It’s lunch time at the Estácio de Sá primary school in the middle of Rio. The menu today is liver, rice, beans and potatoes with fruit salad for pudding. There are 500 pupils at the school and they have to eat in shifts because it’s only a small dining room.

Brazil runs the largest free school meal programme in the world. In Rio alone, that’s 700,000 pupils a day or 21 million meals a month.

Inês Rugani used to run the institute responsible for the city’s school meal programme. She’s  a nutritionist who did her doctorate in public health and now works at the State University of Rio de Janeiro. And she says it’s not just what the kids eat but how they eat it.

“So in our menus, nothing is fried; everything is boiled or steamed and we don’t have any sweet or candy as desert. We don’t offer a juice as a complement and we offer each day around 900 grams of fruit and vegetable which is a huge amount compared to other cities and the amount of salt, fat and sugar is controlled in the menu we prepare.”

At least 30 per cent of the food for school meals must come from local farmers. The programme  is playing an important role in food and nutrition security, says Rugani.

“So when we decided to guarantee that at least 30 per cent of the amount put in the programme, that these products have to come from small farmers, this is a huge change. So we are now guaranteeing a market for them.”

David versus Goliath

Rugani and her colleagues see themselves engaged in a David versus Goliath struggle against multinational food companies which have the power to shape diets on a global scale.

Those companies are excited by Brazil where rising income levels among the C, D and E social classes have created new sources of growth.

The packaged food market here grew 44 per cent between 2005 and 2010, says market research firm, Euromonitor International. This year it’s projected to be worth over 200 billion reais. That’s 100 billion swiss francs.

But there is another side to the coin. At the World Health Organisation in Geneva, Tim Armstrong from the Department of Chronic Diseases, says the rate of obesity worldwide has doubled since 1980. And no end to that trend is in sight.

“Many of the major non-communicable diseases are related to what we eat. Cardiovascular diseases obviously saturated fats, trans-fatty acids in particular. Salt is particularly important for some cancers but most important for stroke. The amount of food and the type of food we eat impacts upon obesity levels. Obesity impacts on a range of non-communicable diseases, and of course diabetes is directly relevant to obesity and what we eat.”

Research firm, Decision Resources, says Brazil’s Type 2 diabetes drug market is growing 15 percent a year. It reckons it will be worth 834 million dollars by 2013. Type 2 makes up about 90 per cent of all diabetes cases.

Critical healthcare issue

“The epidemic of diabetes really is becoming the critical healthcare issue, I think, of the 21^st century.”

That’s Timothy Maloney, head of the primary care franchise at pharmaceutical giant Novartis in Basel.

“If you look at the number of people globally that have diabetes, it’s over 350 million. We estimate that about four million people a year die out of the complications of diabetes and actually probably about one in every ten healthcare dollars globally are spent on diabetes and its complications.”

Novartis’s Galvus is a drug which helps the body balance blood sugar. It posted global sales of 700 million dollars last year.

“If you look at the prevalence of diabetes between now and 2030 what you see is it’s really going to be an explosion around the world. There’s going to be a huge need for new treatment options and better treatment options for patients.”

For Carlos Monteiro at the School of Public Health of the University of São Paulo, prevention is better than cure.

“We can have 10, 20 per cent, let’s say, of our calories from ready-to-eat products. They are tasteful, they are convenient and they had this role in the past. When you see old surveys, you see that people ate bread which is a ready-to-eat product, they ate some biscuits, they could eat maybe some soft drinks but not in the scale that is occurring today. So we are not saying that ready-to-eat products are poison. They just cannot be the base of the diet.”

Self-regulation

The food industry not only generates billions in revenues. It provides hundreds of thousands of jobs. Nestlé, for example, has 21,000 direct employees in Brazil and generates 220,000 indirect jobs. Governments are often happy to let the industry self-regulate and the food industry often assist governments in drawing up policy on public health. Here’s Carlos Monteiro again:

“These associations are very powerful and they lobby in the Congress, they support politicians they finance research so their actions are very efficacious to avoid anything that could introduce a limit for selling of this product.”

Campaigners say if the political will was there, countries could introduce a raft of measures from supporting wholefoods to taxing processed ones. Tim Armstrong of the WHO gives his wish list.

“Ensuring that there are agricultural policies that support the delivery and accessibility and affordability of fresh produce, working with food industry to ensure that they reformulate their products so that they’re lower in salts, fats and sugars, working with the food industry to ensure that they not marketing their foods that are high in salt, fats and sugars, and particularly not marketing those foods to children and ensure that there is adequate labeling on the sorts of foods that are being marketed by the food companies.

Nestlé is positioning itself as the world’s leading nutrition, health and wellness company. So could its biggest contribution to public health be selling fewer products with sugar, salt and fat – a question I put to Nestlé CEO Paul Bulcke.

“The first thing to be said there is no bad food only bad diet. First of all for Nestlé we have to make sure that our products, they like them to eat . Secondly what is healthy? Health is linked with balance. If you take only water, you are not going to survive for a long time. So it is balance. And you can only have balance if you have understanding. Understanding as a company so that we invest a lot in R&D and understanding for the consumer so he can make his decision.”

Letting the consumer decide was an argument the food industry employed when it opposed the ban on vending machines in schools in Rio.  Nutritionist Ines Rugani says children - and adults too - need protecting.

“This is in our tradition of training in nutrition, this mantra. You don’t have unhealthy food. What we have is diet so it’s unhealthy. But if you eat a package of cookies with so many calories and salt it is impossible to balance your day. It would be okay if you eat only one cookie. But nobody eats only one cookie.  

All about balance

It’s all about balance and self-control says the food industry. But one of Nestlé’s advertising campaigns in Brazil seems to undermine that, as Carlos Monteiro explains.

“Nestle has one brand in Brazil of chocolates and biscuits and ice creams. It is called Sem Parar, which means non-stop. And the advertisement says non-stop, the name says everything. Once you start to eat this chocolate, you can’t stop. This is a promotion of a compulsive eating.”

“It’s true that these products are convenient and tasteful. But they become for people still more convenient and more tasteful because of marketing. So marketing is very powerful. Particularly when you have a company like Nestlé which has a fortune to spend on marketing. So they can hire the best psychologists, they can hire the best people in marketing so they can create campaigns that are irresistible in a way. So if we could put some limits to this marketing this would be a big start.”

Nestlé CEO, Paul Bulcke offers his own solution.

“Saying Nestlé has chocolate in its assortment, so that’s bad, so beat them up. I feel this is a little bit of a cheap argument and not really bringing to real responsible solutions. Because the person who normally says that, the first thing he does, he eats a bar of chocolate. So then I would rather bring my knowledge in there so he can have a portion chocolate bite, maybe with air bubbles in there so he has the same enjoyment for half the calories. Well, that’s how we see our responsibilities then there.”

This battle is being fought all over the world. The actors may change but the questions remain the same. What food do we want on our plates?