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The present paper aims at describing the current status of nutrition policy
in the WHO European Region and to discuss the implications for public
health. The stages of policy development in the Region are illustrated and
achievements in specific aspects of food and nutrition policy are
The analysis is based on a WHO survey on nutrition policies in the WHO
European Region in 2005 with information from forty-eight out of fifty-three
countries in the Region. Based on the findings, countries were categorized
according to their stage in policy development. Additionally, fifty policy
documents related to nutrition and published by a national body were
analysed according to certain criteria of food and nutrition policy.
Most Member States (n 46) have available a
policy document related to nutrition and forty have a mechanism to implement
it. Collaboration between sectors is taking place in thirty-one countries.
Implementation tools, such as food-based dietary guidelines and monitoring
and surveillance systems, are in place in twenty-seven countries. The
analysis of policy documents revealed that actions addressing the individual
with information or education are well developed. Actions addressing
environmental determinants, such as food availability, affordability and
accessibility, are indicated in only a few policies.
Food and nutrition policies appear to have developed successfully in the past
decade. However, implementation of the policies seems to be a major
challenge due to lack of funds, political commitment and coordination. More
support should be given to the implementation and evaluation of policies and
a shift towards stronger environmental approaches is needed.
The focus in understanding the causes of and preventing obesity has broadened from the individual level to include the obesogenic environment. Proving a causal relationship between environmental factors and eating patterns poses a great challenge because randomised controlled trials are seldom possible or feasible to conduct. Interactions between the environment and individuals are beginning to be explored in multilevel studies and qualitative and sociological research.
The aim is to give an overview of the wider environmental determinants of diet such as the national food supply, food availability and accessibility in different settings as well as the economic food environment and in relation to socio-economic status.
The indicators suggested are based on the amount of data available in the scientific literature and the potential for intervention. They can be used to monitor societal interventions or evaluate ‘natural’ changes in the food environment. The indicators are of relevance to the Second WHO European Action Plan for Food and Nutrition Policy 2007–2012.
The relatively weak empirical evidence does not imply the absence of causal relationships between environmental factors and diet. Potentially relevant factors have not been evaluated due to the complexity of the task and to lack of political will to change the food environment in a more healthy direction by use of legislation or economic instruments. Future intervention research, targeting the wider environmental determinants of diet, will give us better evidence to propose societal actions to counteract obesity and to strike the right balance between individual and societal action.
To review how countries of the WHO European Region address issues related to the catering sector in their nutrition policy plans.
Documentary analysis of national nutrition policy documents from the policy database of the WHO Regional Office for Europe by a multidisciplinary research team. Recurring themes were identified and related information extracted in an analysis matrix. Case studies were performed for realistic evaluation.
Fifty-three member states of the WHO European Region in September 2007.
The catering sector is a formally acknowledged stakeholder in national nutrition policies in about two-thirds of countries of the European region. Strategies developed for the catering sector are directed mainly towards labelling of foods and prepared meals, training of health and catering staff, and advertising. Half of the countries reviewed propose dialogue structures with the catering sector for the implementation of the policy. However, important policy fields remain poorly developed, such as strategies for stimulating and monitoring actual implementation of policies. Others are simply lacking, such as strategies to ensure affordability of healthy out-of-home eating or to enhance accountability of stakeholders. It is also striking that strategies for the private sector are rarely developed.
Important policy issues are still embryonic. As evidence is accumulating on the impact of out-of-home eating on the increase of overweight, member states are advised to urgently develop operational frameworks and instruments for participatory planning and evaluation of stakeholders in public health nutrition policy.
Reformulation of foods is considered one of the key options to achieve population nutrient goals. The compositions of many foods are modified to assist the consumer bring his or her daily diet more in line with dietary recommendations.
Initiatives on food reformulation
Over the past few years the number of reformulated foods introduced on the European market has increased enormously and it is expected that this trend will continue for the coming years.
Limits to food reformulation
Limitations to food reformulation in terms of choice of foods appropriate for reformulation and level of feasible reformulation relate mainly to consumer acceptance, safety aspects, technological challenges and food legislation.
Impact on key nutrient intake and health
The potential impact of reformulated foods on key nutrient intake and health is obvious. Evaluation of the actual impact requires not only regular food consumption surveys, but also regular updates of the food composition table including the compositions of newly launched reformulated foods.
To consider the use of systematic methods for categorising foods according to their nutritional quality (‘nutrient profiling’) as a strategy for promoting public health through better dietary choices.
We describe and discuss several well-developed approaches for categorising foods using nutrient profiling, primarily in the area of food labelling and also with respect to advertising controls. The best approach should be able to summarise and synthesise key nutritional dimensions (such as sugar, fat and salt content, energy density and portion size) in a manner that is easily applied across a variety of products, is understandable to users and can be strictly defined for regulatory purposes.
Schemes that provide relative comparisons within food categories may have limited use, especially for foods that are not easily categorised. Most nutrient-profiling schemes do not clearly identify less-healthy foods, but are used to attract consumers towards products with supposedly better profiles. The scheme used in the UK to underpin the colour-coded ‘traffic light’ signalling on food labels, and the one used by the UK broadcasting regulator Ofcom to limit advertising to children, together represent the most developed use of nutrient profiling in government policy-making, and may have wider utility.
Nutrient profiling as a method for categorising foods according to nutritional quality is both feasible and practical and can support a number of public health-related initiatives. The development of nutrient profiling is a desirable step in support of strategies to tackle obesity and other non-communicable diseases. A uniform approach to nutrient profiling will help consumers, manufacturers and retailers in Europe.
To describe four different methods of identifying indicator foods that are high, medium or low in fat with reference to dietary patterns and to use these indicator foods to test three sets of definitions of ‘high’, ‘medium’ and ‘low’ in fat from ‘banding schemes’ developed by the Coronary Prevention Group (CPG), the Food Standards Agency (FSA) and Sainsbury’s.
Indicator foods were developed using food intake data from the UK National Diet and Nutrition Survey and two parameters: (i) probability of the food being consumed by an individual with a high-fat diet (Method 1); and (ii) the contribution of the food to the fat intake of the average diet of consumers (Methods 3 and 4). Method 2 used both parameters. The three banding schemes were tested by assessing their levels of agreement with methods in categorising indicators.
Sensitivity in identifying high, medium and low fat indicators was highest with the CPG banding scheme (high and medium fat indicators) and Sainsbury’s scheme (low fat indicators) (Methods 2, 3 and 4). The levels of agreement (kappa coefficient) were 0·68 for the CPG scheme; 0·51 for the Sainsbury’s scheme; and 0·41 for the FSA scheme (Method 3).
It is possible to use indicator foods related to dietary patterns of a specific population to generate more rational definitions of ‘high’, ‘medium’ and ‘low’ in fat. This could be the starting point for the development of indicator foods for testing more complex nutrient profile models (i.e. those that consider more than one nutrient).
The objective of the present study was to determine the dietary patterns of a Mediterranean cohort and relate them to the observed patterns of beverage consumption.
Prospective cohort study. Dietary habits were assessed with a semi-quantitative FFQ validated in Spain. A principal components factor analysis was used to identify dietary patterns and to classify subjects according to their adherence to these patterns. The association between adherence to each dietary pattern and beverage consumption was assessed cross-sectionally. In a longitudinal analysis (2-year follow-up), the relationship between adherence to the baseline dietary patterns and the likelihood of changing alcohol consumption was ascertained.
The SUN (Seguimiento Universidad de Navarra) study is conducted in Spain.
In total, 15 073 university graduates were included in the analyses.
Two major dietary patterns were identified. We labelled them as ‘Western dietary pattern’ (WDP) and ‘Mediterranean dietary pattern’ (MDP). Higher adherence to the WDP was associated with higher consumption of carbonated beverages and whole-fat milk (P for trend <0·001), while higher adherence to the MDP was associated with higher consumption of decaffeinated coffee, orange juice, other natural juices, diet carbonated drinks, low-fat milk and bottled water (P for trend <0·001). Participants with higher adherence to the WDP were less likely to decrease their alcohol consumption during follow-up (OR between extreme quintiles = 0·68; 95 % CI 0·56, 0·84). By contrast, participants with higher adherence to the MDP were less likely to increase their alcohol consumption (OR = 0·66, 95 % CI 0·46, 0·95).
In this cohort of university graduates, a healthier dietary pattern was associated with a healthier pattern of beverage consumption.
To examine the association between overweight and health problems of the lower extremities, i.e. osteoarthritis (OA), pain and disability.
Cross-sectional data from the Dutch population-based Musculoskeletal Conditions & Consequences Cohort (DMC3), comprising a random sample from the Dutch population aged >25 years (n 3664), were analysed using multivariate logistic regression. Overweight was defined as BMI ≥ 25·0 kg/m2, moderate overweight as 25·0 kg/m2 ≤ BMI < 30·0 kg/m2 and obesity as BMI ≥ 30·0 kg/m2. Health problems of the lower extremities were: (i) self-reported OA of the hip or knee as told by a doctor; (ii) presence of self-reported chronic pain (>3 months) of the lower extremities; and (iii) disabilities in mobility as measured by the Euroqol questionnaire (EQ-5D).
Moderate overweight was associated with self-reported OA of the hip or knee (OR = 1·7; 95 % CI 1·4, 2·1), chronic pain of the lower extremities at one or more location(s) (OR = 1·6; 95 % CI 1·3, 1·9) and disability in mobility (OR = 1.7; 95 % CI 1·4, 2·0). For obesity these odds were higher: 2·8 (95 % CI 2·1, 3·7), 2·5 (95 % CI 1·9, 3·2) and 3·0 (95 % CI 2·3, 3·9), respectively. Also, among those with OA, moderate overweight and obesity were associated with disability in mobility.
There is a strong association between overweight/obesity and health problems of the lower extremities, i.e. OA, pain and disability. The increasing prevalence of overweight and obesity worldwide urges for public health action not only for diabetes and heart disease, but also OA.
To test whether reduced away-from-home food expenditure (AFHFE) and better nutrition knowledge and beliefs (NKB) are associated with dietary quality among US adults.
Design and subjects
The dietary intake data (average of two 24 h recalls) used were collected from US adults (20–65 years) participating in two cross-sectional surveys, the 1994–96 Continuing Survey of Food Intake by Individuals (CSFII; n 7148) and the CSFII/Diet and Health Knowledge Survey (DHKS; n 4252).
Dietary quality was assessed using selected nutrients and food groups and the 2005 revised US Department of Agriculture Healthy Eating Index (HEI).
(i) Absolute AFHFE (weekly, per capita) and proportion of this exposure out of total food expenditure (relative expenditure); (ii) NKB score using a composite of an eleven-item scale elicited among the CSFII/DHKS subgroup.
Statistical analyses performed
We used t tests, χ2 tests, Wilcoxon rank-sum tests and multivariate linear regression models adjusting standard errors for sample design complexity. We utilized a change-in-estimate approach to assess mediation. For effect modification, we tested the significance of interaction terms (NKB × AFHFE).
Absolute AFHFE was positively associated with grams of fat (β = 0·14 (se 0·06)) and saturated fat (β = 0·02 (se 0·01)) and negatively associated with fibre (β = −0·02 (se 0·01)) and HEI (β = −0·08 (se 0·01)). Relative AFHFE mediated NKB effects on intakes such as fat, saturated fat, cholesterol, Na, and fruits and vegetables (change in estimate >10 %). Among subjects with a poor NKB score, higher AFHFE resulted in lower diet quality, particularly Na and cholesterol intakes.
Higher AFHFE was associated with a lower dietary quality and interacted antagonistically with NKB in some instances, while mediating the relationship between NKB and dietary quality in others.
The present study examined whether ethanol exposure influences lactation parameters. Specifically, selected constituents in maternal blood and milk and the lactation performance of Chinese lactating mothers were evaluated after they had consumed chicken soup flavoured with sesame oil and rice wine (CSSR), a diet traditionally prescribed during the postpartum ‘doing-the-month’ ritual.
Twenty-three lactating mothers were examined. Informed consent was obtained from each subject. Each subject was tested on two occasions separated by a week. The target alcohol dosage was 0·3 g/kg body weight. Milk and blood samples were collected prior to consumption of soup and at 120 and 150 min, respectively, after consumption. Levels of various constituents were measured. The time for ejection of the first milk droplet and total milk volume yielded were also measured.
Consumption of CSSR influenced TAG, insulin and lactate levels in maternal blood. Likewise, consumption of the soup affected milk composition and its nutritional status, particularly total protein, TAG, fatty acid, β-hydroxybutyrate and lactate levels. CSSR intake significantly affected TAG and lactate levels in milk. The time for the first milk droplet to be ejected was significantly longer in the CSSR group, indicating that the milk-ejecting reflex is inhibited. However, blood prolactin level increased slightly after ethanol intake. Milk yields were reduced after ingestion of CSSR although the difference was not statistically significant.
Consumption of CSSR affects not only the composition of maternal blood and milk, but also lactation performance. These findings suggest that an alcoholic diet should be avoided during lactation.
To make the best use of limited resources for supporting health-related research to reduce child mortality, it is necessary to apply a suitable method to rank competing research options. The Child Health and Nutrition Research Initiative (CHNRI) developed a new methodology for setting health research priorities. To broaden experience with this priority-setting technique, we applied the method to rank possible research priorities concerning the control of Zn deficiency. Although Zn deficiency is not generally recognized as a direct cause of child mortality, recent research indicates that it predisposes children to an increased incidence and severity of several of the major direct causes of morbidity and mortality.
Leading experts in the field of Zn research in child health were identified and invited to participate in a technical working group (TWG) to establish research priorities. The individuals were chosen to represent a wide range of expertise in Zn nutrition. The seven TWG members submitted a total of ninety research options, which were then consolidated into a final list of thirty-one research options categorized by the type of resulting intervention.
The identified priorities were dominated by research investment options targeting Zn supplementation, and were followed by research on Zn fortification, general aspects of Zn nutrition, dietary modification and other new interventions.
In general, research options that aim to improve the efficiency of an already existing intervention strategy received higher priority scores. Challenges identified during the implementation of the methodology and suggestions to modify the priority-setting procedures are discussed.
To examine the relationship between obesity and the community and/or consumer food environment.
A comprehensive literature search of multiple databases was conducted and seven studies were identified for review. Studies were selected if they measured BMI and environmental variables related to food outlets. Environmental variables included the geographic arrangement of food stores or restaurants in communities and consumer conditions such as food price and availability within each outlet. The study designs, methods, limitations and results related to obesity and the food environment were reviewed, and implications for future research were synthesized.
The reviewed studies used cross-sectional designs to examine the community food environment defined as the number per capita, proximity or density of food outlets. Most studies indirectly identified food outlets through large databases. The studies varied substantially in sample populations, outcome variables, units of measurement and data analysis. Two studies did not find any significant association between obesity rates and community food environment variables. Five studies found significant results. Many of the studies were subject to limitations that may have mitigated the validity of the results.
Research examining obesity and the community or consumer food environment is at an early stage. The most pertinent gaps include primary data at the individual level, direct measures of the environment, studies examining the consumer environment and study designs involving a time sequence. Future research should directly measure multiple levels of the food environment and key confounders at the individual level.
Health targets describe government intentions for improving population health. The present paper determines whether the targets which twelve developed countries have set for obesity match the seriousness of the public health problem.
Policy documents on general public health, obesity, nutrition and physical activity were obtained by repeated searches of government websites. Details of all relevant targets on overweight, obesity, nutrition and physical activity were extracted.
Only four of the countries studied have set targets for specific reductions in the prevalence of obesity. Two have targets that only mention reducing the prevalence of obesity and two other countries wish to halt the rise in prevalence. Two countries currently have targets which are much less ambitious than those in previous policies. No obesity targets are stated in the policies of four countries. Many of the countries studied have set detailed nutrition targets, but these seldom identify desired changes in dietary behaviour. No country has set targets for a reduction in energy intake. The physical activity targets reflect recommendations from the 1990s. Few targets are set for health knowledge or behavioural intentions which are prerequisites for desired lifestyle changes.
Most of the countries studied have either set no targets or set very modest targets for reducing the prevalence of obesity. Many countries have physical activity targets that are likely to be insufficient to prevent obesity. Governments need to reconsider targets on obesity and to develop shorter-term targets which monitor desired lifestyle changes.
Inadequate energy and nutrient intakes are a major nutritional problem in developing countries. A recent study in Beninese school-aged children in different seasons revealed a high prevalence of stunting and poor iron status that might be related to the food pattern.
To analyse the food pattern and resulting energy and nutrient intakes of rural Beninese school-aged children in relation to season and school attendance.
Subjects and methods
The study was performed in northern Benin in eighty randomly selected children aged 6–8 years. Dietary intake was assessed using observed weighed records. Food, energy and nutrient intakes were measured in post- and pre-harvest seasons. Complete food consumption data sets were available for seventy-five children.
Food pattern showed seasonal variations. Cereals, roots and tubers were the main staple foods. Contributions of animal products to the diet were very small. The food pattern was not different for either boys v. girls or for children attending v. not attending school. Median daily energy intakes were 5·0 and 5·3 MJ in the post- and pre-harvest season, respectively. Only fat and vitamin C showed seasonal differences (P < 0·05). Energy and nutrient intakes were different for boys and girls but, unexpectedly, not for children attending v. not attending school.
Seasonal variations in food pattern did not result in seasonality in energy and nutrient intakes. Because the children’s diet was low in animal products, protein, fat and vitamin C and high in fibre, the absorption of fat, fat-soluble vitamins, carotenoids, Fe and Zn might be low. Fe and Zn bioavailability from such a diet needs further investigation.
To evaluate the gap between food-based dietary guidelines (FBDG) and the usual food consumption in Belgium.
Design and setting
Information on food intake was collected with two non-consecutive 24 h recalls, using the validated software package EPIC-SOFT in combination with a self-administered FFQ. Habitual food intake was estimated by the Nusser method. Physical activity was evaluated according to the International Physical Activity Questionnaire.
A representative sample of the Belgian population aged 15 years and older was randomly selected from the National Register using a multistage stratified procedure. Dietary information was obtained from 3245 individuals.
Food intakes deviated significantly from the recommendations. In particular, fruit (118 g/d) and vegetable (138 g/d) consumption and intake of dairy and Ca-enriched soya products (159 g/d) were inadequate. Consumption of energy-dense, nutrient-poor foods (soft drinks, alcohol and snacks) was excessive (481 g/d). There were important age and gender differences. Fruit, vegetable and spreadable fat consumption was lowest, while consumption of dairy, starchy and energy-dense, nutrient-poor foods was highest among the youngest age group. Men consumed more animal and starchy foods than women, who consumed more fruits. There were only slight differences by education level.
Food intakes differed substantially from the FBDG. Improvement of the Belgian food pattern, in particular among the youngest age group, is necessary for a better prevention of diet-related diseases. In addition, continuous or regular monitoring is crucial to permit trend analyses and to plan effective education or intervention strategies.