Every once in a while we may meet – and if we are fortunate work with – somebody who is brilliant, honourable, engaged, generous, sagacious and eloquent, and who also has the surely magical ability to bring out the best in us. Such people come to inhabit our higher consciousness, which is to say our conscience. From time to time the thought comes to my mind 'what would Tony say to that?' or, of a piece in which I feel pride, 'shall I send this to Tony?' Frequently, I browse one of his books (1,2). This is Tony McMichael, my hero for this month, pictured above in April 2005 sitting – significantly – on a stone spiral. He has done more than anybody else to insist on the environmental dimension of nutrition, as a discipline and as practiced, and he has succeeded (3). A couple of days after this picture was taken, he inscribed one of his books 'in fond appreciation of a friendship spanning two decades and three continents'. That's not a book I will lend or lose.

This column begins below with the first instalment of a story featuring a number of Association members. Yes, I was there. The prompt to tell the tale now, is that it is the topic of a forthcoming PhD thesis. Then, before I finish this month with more on Tony McMichael, there are some more thoughts about human height. For instance, did you know that Jean-Paul Sartre was…. no no, read on…

References

1. McMichael AJ. Planetary Overload. Global Environmental Change and the Health of the Human Species. Cambridge: Cambridge University Press, 1993.
2. McMichael AJ. Human Frontiers, Environments and Disease. Past Patterns, Uncertain Futures. Cambridge: Cambridge University Press, 2001.
3. The Giessen Declaration. Public Health Nutrition 2005; (6A): 783-786.

History. Policy. The Coronary Prevention Group

This great movement of ours?

Still thinking of making your masterpiece? If so, older readers, here are three hints that you had better get on with it now. One is going downstairs to do something and then not being able to remember why you are there, and having to go upstairs again to remember, and then going downstairs again saying 'coffee, coffee, coffee' (or 'walk the dog, walk the dog, walk the dog', or 'Galeano, Galeano, Galeano', or whatever). Two is women offering to carry your bags (women will have their own version of this).

Three, which introduces my topic here, is being contacted by PhD students and being told that you are included in their theses, and what did you mean by what you wrote (the quote is then emailed or skyped) in 1970-something, or 1990-something, or even more recently. 'You're history, buddy' growls the slit-eyed villain (or hero) in the movie, as he points the pistol at the good guy (or the bad guy) and squeezes the trigger. It's a funny feeling, becoming history while being alive. In my day as a student this didn't happen, not in Britain anyway. My contemporary Alan Coren was told by his Oxford supervisor that a thesis on modern American literature would be possible only if he eliminated writers who were living. Later he quit academia and became a satirist.

It's not like that now. Hot writers and organisations may cache their back pages in university or other archives, saving on storage and sometimes making money, and then have the experience of PhD students buzzing around their hive. In one famous case, the yippie Alan Jules (AJ) Weberman fulfilled his quest to register on punch-cards every single word drafted as well as written and sung by Bob Dylan, by rummaging through the great man's trash-cans, and must surely now be qualified to be Dr Weberman. Indeed, garbology, the area of study he is said to have originated, is now an academic discipline, centred at the University of Arizona, and thus may be the topic of any number of PhD theses, as long as each one is somehow original. The last two sentences are substantially true. Travellers may have noticed the claim that of all the scientists that ever lived, nine-tenths are alive today – this is one of those constantly repeated 'just fancy that!' statements on airport passage walls, designed to keep minds off the schlep from 'doors to manual' to customs hall zoos. What's the proportion with PhD students? Twenty-nine out of thirty? (1).

Living History

Enter, by email and skype, the excellent and assiduous Jerrell B Whitehead, of King's College, Cambridge. Early last year he got in touch and told me that he, with support from his supervisor, the distinguished scholar of history and policy Simon Szreter, had chosen for his PhD thesis, Food and Health Campaigning and Cooperation in England's New Food Movement, c. 1976-1996. He explained that he had dug into the archives of various relevant civil society organisations active in this period, read lots of books, reports and files, had identified me as one of the actors, had browsed google and got hold of my email address, was now ready to interview me, and it was me wasn't it – and would I talk? Yes, it's me, I said. Sure. What do you want to know.

One key point he wanted addressing, is: did the various activities he was investigating in that period, between 15 and 35 years ago, actually amount to a 'movement'? Good question. Veteran British socialists will remember their fellows – called 'comrades' in those days – referring to 'this great movement of ours'. Nobody now would think of the UK Labour Party as 'a movement'. That vanished for ever when Tony Blair and his cohorts invented 'New Labour' in the mid 1990s, and called it a 'project'. 'This great project of ours' doesn't fly. So, what makes a movement, in any social and political sense? And why does this matter?

For instance, I started to wonder, is public health nutrition, as represented by the World Public Health Nutrition Association and such-like bodies, a 'movement'? Unusually, the Shorter Oxford is not helpful. It offers: 'A course or series of actions and endeavours on the part of a body of people towards some special end; a body engaged in such a course'. That's far too inclusive. An example given is by Martin Esslin: 'The Theatre of the Absurd is thus part of the "anti-literary movement" of our time'. This example, and others given, is better than the definition, which could be used of a bunch of chums fixing up a season of bridge nights.

To be a 'movement', the 'actions and endeavours' surely need to be singular, important, and also sustained and effective, at least for long enough to be a suitable topic for history. Further – and this is significant in the context of the story I am about to start to tell – my sense is that a 'movement' is not of one group and certainly not of a clique or gang, but of a number of confluent groups, often and maybe characteristically of various types and with different aims. Did the Pre-Raphaelites amount to a movement? Yes, I would say so. Was Fascism a movement? Certainly, yes – and the suffixes '-ite' and '-ism' indicate as much.

Before talking to Jerrell B, I suppressed my irritating inclination to challenge other key words in his provisional title (why 'food and health', why 'cooperation', why 'England', why that time period?). He indulged me in two vast off-the-cuff skype conversations, one last year, one a few months ago, which taken together, I was appalled to discover, amounted to over 20,000 words of transcribed burble that he proposed to include, along with the transcripts of conversations with half a dozen other actors, as appendices to his thesis, itself at that stage over 80,000 words and rising. Good grief!

He was and is though, on to something. The story of food, nutrition and health campaigning in Britain between the mid 1970s and the 1990s can be divided into four inter-related parts, as follows. This month I tell the tale of the glory days of the Coronary Prevention Group.

1   The Coronary Prevention Group

Ancel Keys, Denis Burkitt, Richard Doll, Keith Ball: scientists and medics sure that diet is crucial in health and disease, all prepared to speak and act

In the early 1970s, governments of most high-income countries had issued dietary guidelines designed to prevent cardiovascular disease (2). This followed the work of many researchers, some of whom advised their governments, of whom the most powerful was Ancel Keys of the University of Minnesota. Here he is (at left above), on the cover of Time magazine in 1961, in a special issue on 'diet and health'. But this message was not getting across in the United Kingdom. A sufficient reason was the extraordinary secrecy by which UK food and nutrition policy was obscured. During the 1939-1945 war, the UK was in some senses necessarily a totalitarian state, in which government and industry representatives, with scientific advisors, combined to agree national policies and actions mainly designed to make sure that people had enough to eat and were unlikely to suffer deficiencies. Good food was 'just the stuff to give the troops', as my mother used to say, full spoon hovering.

Deliberations on UK national food and nutrition were covered by the Official Secrets Act – and remained so in the decades after the war. In and after the 1960s, official advisors tended to opine that US scientists were enthusiastic and even reckless with the evidence and that there was nothing wrong with British food. This suited government and industry, and nobody was rocking the ship of state. As far as the media were concerned, 'nutrition' was about vitamin C, meals on wheels, and – for the ladies – slimming.

By the 1960s cardiovascular disease, and in particular coronary heart disease, had become the biggest single killer in most high-income countries. Guidelines issued by many governments in this period recommended consumption of less fat and less saturated fat, and sometimes specified how much less, and also foods to consume less or more of. In the UK, panjandrums such as Denis Burkitt next to left, above) and Richard Doll (next to him), both FRS (fellows of the Royal Society), also pointed to broader evidence indicating that industrialised diets were in general too refined and degraded, and as such an important cause of other diseases and disorders.

But such views were mostly confined to learned journals, and were not coming to light in the UK. In 1974 the government's Department of Health and Social Security, (known to wags as the department of stealth and total obscurity), issued an official so-called COMA report, on the topic of diet and coronary heart disease. (2,3) Its recommendations were bland. Thus: 'Obesity should be avoided in the child and the adult… those individuals who are already obese should so reduce their food intake in relation to their physical activity that they are no longer obese'. The US evidence? The report muttered about 'dangers of assuming that the results of investigations made in one country necessarily apply to another'. Take that, you Yanks! The general approach of the DHSS chief medical officer, in his introduction, was to quote St Paul telling the Philippians: 'Let your moderation be known to all men'.

This complacent twaddle caused uproar among health professionals who respected the international literature, and among cardiologists overwhelmed by their clinical workloads, who refused to believe that rocketing rates of heart attacks were just one of those things. As a result – a rare event anytime and anywhere – the British medical establishment split. A number of leading cardiologists, of whom the most insistent were Keith Ball of the Central Middlesex Hospital (right, above) and Richard Turner of the University of Edinburgh, were infuriated by the COMA report. They broke ranks and, crucially, gained support from the presidents of the Royal College of Physicians and the British Cardiac Society for a RCP/BCS counter-report, published in 1976 with the pointed title of Prevention of Coronary Heart Disease. Members of the panel responsible for the report, as well as the RCP and BCS presidents, included Geoffrey Rose, professor of epidemiology at the London School of Hygiene and Tropical Medicine. The tone of the report was urgent and its recommendations were expressed also in terms of food – less meat, don't fry but grill instead, more fish, less butter and instead more oil, more vegetables and fruit, for instance (2,4).

In response, the government's Chief Medical Officer claimed there was no major difference between the two reports (2,5). That, so to say, put the fat in the fire. What then happened was even more radical. Keith Ball and Richard Turner went public, wrote more strong letters to medical journals, and also responded to journalists who were now becoming intrigued. Further, with advice from the relatively militant civil society organisation ASH (Action on Smoking and Health), and with colleagues, they created the Coronary Prevention Group (6).

The key development was the appointment in 1980 of a non-medic, the young public interest advocate Christopher Robbins, as CPG director. He and the young public health nutritionist Caroline Walker co-honorary secretary with brain chemist Michael Crawford, campaigned for prevention of heart disease using increasingly plain-spoken and hard-hitting language. CPG began to attract substantial coverage in national newspapers and television programmes (7).A pivotal CPG member was Geoffrey Rose, who chaired an expert panel responsible for a WHO report on prevention of heart disease published in 1982 (2,8,9). Its conclusions and recommendations, while more detailed, were with one important exception much the same as those of the 1976 RCP/BCS report (10).

While tiny, CPG became effective at first between 1981 and 1983. Why, was because of its combination of media-friendly messages and medical and scientific credibility, the edge and sting of controversy and even a whiff of official hanky-panky, and the creative tension between academics and activists who respected one another. Also those in industry, government and the professional establishment who opposed its messages largely failed to get any jointly agreed act together, and at that stage did not mount a coherent plausible counter story. From 1983 and then as skilfully directed by Anne Dillon to around 1987-1988, CPG set the UK national agenda on the prevention of heart disease – an astounding achievement. Indeed, bland references to 'reduction of risk factors' became increasingly replaced by 'prevention' and other plain language with clear meaning. Yes, in the UK, CPG put coronary prevention, and thus the larger idea of chronic disease prevention, on the map.

So did CPG by itself amount to a movement? For the reasons indicated above, I think not. True, in the later 1980s, with an increased turnover and staff, CPG statements and recommendations, backed by steadily mounting supportive evidence, permeated and went quite a long way towards dissolving the previous set positions of the UK established order. But CPG was not, of itself, a movement. It was, as its title stated, one group. The next part of the story, overlapping with that of CPG, a period in the early and mid-1980s sometimes known as 'the great food scandal', introduces another confluence, and is told in my next column.

Notes and references

1. No, I have nothing against the PhD system in principle. My concern is the way it is now used. So often now, academic qualifications, ranging from first degrees to MSc and then PhD and equivalents, are necessary for pretty much any sort of job requiring applied intelligence. In my young day – hrrumph, hrrumph! – most people who went to university other than those who wanted to be academics or to go into the 'learned' professions like medicine or law, plunged into the real world after their first degrees, got a job, and gained knowledge and wisdom in the school of experience. Typical PhD candidates are sequestered from the real world for three or four crucial years, in which they research an original and therefore probably arcane topic, and then draft a book-length thesis that is bound into half a dozen copies that are then deposited in the library of the place of learning, kept by their examiners, and given to admiring parents and lovers. This, I submit, is nuts.
2. Cannon G. Food and Health: the Experts Agree. An Analysis of One Hundred Scientific Reports on Food, Nutrition and Public Health Published Throughout the World in Thirty Years, Between 1961 and 1991. London: Consumers'Association, 1992.
3. Department of Health and Social Security. Diet and Coronary Heart Disease. Committee on Medical Aspects of Food Policy 7. London: HMSO, 1974.
4. Royal College of Physicians of London/ British Cardiac Society. Prevention of Coronary Heart Disease. London: RCP/BCS, 1976.
5. Turner R, Ball K. Prevention of coronary heart disease. [Letter]. British Medical Journal, 7 August 1976, 365-366.
6. For a while the infant organisation was named 'CPAG' (Coronary Prevention Action Group) with ASH (Action on Smoking and Health) as a model. That came to be seen as going too far.
7. Cannon G. Advice. [Chapter 7] The Good Fight. The Life and Work of Caroline Walker. London: Ebury Press, 1989.
8. World Health Organization. Prevention of Coronary Heart Disease. Report of a WHO expert committee. Technical report series 678. Geneva: WHO, 1982.
9. The 1982 WHO report also referred to 'primordial prevention', meaning creation and maintenance of environments in which the risk of coronary heart disease – and other chronic diseases – is low. The purpose of this term, which never really caught on, is to make a distinction from 'prevention' in any medical sense, such as 'primary prevention'. Primordial prevention points to the first duty of governments, which is to protect their people.
10. The WHO report did not recommend increased consumption of polyunsaturated oils or of any other type of fatty acid, including essential fats. The position was: Less saturated fat, and therefore less fat, and as a result a higher proportion but not a higher amount of unsaturated fats and oils. CPG came to accept the WHO position, which was supported in rather vague terms by two UK reports issued in 1983 and 1984 (NACNE, of which more next month, and another COMA report). Probably as a result of this, Richard Turner and Michael Crawford ceased being active in CPG. Keith Ball, a more pragmatic personality, remained. The stance of CPG then became harmonious with the expert progressive consensus view that emerged from the later 1980s. As is the way with consensus positions, this may well be wrong, but that's another story.

Human growth, height, size

Thinking about height

Sometimes Association members are asked: 'Why have a website that includes opinionated signed columns?' One or two members have wondered about this, also. Well, it seems to me that nutrition scientists as a class are strangely preoccupied with their own seclusion (1). Indeed, I cannot think of any other profession whose members would ask such a question (2). The answer is obvious. Nutrition science is a human activity, folks! Hankering for objectivity is a sure sign of desire for the certainties of mathematics or religion. Other professions do not have a hang-up about colour, controversy, character. Physicists and astronomers glory in alternative and conflicting views of the universe.

This brings me to the issue of human height. A couple of columns ago I celebrated short footballers like Lionel Messi and short cricketers like Sachin Tendulkar. OK, that's sport. But lately also, readers and colleagues have been asking me, in my additional role as editor of World Nutrition, and therefore responsible for Thomas Samaras's March commentary and the accompanying editorial 'Are you seriously saying that most human accomplishment is down to small people?'

Good question! Take philosophy. Above left is Jean-Paul Sartre, 1.53.5 metres, or 5 foot 0½, in Havana, with Simone de Beauvoir sitting next to him, copping a light from Che Guevara. Above right is my own Oxford tutor, now emeritus at McGill, the Canadian philosopher Charles Taylor, on the occasion of receiving the 2007 Templeton prize for a life's work reconciling science with religion. Chuck is around 2.05 metres, or 6 foot 8. In my mind's eye I now see him ducking as he entered the mediaeval door of his All Souls chambers. So no, you don't have to be short to be a great philosopher, but you don't have to be tall, either.

The writings of Jean-Paul Sartre and Charles Taylor are not dessicated. They grapple with the great issues of our times. Charles de Gaulle, when president of France in 1968, was asked by his secret police what he wanted them to do about Sartre, who was proclaiming revolution and rebellion against the state, including in incendiary speeches to students. The General simply said 'We do not persecute or imprison Voltaire' – who, as you will remember, was also short even for his time. But no, you don't have to be short to be a philosopher. The point, is that you don't have to be tall, either.

The key issue for me, concerning human size, is environmental. The slide above, which I first showed at the 2009 Porto world congress on public health nutrition, estimates some consequences of the human race being about 5 per cent less tall and somewhat lighter, while more physically active, than the current average in high-income countries, and thus turning over around 10 per cent less energy a day. It works out as something like 150 million fewer cows and 100 billion fewer burgers a year, and a 2.5 per cent drop in greenhouse gas emissions. So my question is: 'If we seriously want the human species to survive and to do well, throughout this century and beyond, what is the best average height and weight for humans?' This is a question I can ask Charles Taylor, who writes expressively about 'the struggle between the technologically and the ecologically orientated' (4). So I will.

Notes and reference

1. For example, take NUGAG. This hilarious acronym stands for the NUtrition Guidance Expert Advisory Group, of WHO, a most important body, that recently met to determine global dietary recommendations for fats and oils. Google NUGAG WHO and you will find it said that: ' The membership of the NUGAG is established for the biennium and includes experts from various WHO Expert Advisory Panels and those identified through open calls for experts taking into consideration a balanced mix of genders, multiple disciplinary areas of expertise, and representation from all WHO Regions'. Very good. But who are they? I know, because I have made it my business to find out. But can you find out, from accessing the WHO website? Unless I am clicking the wrong links, I think you cannot. Why? Does WHO think that any top-class expert provides the same immaculate service as any other, so that who they are is irrelevant? Maybe. Or do UN officials require the NUs to be blindfolded and bound and GAGged before entering the sanctum of deliberation, one trouser leg rolled up? Unlikely. Or does WHO think that as soon as NUGAG names are listed, members will be charmed into compliance by Big Snack Senior Vice-Presidents, Global Nutrition and Health and Corporate Affairs? Perhaps, but transnational corporations have whole departments of folks employed to check people out. Or what? I pause, for a reply…
2. There again, it may well be unfair to single out nutrition scientists. In The Structure of Scientific Revolutions (University of Chicago Press, 1962, 1970), Thomas Kuhn writes of 'the unparalleled insulation of mature scientific communities from the demands of the laity and of everyday life'. Further: 'There are no other professional communities in which individual creative work is so exclusively addressed to and evaluated by other members of the profession. The most esoteric of poets or the most abstract of theologians is far more concerned with lay approbation of his creative work'. He goes on to point out that social scientists feel more need to justify their lines of work. Could this be one reason why there is still plenty of resistance within the profession to the proposal that nutrition is more than a biological science?
3. Taylor C. Our Victorian contemporaries. [Chapter 22.4]. Sources of the Self. The Making of the Modern Identity. Cambridge: Cambridge University Press, 1989.

Tony McMichael

The big picture

We will return to these issues'. As indeed Tony McMichael does, in his first (1) and second (2) books, and in many papers (3) and public statements. My first knowledge of him was at the time when he was rapporteur of the expert group responsible for the 1990 WHO report on diet, nutrition and the prevention of chronic diseases (4). Phil James, who chaired the group, told me that Tony was a diamond, and Phil is sparing with praise of colleagues, so I was impressed.

In the early 1990s Tony became professor of epidemiology at the London School of Hygiene and Tropical Medicine, and joined the expert panel responsible for the 1997 WCRF/AICR report on the prevention of cancer (5). Four things impressed me. First, Tony insisted – as does Shiriki Kumanyika now (6) – that all types of evidence, including that from correlational and migrant studies, need to be taken into account in coming to judgement on the causes and prevention of disease. We need, he said, to see the big picture. Second, in committee he knows how to make exquisitely timed and phrased points which clarify or change the mood of meetings. Third, and more personal, as head of the secretariat responsible for the WCRF/AICR report I was, one day (not for the first or last time) in despair, because I needed a panel member to make a new draft of a chapter, and was getting no takers. Tony took me aside. 'Do it yourself' he said. I protested my inability. 'You do it. You can do it', he said, quietly firm. So I did.

He also made some wise observations, which infused the report. He pointed out that with chronic diseases such as cancer, 'prevention' does not mean elimination, as it may with infectious diseases – smallpox being the outstanding example. With chronic diseases, 'prevention' means reduction and delay of incidence (5). He also pointed out that by its nature, and possibly unlike heart disease, talk of 'conquering cancer' is misleading, because 'cancer is the price humans pay for having a flexible genome'. This saying is on a slide I use in most of my presentations on cancer prevention.

As from 2000 Tony returned to his native Australia, to become director of the National Centre for Epidemiology and Population Heath at the Australian National University. Could he find the time to come to Germany in April 2005 as a participant in the working group Claus Leitzmann and I had set up, whose purpose was to devise a new conceptual framework for nutrition science? Yes, he could. In the course of the second day, in a measured and reasoned rhetorical masterclass, he encouraged all of us to agree, and then finally to affirm, that nutrition has an environmental dimension (7,8). This is almost a commonplace now. It was new then, and it was above all Tony who made the move.

References

1. McMichael AJ. Planetary Overload. Global Environmental Change and the Health of the Human Species. Cambridge: Cambridge University Press, 1993.
2. McMichael AJ. Human Frontiers, Environments and Disease. Past Patterns, Uncertain Futures. Cambridge: Cambridge University Press, 2001.
3. McMichael AJ. Integrating nutrition with ecology: balancing the health of humans and biosphere. Public Health Nutrition 2005; 6(A): 706-715.
4. World Health Organization. Diet, Nutrition and the Prevention of Chronic Diseases. Report of a WHO study group. Technical report series 797. Geneva: WHO, 1990.
5. World Cancer Research Fund/ American Institute for Cancer Research. Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington DC: AICR, 1997.
6. Kumanyika S, Economos C. Prevention of obesity. Finding the best evidence. [Commentary] World Nutrition, June 2011, 2, 6: 272-299. Obtainable at: www.wphna.org
7. The Giessen Declaration. Public Health Nutrition 2005, 6(A): 783-786.
8. The New Nutrition Science. Public Health Nutrition 2005; 6(A): 667-804.

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Cannon G. This great movement of ours? and other items. [Column] Website of the World Public Health Nutrition Association, July 2011. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.