Is Our Food Killing Us?

If there is one thing with the power to unite us as human beings, it is food. Regardless of how different individuals and groups may be from one another, everyone has to eat. Food is among our most basic biological needs. But we all know it is more than fuel.

Food is a way to bond with our families and communities, and to forge new connections with other cultures. It can be sentimental, nostalgic and romantic. Cooking and eating is a form of self-expression; food choices are a political act. We use food to signal our own identities and value systems: 'I don't eat meat', or 'I'm a meat and potatoes kind of a guy', as well as to assign identity to others.

Food is ceremonial, religious, traditional and tribal. In fact, it is one of those aspects of life that looms so large it can become invisible. Dietary patterns and eating habits can be automatic and go unexamined for years, decades or an entire lifetime.

But there is every reason to take a step back and ask ourselves questions about what we eat and why. As often as you have heard the cliché, 'You are what you eat', if you are anything like most people, you have not internalized this wisdom.

Figure B summary: A photograph showing a crowded indoor gathering with people seated at round tables. In the foreground, a person wearing a hairnet stands behind a small table holding several plates of food, while other attendees are visible in the background. The image depicts a large-scale catering or food service event.

Figure C summary: A photo showing a person standing over many small bowls filled with food arranged in neat rows on the ground. The image depicts the large-scale preparation of food, likely for a communal event or distribution.

Thanks to advances in medicine, people do not die from many of the things that used to kill us frequently 100 years ago. In the early 1900s, the most common causes of death were diseases like pneumonia, tuberculosis and diphtheria. Now these illnesses are either nearly eradicated or highly treatable.

Today, some of the most common causes of preventable deaths include heart disease, diabetes, cancer and stroke. In 2017 the Global Burden of Disease study found that a poor diet was the highest risk factor for early death worldwide, responsible for 10.9 million deaths. The second highest risk factor was high blood pressure (itself, determined in part by diet), which caused 10.4 million deaths, and the third highest was tobacco, causing 8 million.

Heart disease, or cardio-vascular disease, refers to the blocked arteries that cause heart attacks and strokes. It is the world's biggest killer, but it is 80 per cent preventable.

Diabetes occurs when either the pancreas does not make enough insulin (Type 1) or the body does not react as it should to insulin (Type 2). Both types cause a dangerous rise in blood sugar.

Cancer is a blanket term for diseases characterized by abnormal cell division. There are more than 100 types, but some of the most common include lung, breast and skin cancer.

A stroke occurs when the brain is deprived of blood, and therefore deprived of oxygen as well. It is compared to a heart attack and sometimes called a 'brain attack'.

High blood pressure is excess force placed on blood vessels. It increases your risk of heart disease but often has no symptoms.

The Industrial Revolution, c. 1760 to 1830, was the transition from a largely agrarian economy to one dominated by power-driven machines.

It fundamentally changed farming and manufacturing.

Food is central to culture around the world. Here, a family shares stories over lunch during the Magalianes district fiesta in the Philippines. The fiesta is an annual celebration during which food plays a central part. Families gather for a large lunch of Lechon, a style of roast pork.

B Volunteers serve free Thanksgiving meals during the annual 'Safeway Feast of Sharing' in Washington, D.C. The event has fed more than 70,000 people since 1999, providing people in need with a vital link to a significant cultural event in the US.

C Meals are laid out on the first day of Ramadan at the shrine of Hazrat Nizamuddin Aulia, a 13th-century Sufi Muslim saint, in New Delhi, India. Throughout the holy month devout Muslims fast until after sunset, when they break the fast with a meal known as iftar.

INTRODUCTION

INTAKE OF DIETARY FACTORS AMONG ADULTS AGED $ \geq $ 25 WORLDWIDE (2017)

A This chart shows the age-standardized intake of processed meat, sugar-sweetened beverages, trans fats and salt among adults aged 25 years or older in 2017. Intake is shown at both the global and regional level. It demonstrates the problems of the modern Western diet, and how extensively it has been exported around the world.

: Chart A summary: Four bar charts showing daily intake of processed meat, sugar-sweetened beverages, trans fats, and salt across various global regions. Intake is generally lowest in Sub-Saharan Africa and highest in High-Income North America and other Western regions for processed meat, beverages, and trans fats. Salt intake is more uniformly high across most regions, though it remains lowest in Sub-Saharan Africa. The overall point is that dietary consumption of these unhealthy components is significantly higher in high-income and Western regions compared to Sub-Saharan African regions.

Our food is killing us. And that is at least partially because we let it.

But it is not all personal gluttony that is to blame for the skyrocketing rates of obesity and diabetes. The forces that shape what we eat transcend the individual. They are largely driven by politics, policies, the needs and whims of multinational mega corporations and, most of all, money. The massive changes to agriculture brought about by the Industrial Revolution set off changes to our food supply that continue to affect the way we eat today.

When most people imagine a farm, they call to mind weathered red barns, lush green pastures and fluffy, happy chickens clucking in the sunshine. It is a relaxing, pleasant scene. And of course, behind it is the family who has cultivated this patch of land for generations.

They produce meat, milk, eggs and a variety of vegetables for themselves and their community. Sounds nice, right? It is the kind of place you would love to support with the money in your food budget and perhaps even visit one day.

Unfortunately, in the industrialized West this traditional family farm is now little more than an historic artefact. In the early 1900s, an era considered by many to be farming's heyday, the United States was home to more than 6 million farms, most of them of the small, family-run type you might still think of when you imagine farming today. More than half of Americans were farmers or lived in a farming community.

By 2012, the number of U.S farms had fallen to 2 million, while the overall area of land being farmed remained the same. Between 2005 and 2016 the number of farms in the European Union decreased by one quarter, and again the land used for agricultural production stayed broadly unchanged.

In developed nations, agriculture is increasingly dominated by large, corporate farms. You may have heard them referred to as factory farms, a term that correctly suggests these operations are more concerned with scale, profit and efficiency than responsible stewardship of the land or the health of their communities. Big Food is now a massive multi-industry that produces and sells the vast majority of what we eat and shapes eating behaviour across the planet with the irresistible ultra-processed foods it churns out and the relentless advertising that comes with them.

Image summary: A photograph of several cows standing in a row within an indoor facility, restrained by metal barriers and tethering equipment. The image depicts the setup of a livestock management or milking system used to organize and secure animals.

Image summary: A photograph showing a person standing in a long, narrow aisle between high, multi-tiered shelving units filled with plants. This setup depicts a vertical farming system designed to maximize crop yield in a limited footprint by stacking cultivation layers.

In the developing world the picture is different. In Asia and sub-Saharan Africa 80 per cent of food is produced by smallholder farmers, and in 2011 in South Asia the average farm size was just 1.4 hectares (in the U.S it was 178.4 hectares). However, even these countries are not beyond the reach of factory farming. It is on the rise everywhere. A 2017 study by the John's Hopkins Centre for a Livable Future on food production in low-and middle-income countries found that while factory farming is not yet dominant, it is a growing trend, and national government policies tend to favour growth and industrialization in animal farming.

A Sheep graze on the Catalan farm of the Plana family in Valigorigua, Spain. The farm has existed for hundreds of years. B Cows being milked on a mechanized carousel on a farm in Dedelow, Germany. C A poultry breeder inspects laying chickens at a large-scale poultry farm in Minsk, Russia.

Factory farms are large industrialized farms. Livestock on such farms are often overcrowded, overmedicated and subject to inhumane conditions.

Big Food is an informal term used to describe the corporate domination of our food supplies. It covers factory farms, large food companies and powerful industry lobbyists.

Ultra-processed foods are packaged and fast foods that bear little resemblance to whole foods. They are high in refined sugar, flour and fat and typically contain many additives and preservatives.

How did this transformation happen?

Mechanization played a large role. As with other segments of the economy during this time, tasks that once required manual labour, and lots of it, were taken over by machines, such as the seed drill and threshing machine. No longer were people milking cows, picking vegetables, sorting eggs or sowing seeds by hand or with the help of animal labour.

This shift greatly improved agricultural efficiency, making it possible to produce larger amounts of grains and seeds quickly and cheaply. It was hailed as a necessary innovation, a way to scale up food production to feed more people as population growth exploded. Between 1950 and the late 1960s the Green Revolution, or Third Agricultural Revolution, increased worldwide agricultural production again, through new technologies including chemical fertilizers, agrochemicals and high-yielding varieties (H.Y.V's) of cereals. These revolutions changed the workforce and the food supply forever. In 1900, 41 per cent of Americans worked in agriculture. By the year 2000, it was only 2 per cent.

Technology also brought chemicals. Traditionally, fields were fertilized with compost and manure produced mostly on the farm itself, while pests were managed by natural means. Today, manufactured synthetic fertilizers and pesticides dominate innovations that dramatically improved crop yields but brought serious troubles of their own.

The Green Revolution was the mid-20th-century boom in grain production.

It was brought about by the introduction of high-yield varieties of grain.

High-yielding varieties (H.Y.V's) are agricultural crops that have been carefully bred or genetically modified to maximize the quantity of food harvested.

Fertilizers are any natural or artificial substance applied to crops with the intention of increasing the yield by returning nitrogen or carbon to the soil.

Pesticides are any natural or artificial substance applied to crops to minimize animals, insects or other pests that inhibit crop growth.

Antibiotics are medicines that work in people and animals to combat bacterial illness. They are also used to promote rapid weight gain in livestock. This practice has contributed to antibiotic resistance.

The World Health

Organization (W.H.O) is an agency of the United

Nations that works on a wide variety of international health initiatives.

And then, of course, there are the drugs. Antibiotics benefit big agriculture in multiple ways. For one thing, routine dosing with these medications allows pigs, cows and chickens to grow fatter faster, and on less feed. It also helps animals survive the crowded, unhealthy conditions that they must endure on factory farms.

A An overhead view of farmers spraying pesticide on a field of rice in Huaian, Jiangsu province, China. Pesticides continue to be a serious issue in China, where their use has increased dramatically. Pesticide use in China is estimated to be 1.5 to 4 times larger than the global average.

Pesticides, antibiotics and other technological advancements that helped pave the way for industrial farms have turned out not to be the miracles early nineteenth-century farmers probably thought they were. The World Health Organization (W.H.O) notes that pesticides are potentially toxic to humans and can have both acute and chronic health effects. Many people have long tried to avoid exposure to them. Certain pesticides remain in the soil and water for years after they were initially applied; many dangerous pesticides have been banned in developed countries but remain in widespread use in developing countries throughout the world. The insecticide monocrotophos is banned in the E.U and U.S but is still available in India, and in 2013 it caused the deaths of 23 children when their school lunch was contaminated.

Image summary: A high-angle photograph showing three people working in a field characterized by alternating green strips of crop and brown strips of soil. The people are spaced apart and appear to be harvesting or tending to the crops. The image depicts agricultural labor in a structured field layout.

In the heyday of family farms, people ate much less meat than we do today. Producing meat was more expensive in the days before ubiquitous automation, and it was therefore much more of a luxury good. Modern, large-scale meat production 'farms', commonly called concentrated animal feeding operations (cafo's), have made meat much less expensive and more widely available.

There is a clear link between wealth and meat consumption however, as wealthier countries eat far more meat than poorer ones. In 2013 Americans ate more than 100 kilograms (220 pounds) of meat per person annually, whilst in Nigeria the average was just 9 kilograms (19 pounds) per person. Culture and history also have an impact, as in India, where vegetarianism has been popular since the introduction of Buddhism and Jainism in the 6th century B.C.E, 38 per cent of the population are vegetarian. However, thanks to the current abundant meat and dairy supply, globally we eat more meat than ever before, even as we learn more about how this meat-rich, high-calorie, high-saturated fat diet is one of the main drivers of heart disease, claiming more than 15 million lives around the world each year.

Figure B summary: A photo showing a large group of pigs in an industrial farming facility, featuring a central automated white feeding hopper and metal fencing. The image depicts the scale and infrastructure of intensive livestock production.

Image summary: A photograph depicting a large number of white turkeys crowded together in an industrial farming facility. The image shows the high-density livestock environment used for commercial turkey production.

Concentrated animal feeding operations (cafo's)

are industrial-scale livestock facilities where hundreds, or even tens of thousands, of animals are raised in overcrowded and inhumane conditions.

Carcinogenic describes any substance known to promote cancer. Examples include tobacco, alcohol and processed meat.

High fructose corn syrup (H.F.C.S) is a corn-derived sweetener in which glucose has been converted to fructose. It is a common ingredient in ultra-processed food.

A scene from a typical cafo, or concentrated animal feeding operation. Here, pigs eat from a feeder in Howard County, Iowa. cafo's like this often pollute surrounding areas.

B Turkey farming places a premium on breeding birds rapidly and for large breast size, which is prized by consumers. This turkey farm in Turkey shows a typically overcrowded growing operation in which the birds have little to no outdoor access.

C An employee monitors stacks of sliced ham as it comes off the production line at a facility in China. The plant imports pork from the U.S, and manufactures products designed to meet the growing demand for American-style processed meat in China.

D Sugary candy canes are a mainstay of the holiday season. Here, the highly processed treats are being made from candy cane scraps and corn syrup at a factory in Denver, Colorado.

Figure C summary: Two photographs of industrial food production. The first shows a conveyor belt carrying numerous round food items, likely patties, moving under a heating or processing unit. The second shows a worker handling a large piece of raw meat on a metal processing table. The images depict typical steps in a large-scale meat processing facility.

Processed meats – a way to use salt, chemicals and preservatives to make a highly perishable foodstuff more shelf stable – are so damaging to our health that they are considered carcinogenic by the World Health Organization.

In fact, most of the fruits of factory farming, meat or vegetable, do no favours for human health. Wholesome wheat is stripped of its most nutritious parts before being refined and turned into nutritionally bankrupt (but highly profitable and shelf-stable) foods such as pizza dough, white bread and breakfast cereals. Soybeans are squeezed for their oil, which is then used for deep fat frying, yielding an abundance of ultra-processed convenience food.

Corn becomes high fructose corn syrup (H.F.C.S), a cheap sugar substitute that many experts believe is largely responsible for the obesity crisis. One reason for this is H.F.C.S is cheaper than the cane sugar used before it, so sweetened products could become cheaper or bigger. Another is that because the body metabolizes fructose differently to regular sugar it converts to fat more quickly, and inhibits the production of leptin, the satiety-inducing hormone.

Image summary: A photograph of numerous red Amka chocolate boxes arranged in rows on a conveyor belt system. The image depicts a mass production or packaging line, showing the scale and uniformity of the product being processed.

An industrial milk packaging line at a dairy farm in the Ryszan region, Russia.

In Delhi, India, corporate giant McDonald's delivers fast food via mopeds. India's first McDonald's opened in 1996, and the restaurants there have an adapted menu to cater to Indian customs and culture. They serve no beef or pork, instead offering alternative products such as the Chicken Maharajah Mac and Aloo Tikki Burger. In 2012 McDonald's opened its first vegetarian-only restaurant in India.

Biodiversity loss refers to a decrease in the overall number of living species of plants and animals.

As farming transforms from a traditional, agrarian way of life to profit-driven factory farms run by corporate C.E.O's living far away from the communities where the food is produced, the food supply itself changes. What we eat – and how much of it – is very different from what it used to be wherever the typical modern Western diet is exported around the world. A revolution that was supposed to make life and the global food system better actually set in motion changes that have made the food we eat, and our health, markedly worse.

Policy makers at local and national levels impact our food environment, for example with programmes that reward farmers for growing more and more corn, or taxes that hit consumers in their wallets when they buy sugary soda. All these forces and more are brought to bear on your dinner plate.

: Image summary: A photograph of a row of red motorcycles and scooters parked on a city street, each equipped with a McDonald's McDelivery thermal delivery box. In the background, a busy street is visible with cars, other vehicles, and pedestrians. The image depicts the logistical setup of a food delivery service in an urban environment.

There is a rising awareness that the typical modern Western diet (now exported globally and increasingly popular in industrialized countries worldwide) while great for multinational corporations, is terrible for public health. It is driving the preventable, chronic diseases that are taking lives in great numbers. Just as tragically, the global food system is responsible for a quarter of the world's total greenhouse gas emissions, and contributes to biodiversity loss, water pollution and the global plastic crisis. As the world population continues to grow, and the food system attempts to expand further, damage to the ecosystem will only increase: a fundamental change in approach is required.

Understanding the complex issues surrounding dietary patterns can be the first step to taking the political actions necessary. Voting for leaders who support more human-centred food and farming policies, and who encourage the development of new cultivated meat and other food-creation technologies, is also key to shifting these disturbing trends in a positive direction.

Image summary: A photograph of a person standing in front of a wall decorated with various food images and a sign that reads "1. The Evolution of an Epidemic." This is a candid photo, with no data or analytical result to report.

Obesity is a global health crisis, and for years it has been referred to as an epidemic.

A in China, where childhood obesity has become more common, many middle class parents send their kids to summer camps geared toward fitness and weight loss. Like this one in Beijing, Body mass index is calculated by dividing a person's weight by their height squared. This chart makes it easy to find your B.M.I number from your height and weight, and to see which weight range it falls into.

Increasingly, medical professionals around the world have adopted a disease model of obesity. Thinking of obesity as an illness makes sense in many ways. During the past several decades, obesity has skyrocketed and its health consequence cannot be denyed. And not just in the rich countries where you might expect it to be high. It has become a problem across the globe. According to a report from the World Health Organization, 650 million adults are obese.

That rate is twice as high as it was 50 years ago. Worldwide, obesity has increased threefold since 1974.

Obesity is defined as having a body mass index (commonly known as B.M.I, a measure of body size that factors in both weight and height) of more than 30. B.M.I is an imperfect tool for assessing a person's health, but it does tell a story about the health risks of obesity, especially when you study, as epidemiologists do, groups of people instead of individuals.

Body mass index is an estimation of body fat based on a ratio of height to weight.

With more people living with obesity than ever, it should come as no surprise that there is a forceful movement around the idea of fat acceptance. With its roots in 1960s activism, and informed by the feminist and gay rights campaigns of the 1970s, the movement fights for an end to prejudice against fat people. Despite this, overweight and obese people continue to face discrimination in all areas of life. This is especially pronounced when it comes to getting medical care. All too often, doctors want to place the blame for unrelated health conditions on a patient's weight.

Image summary: A Body Mass Index (BMI) chart that crosses height in inches against weight in pounds to categorize weight status. By intersecting a person's height and weight, the table assigns a category based on color-coded regions: blue for underweight, green for normal weight, yellow for overweight, orange for obese, and red for extremely obese. The purpose of the chart is to provide a quick reference for classifying weight status relative to height according to BMI standards.

Image summary: A world map showing childhood obesity rates in girls for 2016, with a color scale ranging from dark green for 5% to dark red for 25%. Higher rates are concentrated in North America, parts of South America, North Africa, and Australia, while lowest rates are seen in Central Africa, Northern Asia, and parts of Southern Asia. The point is that childhood obesity in girls varies significantly by region, with the highest prevalence in the Americas and Australia.

Image summary: A world map using a color scale from green to red to represent percentages, with the scale ranging from 5% to 25%. Most of North America, South America, Europe, and Australia are shaded in red, indicating higher percentages, while large portions of Africa and South Asia are shaded in green and dark blue, indicating lower percentages. The map depicts a global distribution where the highest values are concentrated in the Americas and Australasia, and the lowest values are in Africa and parts of Asia.

The U.S is not alone in its position that obesity is a disease. Canada, Portugal, the World Health Organization and the World Obesity Federation all classify obesity in this way. And there is a push among medical associations and organizations in many other countries around the world, including the U.K, to officially recognize obesity as a disease. Doing so could help clear a path for the establishment of treatment, help patients pay for care and lead to greater research funding.

Perhaps because of obesity's very recent classification as a disease, doctors have not historically been well trained on the subject of nutrition. And during a routine surgery visit, they usually have very limited time – 10 or 15 minutes – to spend with a patient. As the idea of obesity as a disease takes hold, the hope is that treatments, including nutrition education and behaviour modification techniques, will be refined and become a more standard part of medical treatment plans.

Childhood obesity is described by the World Health Organization as one of the most serious public health challenges of the 21st century. This problem is especially dire in developing countries, which have a rate of childhood obesity 30 per cent higher than in developed countries.

Type 2 diabetes was long known as 'adult-onset' diabetes because it was a disease of middle-aged and older adults, rarely seen in children. Thanks to the global food system, youth-onset type 2 diabetes is rising at an alarming rate, setting young people up for a lifetime of ill health. Though genetics also plays a role, type 2 diabetes is associated with excess weight, poor diet and lack of exercise.

: Image summary: A photograph of a medical professional in a white coat examining the arm of a young girl, who is being supported by another woman. The image depicts a clinical examination in a medical setting.

Of course, the rise of obesity did not happen in a vacuum. The way people grow, make and distribute food has changed as dramatically as human waistlines. The evolution of the food system from a web of independent family farms to the factory farm model also known as 'big agriculture' has changed much more than the business and practice of farming. Its ripple effects totally transformed the food system by flooding the economy with cheap commodity crops that could readily be transformed into a spectacular range of new foodstuffs.

America led the way in this regard. Perhaps because the United States was such a young country at the time of those sweeping changes to agriculture, the shift to highly processed and manufactured food was enthusiastically embraced. Canned foods were marvels of convenience. When they arrived, frozen T.V dinners were, thanks in part to massive advertising campaigns, regarded as not only a treat but a way to liberate women from the domestic drudgery of cooking from scratch. It could also be America's lack of a single unifying food culture – featuring as it does the influence of numerous immigrant communities and a vast array of regional specialities – that made the country so eager to adopt an entirely new type of diet. Countries that have stuck closer to their traditional healthy food cultures, such as Italy and Japan, have fared better than America when it comes to obesity rates.

Figure A summary: An advertisement for a Swanson T.V. Dinner, featuring a frozen turkey dinner in a divided tray with peas and mashed potatoes. The image serves as a promotional graphic for a convenient, quick-frozen meal that is ready to heat and serve.

A Swanson's 1954 T.V dinner, designed to resemble a television set and encourage the new dining habits made possible by technological innovation.

B The original White Castle restaurant in Wichita, Kansas. In 2014, Time magazine named its slider the most influential burger of all time.

C The first McDonald's in California opened in 1940. The famous golden arches were not introduced until 1953.

Figure B summary: A photo of a storefront with blue posters displaying Covid-19 safety guidelines, such as washing hands and keeping distance, alongside a "Lose Weight" health warning. The image depicts public health messaging integrated into an urban environment during the pandemic.

Figure C summary: A black-and-white photograph of an early McDonald's walk-up burger stand with a large overhead sign advertising "15 cent McDonald's Famous Hamburgers Bought by the Bag." The image depicts the original small-scale operational model of the restaurant before its global expansion.

And of course, it was America that gave birth to fast food when the original White Castle hamburger chain opened in 1921. By 1940, McDonald's was on the scene, followed by K.F.C in 1952. By some estimates, there are a quarter of a million fast food restaurants in the United States. Today, one in three American adults eat fast food every day. It is a cornerstone of what is commonly called the Standard American Diet (sad) or Western diet.

This eating pattern is characterized by an abundance of fast food and other highly processed food. It is full of refined sugars and saturated fat from meat and dairy. Vegetables, whole grains, legumes, fibre and fruit are conspicuously absent.

The North American Free Trade Agreement is a 1994 agreement between the United States, Canada and Mexico intended to promote trade between the countries and eliminate tariffs.

The World Trade

Organization is an international group focusing on global trade rules in an effort to make global trading run smoothly.

Slow Food is a movement founded in Italy in 1989, but now active worldwide, to promote local foodways, sustainable farming, and traditional recipes and styles of cooking.

The name is meant to oppose fast food.

This is the diet that has contributed to America's well-documented and deadly obesity problem. Unfortunately, this diet has also become one of America's most popular exports. A complex web of agricultural, trade, marketing and scientific practices – many of which were initially designed to benefit the U.S in international markets – are helping to drive the global obesity epidemic.

Mexico, for instance, was flooded with cheap junk food and soda following the 1994 passage of the North American Free Trade Agreement. As a result, obesity has spiked in the country, and when the Mexican government tried to tax drinks containing high fructose corn syrup Washington complained to the World Trade Organization and the tax was struck down. McDonald's sells burgers, fries and shakes at more than 34,000 locations in 118 countries around the world, and Coca-Cola and PepsiCo control almost 40 per cent of the world's $53 billion soft drinks market, according to The Economist.

Globalization, trade deals and increasing urbanization have contributed to the rapid rise of the Western diet globally. In places where well established food cultures exist, such as Italy, there has been a measure of resistance to the incursion of mass-produced, processed food.

A In 2018 President Donald Trump invited ncaa football national champions, the Clemson Tigers, to the White House for a banquet of fast food from Domino's, McDonald's, Wendy's and Burger King.

B Over 38,000 McDonald's restaurants may be found in more than 100 countries around the world. Here they are seen in India (above left) and China (above and below right). Their success has also inevitably prompted knock-off versions, such as 'Mash Donald's' in Tehran, ee-rahn (below left).

The Slow Food organization, which advocates for the preservation of traditional food ways, was famously founded after Italy's first McDonald's opened in Rome in 1986. Though Italy's population on average remains thinner than most other countries in Europe, its rate of obesity has climbed since the introduction of the Standard American Diet. This trend is particularly prevalent among children, with the Organization for Economic Co-operation and Development (O.E.C.D) reporting in 2014 that 36 per cent of boys and 34 per cent of girls under 18 were obese, giving Italy the second highest rates of childhood obesity in the world (after Greece). The Western diet has also spread to developing countries and is driving up obesity in those places, as well as the chronic diseases that go along with it, like diabetes. It is estimated that two thirds of people living with obesity around the world live in developing countries.

Image summary: A photograph of a McDonald's restaurant storefront with people walking and a person with a bicycle cart in the foreground. The scene depicts a fast-food establishment integrated into a busy urban street environment.

Image summary: A photo of a small food stall featuring a person preparing food at a counter. On the wall is a large sign mimicking the McDonald's logo but labeled Mash Donald's, with text in another language below. The image depicts an unofficial or knock-off version of the global fast-food brand.

: Image summary: A photo showing a large, yellow McDonald's golden arches sign placed in front of a traditional East Asian multi-tiered building. The image juxtaposes a modern global fast-food brand with traditional architecture.

Figure A summary: A series of six photos depicting various aspects of processed foods and their consequences, including packaged raw meat, a collage of fast food (burgers, pizza, hot dogs), a public health advertisement stating "OBESITY IS A CAUSE OF CANCER TOO," and images of people consuming fast food in a car and at a restaurant. The collection of images serves to illustrate the prevalence of high-calorie, processed diets and their link to obesity and health risks.

An instructive example comes from Samoa. Turkey tails, which can be up to 40 per cent fat, are largely an unwanted by-product of the U.S poultry industry. However, a clever marketing strategy following World War 2 led to them becoming a major export to the Pacific island of Samoa, which enjoyed close economic ties with the U.S at the time. By 2007 Samoans were each consuming an average of 20 kilograms (44 pounds) of turkey tails per year, and unsurprisingly from the 1960s onwards obesity also skyrocketed, reaching 56 per cent in 2008. Traditional, leaner foods in the local diet, such as seafood, were pushed out. Samoan officials banned turkey tail imports in 2007. However, the World Trade Organization blocked their application for membership until 2011, when they agreed to reallow turkey tail imports.

What America is really exporting is not Happy Meals, fries and fried chicken. It is illness, obesity and premature death. A 2019 study conducted by researchers Nita G. Forouhi and Nigel Unwin and published in The Lancet suggests that the Western diet was the underlying cause of one in five deaths around the world. That is roughly 11 million deaths per year.

Of course, no one's cause of death is recorded officially as 'obesity'. Heart attack, heart failure, stroke, diabetes and cancer are some of the life-threatening health conditions in which diet plays a major role. According to the National Institute of Health, excess body weight is the second leading cause of preventable death in the United States. Many experts count it as the first.

Here are some of the common chronic conditions that can be triggered by diet, and the role food plays in getting sick:

A Royal Foods brand turkey tails. This by-product of the U.S poultry industry is exported in large quantities to Samoa, where it is in part responsible for a dramatic rise in obesity.

B In this image, the white globs on each plate represent the saturated fat found in common meals. The white liquid in the glasses represents the empty calories in soda and alcohol.

Heart disease is the top killer all around the world, and eating patterns dramatically shape cardiovascular health. Eating too much saturated fat, found in abundance in meat and dairy products, drives up L.D.L cholesterol (known as 'bad' cholesterol), which is associated with heart disease. Many of the best-loved foods on the planet are full of the stuff.

A. Onion rings, burgers, hot dogs, fried chicken, French fries and pizza are all unhealthy staples of the modern Western diet, now exported around the world. B. Few people who eat a modern Western diet get enough of the colourful vegetables associated with maintaining a healthy body weight.

For example, just 50 grams (2 ounces) of cheese contains around 12 grams (% oz) of saturated fat, the upper limit of what you should eat in an entire day according to the American Heart Association. In the Western diet that cheese often comes on top of a beef burger. Even a modest 230-gram (8-oz) burger will provide another 16 grams (% oz) of saturated fat. And this is just part of one meal. Add in buttered toast and milk at breakfast, a yoghurt snack, another serving of meat for dinner and perhaps some ice cream for dessert and you have eaten more saturated fat in one day than you probably should have in a week.

And then there is the salt. A salt-rich diet can lead to or exacerbate hypertension. Hypertension, also called high blood pressure, is known as the 'silent killer' because it does not have recognizable signs or symptoms – you need to have your blood pressure checked to know what's going on. Even after it is known, only about half the people who are aware of their high blood pressure have it under control. Hypertension can lead to stroke.

Type 2 diabetes is another major killer with an underlying cause at least partially due to eating habits. One of the most significant risk factors for developing type 2 diabetes is being overweight. Excess adipose tissue (body fat) contributes to something called insulin resistance.

When that happens, the hormone insulin is less able to do its job of moving sugar out of the blood, resulting in high blood sugar. In response, the pancreas churns out more and more insulin to do the job, wearing itself out over time.

The typical Western diet is rich in foods that spike blood sugar, such as sweets, hamburgers and soda. Full of added sugars and low in fibre, they are digested quickly by the body, destabilizing blood sugar and leading to hunger soon after eating. The same foods that can help prevent diabetes – high fibre, low-sugar vegetables, whole grains and beans – can also help manage and even reverse diabetes. It is no coincidence that these same foods are associated with lower body weight as well.

Cancer is another deadly illness where food can be an underlying cause. There is a lot still to learn about the relationship between obesity and various forms of cancer. But experts agree that obesity is a major risk factor for at least eight kinds of cancer, including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney and colon. Extremely obese women are seven times more likely to get endometrial cancer compared to women with body mass indexes in the healthy range, according to the National Cancer Institute. Those who are overweight or obese are twice as likely to develop liver cancer.

A This advertisement by Cancer Research U.K sought to help the public understand that obesity, like cigarettes, causes cancer.

B This public health announcement in Slough, U.K, reminds people that obesity increases the risk of becoming seriously ill with COVID-19, and encourages weight loss as a way of protecting yourself from the virus.

Eating patterns that contribute to obesity, such as the Western diet, also tend to be very low in the foods that are known to provide some protection from cancer. Cancer Research U.K recommends a diet rich in vegetables, whole grains and beans for reducing cancer risk. Just as important as what you do eat, is what you do not eat. Cancer Research U.K recommends limiting processed meat, sugary beverages and alcohol.

In 2020, a global analysis conducted by the University of North Carolina suggested that being obese doubled the risk of needing hospital treatment from COVID-19, and increased the risk of dying from the disease by nearly 50 per cent. They suggested this could be due to the fact obese patients were more likely to suffer from other conditions, such as high blood pressure and diabetes. They also warned a vaccine could be less effective for overweight people, as current flu vaccines do not work as well for those with a B.M.I over 30. This has led to governments around the world renewing their efforts to combat rising levels of obesity.

An individual's diet, so connected to getting or avoiding these fatal diseases, is only partially the result of personal choice. Increasingly communities across the globe are living in obesogenic environments, which make choosing health-promoting foods difficult while making obesity-causing foods omnipresent, cheap and attractive.

An obesogenic environment is one that encourages poor food choices for the people who live in it. It is a built environment that makes it easy and cheap to swing through a drive-through to pick up a coffee drink and breakfast sandwich (a morning meal that clocks in at around 1,000 calories) at a fast food chain instead of having a more nutritious and less calorific coffee and oatmeal at home. It is the vending machines stocked with crisps and chocolate bars instead of apples, and the school lunches that are laden with refined flour and saturated fat.

A family of Irequi immigrants living in Arizona stop for fast food at In-N-Out Burger.

An obesogenic environment is one in which social and cultural norms encourage poor eating habits that increase the risk of obesity

A food desert is a neighbourhood without easy access to supermarkets or other sources of fresh, whole foods.

The term was first officially used in 1995 by researchers in the

Low Income Project

Team of the U.K's

Nutrition Task Force The obesogenic environment is a problem for everyone living in urban areas of developed countries, but it hits socioeconomically disadvantaged communities and those living in food deserts especially hard. Food deserts are communities situated more than one mile from a grocery store.

People who live in these disadvantaged areas face challenges to healthy eating that more prosperous people do not have. For example, they are less likely to have cars to take them to a supermarket in another neighbourhood or town. Often, they are working multiple jobs with unpredictable schedules. Lack of time and energy is a formidable obstacle to shopping and cooking healthy foods.

Image summary: A horizontal bar chart showing the top ten sources of calories per person per day for low-income individuals aged two or older. Sodas, energy drinks, and sports drinks provide the most calories, followed by chicken dishes and grain-based desserts. The largest contributors are categorized as grain-based, meat-based, or mixed. The overall takeaway is that sugary drinks and processed grain and meat dishes are the primary calorie sources for this demographic.

Residents of food deserts often rely on the markets they do have: convenience stores. Access to these types of establishments increases the risk of obesity, as does the lack of a local supermarket. Convenience stores offer less fresh food, such as vegetables, and more processed foods, like shelf-stable crisps, crackers and snack cakes. Unfortunately, convenience stores are frequently located near schools, and kids who live in food deserts can develop the kind of eating patterns that lead to obesity at an early age.

Other aspects of the obesogenic environment cut across socio-economic lines. There is an assumption that poor people eat more fast food than those who are wealthy, but that is simply not true. A 2018 report from the Centers for Disease Control and Prevention (C.D.C) showed that, typically, the more money someone makes, the more fast food they eat. In varying degrees, the obesogenic environment affects everyone.

A Fast food giant K.F.C's notoriously unhealthy 'Double Down Dog' is a hotdog wrapped in fried chicken, instead of bread, and covered with cheese sauce.

B A staggering array of processed snacks for sale at a rest stop in Florida, U.S.A. These cheap and unhealthy products are made easy and convenient to purchase by retailers.

A wall of sugar-laden soft drinks for sale at a convenience shop in London, U.K. The high level of sugar in these drinks not only encourages weight gain but is also bad for your teeth, as sugar feeds bacteria in your mouth, producing acid that leads to tooth decay.

Figure B summary: A photo of store shelves stocked with various brands and flavors of bagged snacks, organized in rows and columns. It is a documentary image of retail merchandise, with no data or analytical result to report.

Figure C summary: A photograph of several supermarket shelves stocked with a wide variety of bottled and canned beverages. It is a reference image showing product placement, with no data or analytical result to report.

But it is not just what we are eating that is killing us. It is also how we eat it. Food is part of a complex matrix of meals and behaviour. Feeling lonely, stressed, guilty or hurried can all influence how our food impacts our health. Diet intersects in meaningful ways with family, culture, community and mental health.

About half of all the meals and snacks adults eat in America are eaten alone, according to a report from the Food Marketing Institute. That is not so surprising when you consider that more people are living alone as well. In the E.U one third of households have just one occupant, and in the United States more than a quarter do.

Image summary: A photograph of a row of numbered individual study or work booths, each containing a person focused on a device or reading material. The booths are separated by high partitions and equipped with individual lamps, illustrating a structured environment designed for solitary, concentrated activity.

Eating alone can contribute to overeating and weight gain in a few ways. Without company, you are more likely to try to multitask. Paying attention to your email inbox or the day's headlines will divert your attention from the experience of eating. These kinds of distractions make it all too easy to miss the subtle signals your body sends that you are full and it is time to stop eating. Solo diners may also eat too fast, without the breaks that are built in when you share a meal and conversation with someone else – you cannot chew and talk at the same time. The link between eating alone and weight gain was illustrated by a South Korean study published in Obesity Research & Clinical Practice in 2017, which found that for men eating alone was associated with a 45 per cent increased risk of being obese.

Those who eat alone are also far less likely to go through the hassle of cooking for themselves, so they will call for delivery, receiving the typical super-sized restaurant portion, or eat some other kind of processed convenience food. Pretty much all food prepared away from home is higher in calories and lower in nutrition than meals you make for yourself, as restaurant meals tend to have larger portion sizes, more saturated fat and salt and fewer vegetables. Indeed, the National Health and Nutrition Examination Survey found that less than 0.1 per cent of restaurant meals in the U.S were of an 'ideal quality', as defined by the American Heart Association.

The pace of modern life makes eating on the go – whether you are rushing from meeting to meeting or foraging for food in an airport terminal – inevitable for many. It is hard to find healthy options out there in the obesogenic environment, so eating on the go often adds up to eating junk food.

It has not always been this way. Before highly processed products came to dominate our food supply, when life had a slower pace, meals cooked from scratch and shared as a family were a daily ritual for many people around the world. These customs still exist.

The French are more likely than Americans to share communal meals according to a 2014 University of Pennsylvania study, for example. Today's parents are under a great deal of pressure to provide family meals, which are associated with a decrease in childhood obesity, for their kids. But by and large the culture around food and eating has changed for the worse.

Nowhere are these changes more obvious than at work. More than 62 per cent of the American workforce eats lunch at their desks. In Ireland, more than 50 per cent do, while 39 per cent of Canadians eat their midday meal at their workstation. Often, this is not a wholesome bagged lunch prepared at home. It is fast food, convenience store food or frozen food.

In addition to the overeating that comes from distraction, eating at your workstation only exacerbates another dire health risk – sitting all day – and it also keeps you from experiencing the benefits of connecting with others over a shared meal.

Work, travel and isolation all put the body under stress, and stress and meals would ideally not mix. For one thing, you are much more likely to experience acid reflux when you eat while experiencing stress, especially if you are eating the type of unhealthy foods that cause heartburn. Even worse, the very chemicals your body churns out while stressed (namely cortisol and insulin) are the same ones that signal to your body to store calories as fat. It can also contribute to other sorts of digestive upsets, including constipation or diarrhoea.

Image summary: A photograph showing a person's hands eating a sandwich over a keyboard and a newspaper on a desk, with a computer mouse nearby. The image depicts a casual, multitasking office setting where food is being consumed directly over computer equipment.

Acid reflux is a common condition in which stomach acid backs up into the oesophagus, the tube that connects the throat to the stomach.

Heartburn is the more colloquial term for acid reflux.

Cortisol is a multi- functional hormone.

It is commonly known as the stress hormone because it rises in tense situations.

High levels of cortisol contribute to weight gain.

A Whether in an office in London, U.K, or in a call centre in Cape Town, South Africa, eating lunch alone at your desk is increasingly common. Eating while stressed or distracted is bad for your health.

The COVID-19 global pandemic of 2020 has left people feeling more confined than ever. With people working from home, mealtimes become blurred and all-day snacking can replace a more traditional breakfast, lunch and dinner. A survey of European eating habits during March and April 2020 conducted by Statista revealed that 27 per cent of respondents from the U.K reported that their eating habits had declined during the pandemic.

Food culture, like all aspects of culture, is created and upheld at a societal level. Farming systems, food production, global eating patterns and the environments we live and eat in cannot be refashioned overnight. Changing it will take a rethinking of shared values across families, communities, companies and countries.

CHILDHOOD OBESITY IN GIRLS (2016)

CHILDHOOD OBESITY IN BOYS (2016)

These colours-coded maps show the prevalence of childhood obesity in both boys and girls around the world. The percentage of children that are obese is indicated using the colour scale. This Colombian eight-year-old weighs 90 kg (198 lb) – more than three times her ideal weight. Here, her mother helps at a medical checkup.

THE EVOLUTION OF AN EPIDEMIC 27

Big agriculture (or Big Ag) Is a negative phrase used to describe modern industrial farming and the problems associated with it.

Standard American Diet (SAD) or Western diet refers to a pattern of eating that is high in meat, saturated fat, refined flour and sugar, while low in vegetables and fibre.

THE EVOLUTION OF AN EPIDEMIC 31

typically solid at room temperature and derived from animal products. They are associated with increased disease risk.

LDL cholesterol is low-density lipoprotein cholesterol. Good cholesterol is high- density lipoprotein (HDL).

THE EVOLUTION OF AN EPIDEMIC 33

Insulin is a hormone that reduces blood sugar by helping it into the cells of the body, where it can be used for energy.

B A graph demonstrating the top ten sources of calories for low-income individuals. Socioeconomically disadvantaged people may live in a food desert, making it harder to access healthy and nutritious food.

A Customers await a meal they will eat solo in partitioned booths at a chain restaurant in Tokyo, Japan, serving ramen noodles. Solo dining is a growing trend. In South Korea there is even a new word for it: honbap, a portmanteau of honja (alone), and bap (food).