Mary A. T. Flynn

Session 1: Public health nutrition. Folic acid food fortification: the Irish experience.

Adequate intake of folic acid by women during very early pregnancy can markedly reduce risk of the development of neural-tube defects (NTD). The effectiveness of advice to women to take folic acid supplements is limited, mainly because 50% of pregnancies are unplanned. However, mandatory folic acid food fortification programmes in North America have been very successful in reducing NTD rates. In Ireland higher rates of pregnancies are affected by NTD and the option of termination is illegal. Consequently, the much higher burden of disease makes primary prevention of NTD an important public health issue in Ireland. During 2006 a decision was taken in Ireland to initiate mandatory folic acid fortification of most bread to prevent NTD. Priority work was immediately undertaken to establish reliable and comprehensive baseline information on factors that will be affected by fortification. This information included data on: the national prevalence of pregnancies affected by NTD; the current extent of voluntary folic acid fortification of food on the Irish market and how it affects folic acid intakes; blood folate status indicators assessed for various subgroups of the Irish population. In addition, scientific developments that have arisen since 2006 relating to the risks and benefits of folic acid intake are under ongoing review. The present paper summarises the rationale for mandatory folic acid food fortification in Ireland and recent scientific developments relating to risks and benefits of folic acid intake. In this context, preliminary findings of baseline monitoring investigations in Ireland are considered.

Revision of food-based dietary guidelines for Ireland, Phase 2: recommendations for healthy eating and affordability.

OBJECTIVE To revise the food-based dietary guidelines for Ireland and assess the affordability of healthy eating. DESIGN An iterative process was used to develop 4 d food intake patterns (n 22) until average intakes met a range of nutrient and energy goals (at moderate and sedentary activity levels) that represented the variable nutritional requirements of all in the population aged 5 years and older. Dietary guidelines were formulated describing the amounts and types of foods that made up these intake patterns. Foods required for healthy eating by typical households in Ireland were priced and affordability assessed as a proportion of relevant weekly social welfare allowances. SETTING Government agency/community. SUBJECTS General population aged 5+ years. RESULTS Food patterns developed achieved energy and nutrient goals with the exception of dietary fibre (inadequate for adults with energy requirements <9·2 MJ) and vitamin D (inadequate for everyone). A new food group to guide on fats/oils intake was developed. Servings within the Bread, Cereal and Potato group were sub-categorized on the basis of energy content. Recommendations on numbers of servings from each food group were developed to guide on energy and nutrient requirements. Healthy eating is least affordable for families with children who are dependent on social welfare. CONCLUSION Daily supplementation with vitamin D is recommended. Wholemeal breads and cereals are recommended as the best source of energy and fibre. Low-fat dairy products and reduced-fat unsaturated spreads are prioritized to achieve saturated fat and energy goals. Interventions are required to ensure that healthy eating is affordable.

Empowering people to be healthier: public health nutrition through the Ottawa Charter

The WHOs Ottawa Charter highlights five priority areas for taking action in public health. Only one of them is at the individual level as action at more upstream intervention levels, such as community or policy levels, is critical for enabling individuals to succeed. The objective of the present paper is to give insight into the many complex processes involved in public health nutrition by describing the Ottawa Charters five priority areas for taking action using public health nutrition initiatives I have been involved in. Evidence-based guidelines for healthy eating and infant feeding provide an essential basis for individuals to ‘develop personal skills’ (Action Area 1). ‘Re-orienting health services’ (Action Area 2) can address the needs of vulnerable population subgroups, such as the culturally sensitive diabetes prevention programme established for an Indo-Asian community in Canada. Identifying geographic areas at high risk of childhood obesity enables better strategic planning and targeting of resources to ‘strengthen community action’ (Action Area 3). Calorie menu labelling can ‘create supportive environments’ (Action Area 4) through encouraging a demand for less energy-dense, healthier food options. ‘Building healthy public policy’ (Action Area 5) to implement mandatory folic acid food fortification for prevention of birth defects has many advantages over a voluntary approach. In conclusion, evaluation and evidence-based decision-making needs to take account of different strategies used to take action in each of these priority areas. For this, the randomised control trial needs adaptation to determine the best practice in public health nutrition where interventions play out in real life with all its confounding factors.

The breads, cereals and potato food group: perceptions of average portions in Ireland

Current healthy eating guidelines recommend at least six servings from the breads, cereals and potato group of the food pyramid, depending on energy requirements (age, gender and activity levels). However, there is evidence that the rise in obesity is occurring in parallel with consumption of larger portion sizes. Differences in size between portions that are normally consumed and those that are recommended may confuse individuals who are attempting to follow healthy eating guidelines. The aim of the present study was to determine ‘what makes the most sense’ to consumers in terms of ‘average portion size’ for foods within the breads, cereals and potato group. A standardised questionnaire designed to assess preferences and understanding of portion size was administered to 1011 respondents surveyed at two large Dublin supermarkets. Two food displays were created as a visual aid to help respondents provide answers to the questionnaire: one contained smaller portion sizes, based on Irish and UK portion sizes data; the other contained larger portions of the same foods modelled on Australian portion sizes. The energy content ranged between 293 and 523 kJ (70 and 125 kcal) for the smaller display and between 460 and 912 kJ (110 and 218 kcal) for the larger display. The two supermarkets represented both an advantaged and a disadvantaged socio-economic area. A wide range of adult age groups were surveyed and 72% were female. SPSS (version 14.0; SPSS Inc., Chicago, IL, USA) was used to analyse the data (c).

New recommendations for food-based dietary guidelines for healthy eating in Ireland

• Twenty-two sets of 4-day food intake patterns were developed iteratively with the input of dietitians specialising in pediatrics, geriatrics and public health. • Portion sizes and categorisation of foods in certain food groups were addressed in consultation with dieticians/ nutritionists. • The patterns met age and gender specifi c requirements at sedentary and moderate activity levels for energy1, macronutrients2, fi bre3,4, iron5, calcium6 and vitamin D6. • The food intake patterns were used to develop healthy eating guidance on the number of servings required from each food group for males and females aged ≥ 5 years. 3. Results

Evaluation of current food-based dietary guidelines for healthy eating in Ireland

• Appropriate goals for energy and nutrient intakes for the Irish population were selected based on internationally developed standards for nutrient requirements.3-8 (see Table) • Using the food pyramid, 4-day food intakes were developed for 11 normal weight theoretical subjects, representative of different age and gender groups from age 5-51+ years. (see Table) • The food intake patterns were analysed using NetWisp9 and compared to the established energy and nutrient goals to assess the nutrition quality. • The appropriateness of advice on food choice as directed by the food pyramid was also evaluated.