Aileen Robertson

The potential contribution of increased vegetable and fruit consumption to health gain in the European Union.

BACKGROUND The risk of many important diseases can be reduced by consuming a diet rich in vegetables and fruit. For this reason the World Health Organization (WHO) recommends a daily intake of more than 400 g person(-1). The pattern of both the supply and intake of vegetables and fruit and the potential health gain achieved by increasing intake in the European Union (EU) and three accession countries are presented in this paper. METHODS Patterns of supply and dietary intake were assessed using (1) FAO food balance sheets, which allow comparison between the levels of supply in countries but do not reflect actual intake; and (2) survey data reflecting dietary intake. Using WHO mortality data for coronary heart and cerebrovascular disease and major cancers up to age 65 years, the number of preventable deaths is estimated, assuming vegetable and fruit consumption were levelled up to that of the highest consuming group, and assuming relative risks of 0.5, 0.7 or 0.9. RESULTS Vegetable and fruit consumption varies considerably between EU Member States. The populations of about half (seven) of the EU Member States have a mean daily intake of less than 275 g. Using the best current estimates of relative risk, over 26,000 deaths before the age of 65 years would be prevented annually in the EU if intake was levelled up to the highest consumption levels (and about double this number of deaths before the age of 75 years). CONCLUSION Increasing the intake of vegetables and fruit is feasible and could result in considerable improvements in public health within the EU. Priority should be given to developing methods that demonstrate the burden of disease caused by too low intakes of vegetables and fruit. This would enable the appropriate social, cultural and economic policies to be developed within the EU.

Sustainable prevention of obesity through integrated strategies: The SPOTLIGHT project’s conceptual framework and design

BackgroundThe prevalence of overweight and obesity in Europe is high. It is a major cause of the overall rates of many of the main chronic (or non communicable) diseases in this region and is characterized by an unequal socio-economic distribution within the population. Obesity is largely determined by modifiable lifestyle behaviours such as low physical activity levels, sedentary behaviour and consumption of energy dense diets. It is increasingly being recognised that effective responses must go beyond interventions that only focus on a specific individual, social or environmental level and instead embrace system-based multi-level intervention approaches that address both the individual and environment. The EU-funded project “sustainable prevention of obesity through integrated strategies” (SPOTLIGHT) aims to increase and combine knowledge on the wide range of determinants of obesity in a systematic way, and to identify multi-level intervention approaches that are strong in terms of Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM).Methods/DesignSPOTLIGHT comprises a series of systematic reviews on: individual-level predictors of success in behaviour change obesity interventions; social and physical environmental determinants of obesity; and on the RE-AIM of multi-level interventions. An interactive web-atlas of currently running multi-level interventions will be developed, and enhancing and impeding factors for implementation will be described. At the neighbourhood level, these elements will inform the development of methods to assess obesogenicity of diverse environments, using remote imaging techniques linked to geographic information systems. The validity of these methods will be evaluated using data from surveys of health and lifestyles of adults residing in the neighbourhoods surveyed. At both the micro- and macro-levels (national and international) the different physical, economical, political and socio-cultural elements will be assessed.DiscussionSPOTLIGHT offers the potential to develop approaches that combine an understanding of the obesogenicity of environments in Europe, and thus how they can be improved, with an appreciation of the individual factors that explain why people respond differently to such environments. Its findings will inform governmental authorities and professionals, academics, NGOs and private sector stakeholders engaged in the development and implementation of policies to tackle the obesity epidemic in Europe.

Patterns of body weight in the Baltic Republics.

OBJECTIVE Previously recorded rates of obesity in the Baltic Republics have been among the highest in the world although little is known about how they vary within the population. This study investigates the distribution of body mass index (BMI) and obesity in these countries. DESIGN Three cross-sectional surveys conducted in the summer of 1997. SETTING Estonia, Latvia and Lithuania. SUBJECTS Representative national samples of adults with measured weight and height (Estonia: n=1154; Latvia: n=2292; Lithuania: n=2096). RESULTS Between-country differences are particularly large among women: women from Latvia and Lithuania are approximately three times as likely to be obese as those from Estonia (17.4%, 18.3%, 6.0% respectively); only about one-third of this difference is explained by the sociodemographic and behavioural factors studied. In men, the prevalence of obesity varied only slightly among countries (Estonia: 9.9%; Latvia: 9.5%; Lithuania: 11.4%). While the prevalence of obesity increases with age within each republic, particularly in women, it is not associated with nationality or urban/rural region, and no consistent association is observed with income. Obesity is inversely related to education in Latvia and in Lithuanian women. Latvian men and women and Lithuanian men who smoked had a lower prevalence of obesity than non-smokers. Leisure time physical activity was not associated with obesity. CONCLUSIONS Obesity is a major health problem in the Baltic Republics, particularly among Latvian and Lithuanian women. The lack of association between obesity and most demographic, socioeconomic and behavioural factors suggests that the problem is generalized. Health promotion strategies aiming at preventing and controlling excess weight gain in the Baltic Republics will need to target the general population.

Are taxes on fatty foods having their desired effects on health

We don’t know because governments are not instigating the most appropriate evaluations

Dietary beliefs in the Baltic republics

OBJECTIVES As beliefs and knowledge about the possible effects of foods on health can influence food behaviours, this study examined selected dietary beliefs in the Baltic countries and the association of beliefs related to salt intake and to types of fat with food behaviours. DESIGN A cross-sectional study. SETTING Data from three surveys conducted in Estonia, Latvia and Lithuania in the summer of 1997 were used to describe the prevalence of dietary beliefs in these countries and to investigate the association between beliefs and behaviours (using logistic regression). SUBJECTS Representative national samples of adults were selected in each country (Estonia, n = 2018; Latvia, n = 2308; Lithuania, n = 2153). RESULTS Misunderstood concepts (myths) related to dietary salt, types of fat, meat consumption and bread and potatoes were observed in high proportions of the population. Education level was an important correlate of beliefs related to salt intake and types of fat, people with a higher education level being more likely to be familiar with these issues. Correct beliefs were not consistently associated with healthier behaviours (e.g. less frequent use of salt at the table and use of non-animal fats for cooking), except for salt intake in Estonia. CONCLUSIONS Several misunderstood dietary concepts (myths) are still prevalent in the Baltic countries. Correct beliefs related to salt intake and types of fat were not consistent predictors of healthier food behaviours. In-depth qualitative investigations are needed to better describe and understand dietary beliefs and attitudes in the Baltic countries, and to identify barriers to the adoption of healthy food habits.

Making Public Health Nutrition relevant to evidence-based action

Public health nutrition enjoyed many breakthroughs in the 20th century ‐ from the discovery of vitamins and the metabolic roles of some 60 macro- and micronutrients, to the effects of maternal and childhood diet on health over the life course. Moreover, the food shortages in the UK that were experienced during World War II gave the first opportunity to show that nutritional science could make a valuable contribution to public policy. However, public health nutrition is now facing the challenge of deriving recommendations based on systematically evaluated evidence; that is, the new concept of evidence-based nutrition. This challenge was foreseen by John Garrow almost 10 years ago in his lucid editorial proposing the formation of meta-analysis ‘clubs’ 1 .

Use of Linear Programming to Develop Cost-Minimized Nutritionally Adequate Health Promoting Food Baskets.

Background Food-Based Dietary Guidelines (FBDGs) are developed to promote healthier eating patterns, but increasing food prices may make healthy eating less affordable. The aim of this study was to design a range of cost-minimized nutritionally adequate health-promoting food baskets (FBs) that help prevent both micronutrient inadequacy and diet-related non-communicable diseases at lowest cost. Methods Average prices for 312 foods were collected within the Greater Copenhagen area. The cost and nutrient content of five different cost-minimized FBs for a family of four were calculated per day using linear programming. The FBs were defined using five different constraints: cultural acceptability (CA), or dietary guidelines (DG), or nutrient recommendations (N), or cultural acceptability and nutrient recommendations (CAN), or dietary guidelines and nutrient recommendations (DGN). The variety and number of foods in each of the resulting five baskets was increased through limiting the relative share of individual foods. Results The one-day version of N contained only 12 foods at the minimum cost of DKK 27 (€ 3.6). The CA, DG, and DGN were about twice of this and the CAN cost ~DKK 81 (€ 10.8). The baskets with the greater variety of foods contained from 70 (CAN) to 134 (DGN) foods and cost between DKK 60 (€ 8.1, N) and DKK 125 (€ 16.8, DGN). Ensuring that the food baskets cover both dietary guidelines and nutrient recommendations doubled the cost while cultural acceptability (CAN) tripled it. Conclusion Use of linear programming facilitates the generation of low-cost food baskets that are nutritionally adequate, health promoting, and culturally acceptable.

WHO tackles food inequalities: Europe's first comprehensive Food and Nutrition Action Plan debate, 8–10 November 1999, Malta

Dietary habits are an important determinant of the major causes of morbidity and mortality (cardiovascular diseases, hypertension, stroke, non-insulin-dependent diabetes, obesity and some cancers) within the WHO European Region. Estimates suggest that 30–40% of some cancers are preventable by dietary means. In addition in 1995, 130 million Europeans suffered from food-borne illnesses. Recent scares related to bovine spongiform encephalitis (BSE) and dioxins have fuelled the concerns of consumers who no longer have confidence in government and industry to provide safe food. Access to a safe, healthy diet is one of the most important public health actions that a country can take to improve health and increase economic gain. Well coordinated action between the many players involved can reduce levels of disease, protect and promote health, and provide the added benefit of protecting the environment and stimulating socioeconomic growth and sustainable development. Growing the right kinds of foods for health can reduce fuel consumption, pollution, transport and packaging costs and promote biodiversity, especially if grown near where it is consumed. This can help create local jobs, improve food and nutrition security and promote a sustainable environment. The draft Food and Nutrition Action Plan discusses the need for a shift in traditional approaches to food inspection and end-product testing and calls for broader approaches to address changes in the food supply system (intensive agriculture and animal husbandry, mass production and distribution), in the new health and demographic situation (population growth, mainly urbanized and more vulnerable), and in the social situation, behaviour and lifestyles (increased travel, ethnic foods and increased food trade). The Plan calls for better and more accessible food and nutrition information systems, improved pricing and advertising policies. Marketing aimed at children, focusing on high-fat and energy-dense snack foods is raised as a concern. The Plan also calls for ministries of health to participate more in Codex committees and to be represented on delegations attending World Trade Organization committees. In addition National Food Control agencies have to consider how best to respond to consumers fears and demands for safer food. The Plan proposes that each WHO European Member State establish or strengthen intersectoral mechanisms to secure better coordination between different ministries dealing with food and nutrition – seeing to it that public health concerns are taken into account. At present, responsibility for the food system is divided among various ministries and sectors including trade, labour, tourism, education, finance, environment and health. Unless actions are coordinated there is a risk of duplication or – even more likely – the risk that certain public health concerns could be overlooked in efforts to promote economic activity. In addition, global food trade makes it more difficult to contain food-borne diseases within national borders, so effective international and regional health strategies are needed. To achieve effective action in the WHO European Region, it is proposed that a Food and Nutrition Committee for Europe be set up to support the development and implementation of action plans, and to advise on international aspects of food control and nutrition policy. The draft First Food and Nutrition Action Plan will be presented to the WHO Regional Committee for Europe in September 2000.

Nutritionally Optimized, Culturally Acceptable, Cost-Minimized Diets for Low Income Ghanaian Families Using Linear Programming

The Ghanaian population suffers from a double burden of malnutrition. Cost of food is considered a barrier to achieving a health-promoting diet. Food prices were collected in major cities and in rural areas in southern Ghana. Linear programming (LP) was used to calculate nutritionally optimized diets (food baskets (FBs)) for a low-income Ghanaian family of four that fulfilled energy and nutrient recommendations in both rural and urban settings. Calculations included implementing cultural acceptability for families living in extreme and moderate poverty (food budget under USD 1.9 and 3.1 per day respectively). Energy-appropriate FBs minimized for cost, following Food Balance Sheets (FBS), lacked key micronutrients such as iodine, vitamin B12 and iron for the mothers. Nutritionally adequate FBs were achieved in all settings when optimizing for a diet cheaper than USD 3.1. However, when delimiting cost to USD 1.9 in rural areas, wild foods had to be included in order to meet nutritional adequacy. Optimization suggested to reduce roots, tubers and fruits and to increase cereals, vegetables and oil-bearing crops compared with FBS. LP is a useful tool to design culturally acceptable diets at minimum cost for low-income Ghanaian families to help advise national authorities how to overcome the double burden of malnutrition.