still an option that is little discussed publicly and consciously applied.
This intervention model for eating disorders, particularly obesity, appears to be important in reducing stigma and patient blame, and opens new perspectives for personalized and successful intervention in specific cases. This new narrative, which has been strongly promoted by the pharmaceutical industry and health-related professional groups, notably the medical profession, raises other concerns .
The first is that it continues to focus the response at the individual level, although in a less blame-laden way for any failures. In this model, the choice remains the individual's. The ability to make a decision regarding treatment, and ultimately the payment for treatment, will also depend on the individual's economic capacity. Given the cost of these personalized interventions, the individual's capacity to make decisions will depend heavily on the economic capacity of the individual or the State, should citizens collectively (the State) wish to adopt the principle that these illnesses are not the responsibility of the individual.
It is worth highlighting that inadequate nutrition and food-related diseases are so prevalent in society today (more than 2 million obese and 1 million diabetic, for example) that any public intervention in this area, comprehensive and for all those in need, will have very high and practically unaffordable costs, which may continue if the root of the problem cannot be resolved or substantially improved.
We can summarize the scale of the problem, in its pharmacological aspect alone, with a recent example that we have transformed into a Case Study – The treatment of obesity with pharmacological therapy.
Case Study – The treatment of obesity with pharmacological therapy
GLP-1 is an incretin secreted by L enteroendocrine cells in the mucosa of the ileum and colon, (1) it has been identified for its role in stimulating insulin secretion, inhibiting glucagon secretion and gastric motility, both essential effects in the regulation of glucose homeostasis (2-4). In fact, studies have shown that the inhibition of glucagon secretion by GLP-1 is as important as the increase in insulin secretion in controlling glucose levels in type 2 diabetes mellitus (DM2).(5) In addition to its role in glucose metabolism, GLP-1 is known to have cardio- and neuroprotective effects, reduces cell apoptosis and inflammation, and modulates reward behavior and palatability (6,7). Furthermore, GLP-1 exerts a significant effect on body weight by inhibiting food intake through centrally mediated mechanisms. (6) This last aspect has aroused tremendous interest in GLP-1 and, together with GIP, has placed both on a trajectory as promising candidates for the treatment of obesity. The physiological action of the GLP-1/GIP axis, therefore, has made these intestinal hormones attractive therapeutic targets for treating DM2 and, subsequently, obesity. In particular, GLP-1 receptor agonism (GLP-1R) has not only emerged as a powerful tool in the treatment of DM2 and excess adiposity (8), but has also shown favorable effects on the cardiovascular system (9) and neurodegenerative diseases. (7) This highlights that GLP-1R agonists have an appreciable action profile outside their original targets in the pancreas. (7)
According to the information available in the online National Therapeutic Index (10) for the GLP-1 receptor agonist semaglutide (available in Portugal under the brand name Ozempic), the recommended dosage for the treatment of adults with poorly controlled type 2 diabetes mellitus, as an adjunct to diet and exercise, indicates that after at least 4 weeks with a dose of 0.5 mg once a week, the dose may be increased to 1 mg once a week to improve glycemic control. Thus, a patient would need 4 mg of semaglutide per month. If we assume that the presentation of a pre-filled 3 ml sol. inj. pen (1 mg/0.74 ml) is sufficient for one month of treatment, and the unit price of the same is €106.87 without any state or private co-payment, (10) the annual cost of treatment per patient will be for this medicine alone €1282.44.
In 2021, the U.S. Food and Drug Administration (FDA) approved weekly semaglutide at a dosage of 2.4 mg for the treatment of obesity. After 68 weeks of treatment, semaglutide impressively reduced body weight in non-diabetic obese patients by 14.9%, compared to 2.4% in placebo-treated controls. (11) In contrast, semaglutide was less effective in subjects with obesity and type 2 diabetes, with a placebo-corrected weight loss of only 6.2% reported after 68 weeks of treatment. (12) Thus, treating obesity would require 9.8 mg of semaglutide per month, which would imply a dosage presentation adjusted to these values in our country. However, if we assume the use of the current presentation available in our country, 2.5 pre-filled 3 ml injection pens would be needed. (1 mg/0.74 ml) for one month of treatment, and that the unit price thereof is €106.87 without any state or private co-payment, (10) the monthly cost of treatment per patient will be €267.18 for this medicine alone and the annual value €3206.16.
If, hypothetically, 250,000 patients with type 2 diabetes mellitus were treated with semaglutide, 1 mg/week, this intervention would represent, based on the values presented above, an expenditure of €320,610,000.00. This is equivalent to 13.07% of the total expenditure on outpatient medications in 2023 in mainland Portugal (see table below).
If, hypothetically, 250,000 obese patients were treated with semaglutide, 1 mg/week would represent, based on the values presented above, an expenditure of €801,540,000.00. This is equivalent to 32.67% of the total expenditure on outpatient medications in mainland Portugal in 2023 (see table below).
Given the prevalence of obesity and type 2 diabetes in our country, we can argue that the number of patients to be treated as described above would not be excessive; even so, it would have a huge impact on outpatient medication costs.
Outpatient Medication Expenses in Euros
| Period | Year 2023 |
| Region | Mainland Portugal |
| NHS Charges (Outpatient) | 1.593.847.981,50 |
| Patient Charges (Outpatient Clinic) | 859.633.237,07 |
| Total | 2.453.481.218,57 |
It is also important to consider that, according to the European Medicines Agency (EMA), the GLP-1 receptor agonists Bydureon, Byetta, Lyxumia, Ozempic, Rybelsus, Trulicity, and Victoza are indicated only for diabetes, while Saxenda and Wegovy are indicated for body weight management as an adjunct to diet and exercise in people who are obese or overweight with weight-related health problems. Mounjaro is authorized by the EMA for both diabetes and weight management under certain conditions. Any other use represents an unapproved use that will worsen the already existing shortage of these medicines on the market. GLP-1 receptor agonists are not approved for, and should not be used for, cosmetic weight loss, i.e., for weight loss in people without obesity or overweight people who do not have weight-related health problems. Healthcare professionals should consider offering these people lifestyle advice as an alternative to these therapies (13).
Since obesity is considered a complex , the use of innovative medications in its treatment, such as GLP-1 receptor agonists, would have to be considered a long-term or even lifelong therapy. Besides the enormous associated cost, unfortunately it is still not known for certain whether there are side effects or complications that only manifest with prolonged use, especially when these medications are used for weight loss, which usually involves higher dosages than those used in the treatment of type 2 diabetes. Thus, even in cases of successful weight loss, if there is no simultaneous and relevant change in lifestyle factors, an undetermined number of patients may not be able to maintain pharmacological treatment (due to adverse effects, cost, etc.) and will suffer the consequent recovery of body fat and worsening of obesity-related pathologies.
It should also be emphasized that inadequate nutrition and food-related diseases are more frequent in the lower social classes, precisely those with less ability to afford this personalized nutrition model. In other words, any intervention using this model would have to be carefully considered so as not to increase existing inequalities in health and nutrition.
These are some obstacles to this personalized intervention model that could be adopted, particularly in situations where the cost-benefit for the patient is evident, but which will still not solve the problem of obesity or its determinants. And even less will it change the course of adopting dietary consumption patterns that lead to these diseases.
It is worthwhile to revisit the topic of obesity and review a recent analysis of the determinants of obesity in Latin America, which we can easily extend to other parts of the world. According to the authors, the determinants of obesity have a largely systemic cause that goes beyond individual choice or characteristics. These eight determinants include: the physical environment, exposure to food, political and economic interests, social inequalities, limited access to scientific knowledge, culture, behavioral context, and genetic factors.
Fig. 1 Determinants of obesity in Latin America
This text, recently published by Professor Sandra Ferreira from the University of São Paulo and colleagues in Nature Metabolism, attributes a substantial part of the responsibility for the appearance and development of the disease to the obesogenic environment. Other authors such as Meijers P and collaborators and Nicolaidis S have linked the built environment (urban planning, transport, ease of walking, sedentary lifestyles that promote excessive screen time) and agri-food factors such as the local availability of certain foods and their promotion as central to the genesis of obesity. In addition to the analytical examination of the factors promoting an "obesogenic environment," it is worth mentioning the cumulative effect that tends to coexist in the same population, thus amplifying its pathogenic consequences. Furthermore, it is common to find more than one determinant of obesity in the same population because it is the expression of another common underlying cause – poverty.
Given the complexity and interrelationship between these factors, seemingly external to the individual, it is worthwhile to look at the food system as a whole, which is the main determinant of our eating habits. And to try to understand how we can act upon this system, usually considered something beyond our control.
Models of action for nutritionists – Group-based interventions
To work on the systemic determinants of our dietary patterns, we must understand the food system. We can define food systems as the set of people, institutions, places, and activities that play a significant role in the production, processing, transportation, sale, marketing, and ultimately, the consumption of food. Food systems influence dietary patterns by determining the types of food that are produced, the foods that are accessible, both physically and economically, and people's food preferences. They are also fundamental to ensuring food and nutritional security, people's livelihoods, and environmental sustainability.
For example, the decision to plant a vineyard and produce wine can be stimulated by public funds and the political will to support production, and ultimately, almost at the end of the food system, the availability and promotion of alcoholic beverages may depend on regulatory rules that are state initiatives where the citizen can also have a more or less active role. Other examples could be given where citizen participation can help shape the food system, although this is not always visible or even possible. In many situations, the food system responds to economic stimuli and, ultimately, to climate change, where the citizen's capacity for intervention may be less.
In Portugal, over the last few decades, several interventions have taken place in the food system, impacting production, availability, access, and citizens' preferences. For example, subsidies for olive oil production made Portugal a major producer and exporter, although it has not been possible to reduce the cost to consumers in recent years. Increased supply from distributors and extended opening hours for commercial establishments have facilitated access to food. The approval of Law No. 42/2016, of December 28, which created the "Special Consumption Tax on Beverages with Added Sugar or Sweeteners," allowed for a 36% decrease in the proportion of beverages in the highest tax bracket (sugar content equal to or greater than 8 g/100 mL) and a 54% increase in beverages in the lowest bracket (sugar content less than 2.5 g/100 mL), thus suggesting that the soft drinks currently most consumed by the Portuguese now have a significantly lower sugar content. The approval of Law No. 30/2019, of April 23, which introduced restrictions on food advertising aimed at children under 16, and the implementation of measures that encouraged the reformulation of food products. The results of the food product reformulation process in Portugal, between 2018 and 2021, allowed for an overall reduction of 11.5% and 11.1% in the average salt and sugar content (per 100g), respectively, in the products covered by this commitment (potato chips and other snacks, breakfast cereals and pizzas (salt) and breakfast cereals, yogurts and fermented milks, chocolate milk, soft drinks and nectars (sugar)). Overall, it is estimated that, during this period, there was a reduction of approximately 25.6 tons of salt and 6256.1 tons of sugar in the foods covered.
Despite the success of many of these measures, they are still scarce and mostly encouraged by public institutions with mandates to intervene in the area of promoting healthy eating, such as the Directorate-General of Health. These initiatives are still a small sample of what could be done if there were greater capacity and interest on the part of health professionals, namely nutritionists, and also civil society organizations, for a more continuous, efficient and organized intervention in the food system that should complement the essential individual interventions.
The fragile participation of Portuguese citizens and even healthcare professionals in public policies and systems that influence their health and well-being (such as the food system) is still poorly documented .
We can understand political participation as the voluntary actions undertaken by the public to influence public policies, either directly or indirectly through the selection of political decision-makers. These actions can include activities such as voting, campaigning, donating, contacting politicians, submitting petitions, protesting, and collaborating with others on various issues.
One explanation for the weak participation or action of health professionals in political processes and systemic issues that determine food consumption may be related to the forms of representation and expression of professional classes, through professional bodies, unions, and even scientific societies, which mostly prioritize responses to the most pressing individual problems of their members, related to their professional status, career progression, employment, job qualification and remuneration, the protection of citizens as consumers of health products, or interventions focused on the patient and food-related diseases, which are, incidentally, very prevalent in society. The concentration of efforts in these areas leaves little room for action on the food system and the determinants of poor nutritional quality food, namely the commercial determinants that underlie the problem.
Models of action for nutritionists – Interventions based on compromised nutrition
We understand "committed nutrition" as a model for action on food and nutrition issues that integrates the determinants of inadequate food intake within a systemic framework that goes beyond individual issues and has the capacity to make pragmatic proposals for action and collective mobilization on these determinants, both locally and globally, involving civil society, stakeholders, political forces, and academia. This model of action also prioritizes transparent participation free from conflicts of interest.
This model presupposes the need for adequate training of health professionals in this field, particularly nutritionists, knowledge of monitoring processes and participation in public policies, especially in areas that shape food consumption, and greater intervention throughout the food system, particularly in the most sensitive and influential areas of inadequate intake by the most vulnerable population groups, such as the production, marketing and promotion of food products.
Interventions based on the concept of "compromised nutrition" primarily involve citizen participation and mobilization. In the definition of "compromised nutrition," citizens are seen as active participants in the processes, empowered to think critically about food systems and aware of how they can participate in this change. This issue is central when we know that the citizens who participate least in political processes and decision-making are precisely those most affected by inadequate nutrition and food-related diseases. Capacity building in the area of nutrition must also address "who to empower," "how" to do it, "where," and "for what purpose," in a format that should be adapted on a case-by-case basis.
Since the 1960s, food justice movements have been drawing attention to socioeconomic, environmental, and cultural inequalities that affect access to food and that are partly constructed throughout the food system. These inequalities may be further exacerbated by the current influence of nationalist discourses and the concept of food sovereignty. One criticism of these movements is that, in addition to drawing attention to the problems, they were not very effective in implementing large-scale proposals for change.
The experience gained over the last few years in public institutions and in the work that is occasionally published by colleagues who interact with the food system in their communities, particularly experiences at the local government and municipality levels, allows us to identify interventions that resemble the models advocated by the concept of "committed nutrition." In particular, when it is possible to transform basic food problems, felt by the community or by professionals, into matters of public interest that in turn lead to political action for their resolution.
Recent examples in Portugal include the recognition of excessive sugar consumption from sugary drinks, initially detected by health professionals, which subsequently led to a public debate and political decisions to regulate them, reducing the availability of sugary drinks on the market. Another example is the food support program for disadvantaged families ( PO AMC ) through the European Fund for Aid to the Most Deprived, which has successively modified the food supply of certain foods based on problems detected by nutritionists and the technicians and communities involved. At the municipal level, we can cite examples of municipalities, such as Benavente , which, in collaboration with their nutritionists, mobilized the community and local producers for healthy consumption in their schools through three in-house food preparation centers in participatory projects with the community in building solutions and in models for sharing experiences, such as the "Open Refectory," which aims to promote contact between parents and guardians with school canteens/meals. Or even NGOs like " In Loco, " which in the Algarve has supported various initiatives to empower and organize people and regional entities in promoting Mediterranean food in partnership and within a framework of integration with the aspirations and needs of the communities, and which are then expanded nationally.
These models tend to counteract the reduced intervention of policymakers in food systems for fear of affecting consumer rights and their autonomy and freedom of choice. This idea of "depoliticizing" food issues is also reinforced by the tendency to accept a narrative excessively focused on individual responsibility or, more recently, on the individualized and personalized resolution of basic food problems with pharmacological or surgical support, as we have seen. The concept of "committed nutrition" refers to health professionals and active citizens empowered to make individual decisions based on the best available science, but at the same time it includes the need to improve the quality of public participation in the transformation of food systems.
Public participation and the need to unite nutritionists, as a profession, around public health causes that unite us and require a concerted effort for their resolution is another challenge of the concept of "committed nutrition." Changing food systems, given their complexity, cannot be achieved through the isolated efforts of nutritionists. It requires associative models, leadership from health professionals, and public perception that these causes are worthwhile and are carried out by parties not interested in commercial or corporate interests.
On the other hand, the profession of nutritionists in Portugal, despite already having more than 6,000 members and possessing high individual dynamism, particularly in service provision projects and social media, has, in recent years, had a weak associative experience around causes that concern us. Around causes that move us and make us believe that we can make a difference in our communities.
Public participation and the need to unite nutritionists, as a profession, around public health causes that unite us and require a concerted effort for their resolution is another challenge of the concept of "committed nutrition." Changing food systems, given their complexity, cannot be achieved through the isolated efforts of nutritionists. It requires associative models, leadership from health professionals, and public perception that these causes are worthwhile and are carried out by parties not interested in commercial or corporate interests. On the other hand, the profession of nutritionists in Portugal, despite already having more than 6,000 members and possessing high individual dynamism, particularly in service provision projects and social media, has, in recent years, had a weak associative experience around causes that concern us. Around causes that move us and make us believe that we can make a difference in our communities.
It is necessary that these modes of action can be extended to other contexts, in learning experiences, discussion of experiences, and capacity building to transform the food system and promote equity in access to healthy, sustainable, and balanced food. The solutions to be tested, within the framework of "committed nutrition" and regarding the food system, must simultaneously consider social justice, environmental sustainability, the improvement of the nutritional status of all, and the active participation of the community in decision-making. We hope to soon be able to describe more work using these models of action.
Bibliography – Case study
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Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto
