 Professor Marcazzini, Julia is a good friend of us, I mean a long-standing collaborator and Julia from the University of Bologna is going to think about adults nutritional problems. Julia, 20 minutes. Well thanks Claudio and thanks to you all for inviting me to this very challenging meeting and I am also part of the group set in Bologna who is specifically devoted to energy which is called energy for Italy. So I take care of the problem of the sustainable development of foods in this area which is a sort of transition also like the one which is from electric powered and combustion powered engines and so on. My main concern is that malnutrition affects all regions worldwide, we have a lot of differences in the world, we have billions of people who are overweight or obese, 600 million individuals who are obese around the world and we have about the same number of people who is underweight and this is the reason why we have so much differences around the world in terms of nutritional problems which comes, which go from obesity to stunting and children who cannot grow up correctly. If we look at the daily supply of calories around the world, this is a map of what is the daily supply, you see that there are very large differences in the amount of calories which are distributed around the world as well as we have differences in disparities in food consumption that means that we have areas where the distribution of food is more or less regular distributed with an narrow coefficient of variations but we have areas where we have persons who are very obese and probably they eat much more than needed and there are persons who eat much less than needed so are stunting or malnourished. I'm sorry for a few slides which do not show perfectly and you see that I try to turn them into PDF but it didn't work and this is the other side of the coin in the insufficient number of persons who make sufficient hours of physical activity and this is the other coin of the medal in terms of obesity. You see there are very, very large differences across the world and this is the overall number of people who are obese around the world. We have scattered area where obesity is very, very high and the colors are self-explanatory, I'm sorry for not showing correctly but anyway you see that areas of more the most concerned areas are the Middle East countries and Egypt where we have a lot of obesity and this is an additional problem because most of these countries also have migrants to Europe and they come to Europe where they immediately develop other diseases such as diabetes. The century is not the 21st century but it has also been named as the extra-large century and this is what is happening because of the amount of obesity around the world. This is the estimated annual death due to obesity taken from the global burden of diseases and also in this case you see that there are countries where we have no data but we have many more data from other countries where the number of deaths attributed to obesity is extremely high and as well as we have the estimated annual deaths in terms of calorie supply which is also quite different around the world and all over the world we have different patterns of nutrition for example the estimated per capita fluid intake is totally different around the world and we have also a totally different average per capital dietary supply and we have a total different consumption of meat around the world which give rise to totally different patterns of malnutrition and around the world. There are a few points that I would like to stress for example what has changed during the last say 50 years or so and this is a picture taken also from the our world in data where the amount of daily and plant protein in different states is taken and if you look at the amount of dietary protein of China now it's around the same pattern which is in most developed countries but it was not like this in 1961 if I remember well where the number of protein in China was almost from vegetable proteins we had very very few proteins from animal meat and if we assume that all over the world every underdeveloped countries will move towards the western pattern the amount of proteins from both animal and vegetable sources will be absolutely unachievable by any food supply all over the world and this is consumption of animal fats which is also extremely different around the world and this is the final one the consumption of vegetable oils which differs in terms of the different areas or the consumption of sugar take there are countries where the consumption of sugar per capita is over 150 kilograms and this means that we definitely eat much more than we need for our everyday life and we have a few assumptions which are very well supported by scientific and literature evidence one is the Mediterranean diet is probably the best diet we could afford in order to reduce the burden of diseases across the world and the Mediterranean diet is a diet which contains an amount of fat which is probably much more than what is what is dictated by regulatory agency for example the American agency strive for having a much less content of fat but the Mediterranean diet probably is the one which is mostly usable and can give rise to a lower number of deaths and however it is also difficult to implement in western countries and the why I say that Mediterranean diet is the best because it probably as you can see here is the diet which provides the lower or the most achievable weight loss in people who are obese and the most sustainable weight loss contrary for example to a low carbohydrate or a low fat diet which have probably a higher impact in the short term but do not matter no longer sustainable in the long run and we have a lot of data on the Mediterranean diet as this is the very famous Spanish experience of the pre-med trial where they showed that the Mediterranean diet as supplemented by extra virgin olive oil or by nuts is extremely effective in reducing the deaths or the primary end point which was which was a composite of acute myocardial infarction stroke or death from cardiovascular causes in the population this is one of the very few studies which I know was interrupted by the ethical committee because of a striking advantage of the experimental diet versus the control diet and the monitoring system imposed to stop the trials in order to avoid unnecessary deaths in the control population however the number of people who attain a Mediterranean diet is probably very different and if we look at how things have been changing from 1990 to 2018 you see that in most countries the adherence to the Mediterranean diet has colors which are definitely not in favor of a higher adherence in the population and we have to transform our food system in order to prevent non-communicable diseases and this is a very very challenging procedure we have to take care of a lot of systems which are intimately connected with each other which is food environment which is consumer behavior which is diet which is the impact of the social economic and environmental impact of the diet and this is the reason why it is so difficult to advise people what is probably best and I am sure that you will focus on these problems in your attempt to validate all these challenging situations. One of the main problems is that the more we eat the more we will develop diabetes and diabetes is another of the conditions which will definitely impact on the survival of the population or the burden of diseases of the population this is a map of different countries and we have an estimated of four five hundred and thirty six million adults which are currently living with diabetes but this number is expected to increase dramatically to over six hundred millions by 2030 and over seven hundred and eighty millions in 2045 and the distribution of diabetes across the world is totally different for example we are expecting a very narrow increase of diabetes in a few areas for example central europe will increase by only 13 percent we have to expect a very high rate of increase of diabetes in other countries and one of the most challenging areas are africa and the middle east and north africa not to say india and other countries where these numbers will increase dramatically and this is one also these are areas where the possibility to cure diabetes is very far from the national health systems they have and this will expose the population to a tremendous impact in terms of the burden of diseases the other the other problem with obesity is the number of people who will develop a cardiovascular disease which is another of the conditions we have to take care of if we went to if we wish to reduce the burden of diseases and the positive energy balance give rise to obesity which causes cardiac steatosis excess of visual fat around the world around the body and the liver steatosis which is something we I take care of mostly but we should not forget the inner risk of obesity in terms of the developing of cancer mortality in both men and women we are very well aware this is a very old study dates back to over 20 years carried out in one million people of americans where they showed that the possibility to develop a cancer and we have multiple areas where these applies are all due to an increase in body weight and an increase in bmi so we had to we have to take care of the of the possibility that every obese or overweight person will ultimately develop cancer at rates which are much higher than in the normal population this is the amount of men this is the amount of women you see that most most bars are totally outside the linear of the line of indifference so it's definitely a problem what about the possibility to define a healthy diet all over the world this is very different the difficult we have a group of of people involved in nutrition who have declined an optimum diet that would save approximately one 11 million people every year but if we look at the how this diet could be implemented and what is the global average compared to what would be the best diet we have areas which are definitely much more over consumed with respect to what should be done and we have other areas other groups of other foods which are definitely under consumed and the daily income per person in terms of this healthy diet around the world would be about 41 percent of total budget which is it's definitely too much to be to be sustained and probably in North American moving from a healthy diet to moving to the normal diet to a healthy diet would be definitely possible but as you can see here there are areas around the world where this would be absolutely unbearable in terms of cost and so we need somebody who takes care also of the economic consideration when planning a normal diet or best diet this is something which does not add much to what you have already seen it is that if we move from a seven days beef meat diet to a two days beef and five days vegetarian or to a full vegetarian diet we may save the carbon footprint water footprint and also the ecological footprint of our diet and we have data for example this scenario which was studied by a group of English nutritionists in 2012 and was published in 2012 that is a reduction of livestock product supplies balanced by an increase in plant commodities or scenario two that is moving from beef and sheep meat to white meat or scenario three moving from white meat to plant commodities would save an enormous amount of cardiovascular deaths cancer deaths total deaths according to the scenario we choose so we know that we could definitely implement the health of our population simply moving from one diet to the other that data shows that possibly the best compromise for an optimum intake of carbohydrates here is around 50 percent but this is not we are currently using in our diets to reduce obesity for example and we have or in the normal population we have we have persons who prescribe or trying to move people towards very unbalanced diets without any any definitely improvement in what they can do in terms of obesity this is what for example a vlcd intervention and the very low diet may be implemented in people with diabetes which definitely improves the number of persons who weight loss but in the long term it will never be able to be maintained and the return they may improve diabetes in the short term they may even solve diabetes in the short term people get rid of diabetes but we must be aware that the this sort of diets are definitely not bearable in the longer term and dietary carbohydrate intake in court analysis for example the substitution of carbohydrate for animal protein and fat you see that improves life expectancy in the population and the substitution of carbohydrate for plant and protein fat may in some way be favorable but definitely plant protein intake and fat intake were associated with different mortality rates so we must be aware that we have to take care of how we modify our diet if you want definitely to improve the rates of our population the other types of dietary intervention are still more difficult for example the massive carbohydrate restriction is one of the way is one of the strategies which has been implemented to reduce obesity and a totally restriction of carbohydrate might be sustained in the short term as you can see here in the long term it's definitely unsustainable and the same is true if we look at other dietary regimens for example moving from low fat plus physical activity or a Mediterranean diet, low carb diet we have definitely the idea that is very difficult to sustain different diets in the long terms and the same is true if we look at the intermittent fasting which is something which is now very very common in the Italian population and alternate day fasting improves leads to a moderate weight loss but benefits on cardiometabolic health may be unsustainable in the long terms or time restricted eating which is the last way we are trying to modify the personal behaviors and all these attempts to modify the diet of the population seems to be quite unbearable in the long run. The problem is that if we look at what happens in the population and I took Mexico City we have been talking about yesterday of Mexico City in Mexico City the number more than 200,000 cars are added every day every year sorry and there are 3.6 million of cans of soft drinks which are drank every day and a lot of people were moving with the metro and the high density of the population and the high use of street food with a massive obesity in Mexico City Mexico City is enormous town which is approximately 140 kilometers long and if we look at the population and this is what I fear that they are very strict division which is a part which is a part of population which is living well and probably is eating well and the population which is not eating well is not living well and eat junk food and this is the problem we have to address the global syndemic of obesity and malnutrition together with climate change and it's a very very difficult task and can diets be healthy sustainable and equitable I don't know if it could ever be done in the future. Thank you for your attention. Thank you very much Julio. That's been an excellent lecture. We're going to have questions at the end of the second presentation. The second presentation will be given by Claudia Mufes from the University of Verona and please 20 minutes.