keynote addresses nutrition and diet for healthy ... · 2000 is putting healthy nutrition high on...

Public Health Nutrition: 4(2A), 339-351 339

Keynote addresses

Nutrition and diet for healthy lifestyles in Europe: science and policyimplicationsMatti Rajala*

Directorate General for Health and Consumer Protection (Unit F/3), European Commission,Batiment Euroforum - L-2920 Luxembourg

KeywordsEuropean Commission,

Eurodiet, Policy

situation, instead of enabling healthy choices, wouldmake peoples' lives more complicated.

Nutrition and diet is not only a matter of informedchoices at the level of an individual. Increasinglypeople eat out e.g. in restaurants, and in the canteensof the workplaces and schools. There the choices havealready made regarding the nutritional contents of theavailable food. The same applies to certain extent alsoto the food we prepare at home.

We depend on what the agriculture and foodindustries through the retail system make available forus. Of course supply and demand depend on eachother but it would be too simple to think that thismechanism could not be influenced. I am absolutelysure that the producers and the industry are willing todevelop healthier alternatives for the consumers.Here it is possible to create win-win situations, wherethe interests of health promotion and the interests ofproducers and industry can meet in synergy.

Let me come back to the question of messages, whichI said should be understandable and clear. Thesemessages stem from the scientific knowledge, or atleast should stem from science. The problem with thisrequirement is the always-developing nature of thescientific knowledge. Science also has an in-builtquality of questioning everything that has been said.We must of course accept these facts but at the sametime we must be able to define what is our currentunderstanding. That is to say, what is our bestknowledge today on nutrition and health? This mustbe based on the bulk of the evidence and the scientificdiscussion on it; i.e. in the context of a systematicreview of the total accumulated scientific knowledgeof the respective field.

When we talk about food, we also have to keep inmind the safety aspect. I am not going to enter thetraditional food safety domain, but would like tobridge the food safety and healthy nutrition areas. In

© The Author 2001

First let me thank Professor Kafatos and his teamfor organizing this important conference andbringing us here to the lovely island of Crete.Second, I am pleased to inform you that theEuropean Commission is launching today a proposalfor a new health program of the community. One ofthe main planks of this proposal tackles healthdeterminants.

I trust that it is not necessary for me to convince thisaudience that nutrition is a major determinant forhealth. That is to say that some elements of ournutrition are beneficial for our health and someother elements may be detrimental. All this soundsstraightforward and simple. However, I have learnedduring the course of the EURODIET Project thatthe question is not at all either simple orstraightforward.

The core policy question to answer in this context is:How can we enable the people to enjoy healthynutrition, and thus promote and protect their health.Evidence from Member States with active nutritionpolicies show that clear and convincing basicmessages form an irreplaceable foundation for thatstrategy.

There are strong cultural and regional differences indiets and also differences in how the science isinterpreted. Considering these differences, is itfeasible to aim at European action in this field? Ibelieve that it is indeed feasible. It is already evidentthat although the differences are there they arediminishing. European travel and increasing foodavailability are contributing to our societiesbecoming more multicultural also with regard tonutrition and diet. It is also quite clear that thecultures are not carved in stone but they aredynamic. If the messages differ substantially or inthe worst case are controversial, the outcome is thatthe people do not know what to do. Such a

Correspondence: Email [email protected]

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340 M Rajala

our advice to people the issues of safe storage,handling and preparing of food form an essentialpart. On the other hand in the healthy nutritionadvice we always must also analyze if our advice andrecommendations entail risks for the population as awhole or to certain groups of it. The basic minimumrequirement is that advice should not harm. Thismeans that if we would like to recommend thatpeople change the intake of a given component oftheir diet, at the same time we have to carefullycheck if this recommendation implies any risks. Onthe other hand, and especially if no risk is involved,careful consideration is also called for if and howcontroversial scientific findings should be taken intoaccount when formulating recommendations.

I believe it is also fair to say here that the policymakers expect from the scientific community clearpositions on main nutritional issues such ascarbohydrates, proteins, fat, salt, fruit andvegetables, and energy-intake, just to mention some.

The EURODIET project, which is part of HealthPromotion Implementation, is a scientific project,and we are here primarily to validate the current

state of this project. This nature, science-based, shouldbe kept in mind during the conference. It is, however,also obvious that the policy line that may follow oneday in this process, will not only build on the scienceof healthy nutrition but will also take into accountother relevant factors, such as the capabilities of theproduction sector and industry.This conference is of utmost importantce. I am certainthat the outcomes will be fruitful for the nutritionpolicy of Europe. I would also like to take theopportunity to thank the French government, which, ina very dynamic way, is playing a major role in this field.The French Presidency in the Council starting in July2000 is putting healthy nutrition high on the politicalagenda. The European Commission has already doneso as you have certainly observed when reading therecent White Paper on Food Safety, and also by givingnutrition a high priority in the implementation ofcurrent public health programmes, Health Promotion,Health Monitoring and also Cancer Programme. I amconfident that nutrition will continue to be a majorpriority in the Commission's future public healthprograms.



Keynote addresses 341

The dietary challenge for the European UnionW P T James *

Public Health Policy Group and International Obesity Task Force (IOTF), 231 North Gower St., London NW1 2NS, UK

This conference comes at a very appropriate time: theEU Commission has just published its White Paper onthe formation of a Food Safety Authority; DGSANCO is being reorganised to accommodate publichealth issues; the EU French Presidency is proposingan EU initiative on nutrition and health and theEuropean Region of WHO will be embarking in thenear future on a new set of analyses and policies fordiet-related diseases.

Nutritional deficiencies

Traditionally Europeans have considered theproblems of nutrition as those of deficiency diseases -and deficiencies do still give grounds for concernwithin the EU. The classic problems of iodinedeficiency disorders and iron deficiency anaemiaremain unsolved in many countries, despite ourunderstanding of how to prevent these problems. Atpresent only in Finland, Sweden and the UK areiodine intakes adequate; a discernible goitre frominadequate iodine intakes continues to affectappreciable numbers of people in France, Germanyand Italy, where there are no established nationaliodination policies1. The International Council forControl of Iodine Deficiency Disorders (ICCIDD),the non-governmental organisation involved incombating iodine deficiency, has classified theEuropean region as the most backward in the recentremarkably successful global drive to introduceroutine iodization policies. The problem of irondeficiency is also surprisingly prevalent in Europe withup to 10% of girls and women suffering from irondeficiency anaemia and with perhaps a third ofchildren, adults and the elderly having subclinical irondeficiency, i.e. with no measurable iron stores formobilising iron, should the need arise. To these classicdeficiency problems we must now add new evidencerelating to folk acid deficiency if this is judged inbiochemical terms2. This deficiency, now proven to besignificant in determining the development of neuraltube defects in the early stages of pregnancy3, is linkedto the risk of having a small baby with all the short-

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and long-term handicaps that this entails, and thedeficiency is now also being linked to the risk ofboth coronary heart disease and strokes. Thus folkacid deficiency may prove to be a substantial publichealth problem in the European population. VitaminD deficiency has long been known to be a commonproblem in Asian immigrants to Europe and tothreaten those in the more Northern regions ofEurope where the benefits of sunlight in summer aretoo short-lived, e.g. in the UK and Scandinavia.However, recendy, vitamin D deficiency has alsobeen found to be a particular problem in the elderlypopulation throughout Europe; surprisingly, theelderly living in the Mediterranean region areparticularly deficient, presumably because despitecurrent recommendations, they do not stay outsidewith their skins exposed to catch the irradiationneeded to stimulate the synthesis of vitamin Dwithin the skin. Their fat intake is also basedpredominandy on unfortified olive oil so they do nothave the benefit of the additional vitamin D which isa required addition to some fats and oils in manyNorthern member state regulations.These examples accord with the classic concepts ofdeficiency which are readily accepted by the generalpublic. The subtlety of iron deficiency, which isparticularly evident in a subgroup of women with astrong familial and, indeed, genetically determinedhigh menstrual loss, is also easily understood. Morecomplex is the possibility that some aspects ofhealth are related to modest intakes of vitamins andminerals which do not lead to clear cut evidence of aclassic deficiency disease such as scurvy. Thus it hasbeen shown that vitamin C intakes may need to be100 mg/day to limit the emergence of abnormaloxidised DNA in the genome and this damage maywell serve as a marker of cumulative life-longdamage. Other subtle deficiencies may becomeapparent as we learn more, e.g. whether seleniumdeficiency, as yet poorly defined, is involved inpromoting the development of some cancers.Similarly a complex of antioxidant vitamins and

© The Author 2001



342 WPT James

other biologically active compounds found invegetables and fruits may well play a role in limitingarterial damage.

These examples are an extension to the classic pictureof deficiencies which were well described during thefirst half of the 20th century. The second half of thecentury, however, saw a very different set ofnutritional principles emerging of even greater publichealth significance. The idea that the steadilyescalating problems of so-called adult chronic disease,i.e. coronary heart disease, stroke, high blood pressure,diabetes mellitus, gallstones, many intestinal diseasesand some cancers, might not only have a nutritionalcomponent but be essentially caused by dietaryimbalances, is still difficult for some scientists andpolicy-makers to fathom. A vivid illustration of theimportance of this concept is, however, shown by thebenefits which are evident when action is taken toimprove the diet. Pre-war studies in the UK andAmerica had shown the value of meat and milk inpromoting children's growth in height and in limitingthe development of iron deficiency; milk consumptionwas also thought to promote bone growth. Thus meatand milk production and consumption becameEuropean and American priorities for agriculture,health and social policies. Special grants were made tofarmers and there was a major investment in researchon animal production. The eventual establishment ofthe Common Agricultural Policy within the EuropeanCommunity was initiated to protect the livelihood offarmers but also served to promote the supposedlybest practice in agriculture with ample meat and milkproduction. Thus, after the Second World War, publichealth policy was geared to the provision of enoughhigh quality food to guarantee the absence ofdeficiencies so that children would grow well withnobody going hungry. Yet while children's growthimproved, new disease patterns emerged with thechronic adult diseases, noted above, becomingepidemic.

The post-war emergence of chronic diet-relateddiseases in adults

As the national changes in diet took hold during the1950s, the new diseases became apparent. Angina andcoronary heart disease, rare clinical conditions fordoctors' training in the 1930s, soon took on epidemicproportions in Northern Europe. However, Keysfrom Minnesota in the US, fresh from his meticulousand now classic studies on semi-starvation in youngconscientious objectors4 embarked on a study in sevencountries across the globe to work out why CHD wasso unusual in Japan, Crete and Corfu, Yugoslavia andItaly but a scourge in Finland, the Netherlands and theUnited States5. This remarkable cross-cultural

epidemiological study revealed that CHD rates couldbe predicted from the level of serum cholesterol in apopulation's adults. Hitherto serum cholesterol wasonly used as a general marker of malnutrition! Keysand his colleagues linked these findings with dietarystudies on animals fed high animal fat diets whichinduced vascular damage. New volunteer feedingstudies on the impact of different saturated fattyacids from animal fats showed that these fatty acidshad selective effects in increasing blood cholesterollevels but polyunsaturated fatty acids suppressedthese elevated blood cholesterol levels. Keys'physiological studies revealed starkly how someindividuals were very sensitive to changes in dietarysaturated fat whereas others were almostunresponsive for reasons we now know to begenetically based. Keys also highlighted theimportance of the three risk factors - smoking, highblood pressure and high serum cholesterol levels - inpromoting CHD but recognized that Japanese men,with the highest blood pressure levels in the worldand also higher smoking rates, had the lowestcholesterol levels and the lowest CHD rates. Thussmoking and blood pressure were additionalamplifiers of risk, whereas the dietary factors leadingto blood cholesterol increases were fundamental tothe development of CHD. Overweight and obesitywere not predictors of CHD and it was the saturatedfat, not the total fat, intake which was important. Bythe early 1960s Keys was already promulgating thisanalysis which was then crudely explained ascholesterol accumulating in the vessel wall toocclude the blood flow to the heart.

The American Heart Association soon took on theseconcepts but in Europe change came more slowlywith the exceptions of Norway and then of otherScandinavian countries, particularly Finland. InNorway a series of moves by academics established apolitically effective National Nutrition Council 6

which led to a transformation of the health services:tuberculosis clinics were converted intocardiovascular monitoring centres and there weremajor national campaigns to reduce saturated fatintake and enhance vegetable and fruit consumption.Agricultural priorities were also changed with pricingpolicies developed to ensure that vegetables and fruitwere delivered to the most northern towns andvillages throughout the year at the same price asthose found in Oslo. This sustained national effortled to a major reduction in the incidence of CHDwhich was particularly evident in the younger agegroups. It is also noteworthy that these campaignsand policies were aimed at everybody and not simplyat a subgroup of citizens who were found to havehigh cholesterol levels. In fact it was soon evident




that the average blood cholesterol of Scandinavianswas so high that if a Japanese man were found to havesuch a level, there would be immediate concern thathe had some rare genetic abnormality! Thus thesuccessful population approach in public policy-making was initiated before there had been any of themodern validating mathematical analyses of theburden of disease and the fraction of that burdenwhich could be attributed to diet and how populationrather than high risk strategies would maximise thenational benefit.

Ago standardised death, from CHD800

Finland

1968 1971 1974 1977 1980 1983 1986 1989 1992 1995

Rayner end Petorsen, Eur CVD Stats, 2000, Brit Ht Fdn

Fig. 1

Population preventive strategies as well asindividual therapy are needed

These analyses in nutrition/public health terms werefirst introduced into international strategies by Roseand Blackburn in their 1982 WHO Technical Report7.This is illustrated in Fig. 1 of the Eurodiet firstWorking Party's analyses of nutrients in relation topublic health. This analysis showed that if one tackledthose in Europe with about an average cholesterollevel, then the gains in preventing heart attacks wouldbe about fourfold greater than that found by takingthe classical medical approach of identifying onlythose with the highest cholesterol levels and reducingthose levels to the lowest risk category. This analysisled to the idea that one should propose a shiftdownwards in the whole population's spectrum ofcholesterol levels. This is conceptually completelydifferent from the personal approach to healthproblems which most individuals have and on whichdoctors are trained to concentrate. So strong is the"prejudice" to concentrate on individual action thatpublic health strategists have always been formulatedto specify that both an individual high risk approachand a population strategy is needed. In practice thechallenge is how to induce a shift in the distribution ofrisk without being accused of draconian measures

which specify exactly how people should behave andwhat they should eat, i.e. to avoid the crude andmisguided criticism that public health strategies denyfreedom of choice and require a "nanny state"approach.

The early Mediterranean diet prevented coronaryheart diseaseFigure 1 sets out differences in EU death rates fromcardiovascular disease based on the latest analyses8.They indicate that Ireland, Finland and the UK stillhave the highest death rates for CHD in those belowthe age of 74 and within the EU the rates are 3 to 5times greater than those observed in France. Thesestartling differences apply on a national basis andmust relate to environmental issues rather thangenetic differences between the different nationalEU groups. A number of analyses have been madeof the basis for these differences. Keys' three majorrisk factors certainly apply when there are studiesconducted prospectively within each national group,but additional factors are still being sought toexplain the remarkable national differences.Originally Keys and his colleagues in the SevenCountry Study showed that the intake of saturatedfat was highly correlated with the risk of death inmen and at that stage the Greek, Italian andYugoslav data suggested that saturated fat intakes of7—10% were associated with a death rate which was4—10 times lower than that observed in Finlandwhere saturated fat intakes were about 23%.Detailed chemical analyses of composite diets basedon the original diet records are shown in Table 1which reveals the modest polyunsaturated fatty acidintakes, the much lower intakes of total fat thanthose currently consumed and the modest intakes ofmonounsaturated fats observed in all the low riskcountries except Corfu and Crete. The intake ofsimple refined sugars at that stage was also negligiblein these Mediterranean diets which in practicewerebased on substantial amounts of cereals, e.g.about 500 grams or more, vegetables (about 250grams or more) and in Greece surprisingly highintakes of fruit. The intake of milk, fats and oils,meat and eggs was extremely small. It is this dietwhich therefore would appear to be optimum. Inpractice more recent studies have highlighted thefact that the differences across Europe are notreadily explained by smoking, hypertension or highcholesterol rates so the less well specified, mustapply. These include the benefits of high fruit andvegetable diets and other factors, e.g. low trans fattyacid intakes, all of which are thought to contributeto these different national levels of CHD.



344 WPT James

Table 1 The traditional Mediterranean diet

% Energy

FatsSaturated FAsMonounsaturated FAsPolyunsaturated FAsSimple refined sugars

Southern

1930s20

51052

Italy

1960s27

81632

Greece

1960-6526

9134

<5

1960-65*32.5

722

3Approx. 0

*Chemical Analyses in the 7-Country Study with Crete 36%, Corfu 27%. Recent re-evaluation of someoriginal diet records suggest 42% for Crete. Some fatty acid values estimated by difference.

Excess weight gain and obesity

Physical inactivity and excess weight gain are alsoimportant as illustrated in Fig. 2. There is no doubtthat as the body weight of adults rises the prevalenceof high fasting cholesterol and triglyceride levels andlow HDL cholesterol concentrations increases as doesthe proportion of the population which has highblood pressure. These changes become very evidenteven within the normal body weight range (i.e. 18.5—24.9)9. It is important, however, to recognises asindicated in Fig. 2, that the impact of weight gain oncardiovascular disease is indirect with a whole host ofother dietary factors and physical inactivitycontributing independently to the risks of thrombosisand atherosclerosis. It is important to recognise, andoften misunderstood, that the total fat intake hasnever been linked to the likelihood of cardiovasculardisease - it is the quality of the fat that becomescrucial. Nevertheless, it has become increasingly clearin the last 15 years that obesity is particularly likely inindividuals who are both physically inactive and on ahigh fat diet. Keys own studies revealed that theGreeks had the highest average body mass index

(BMI) on their higher fat diet but they hadexceptionally low heart disease rates because the fatwas very low in terms of its saturated and trans fattyacid content.Numerous studies have shown the link between thefat intake of a group of individuals and the likelihoodof gaining excess weight. There has recently, however,been much debate, led by Willett and his colleagues,suggesting that the transfer from a high to a lower fatintake might be hazardous because of the adversechanges in HDL and triglyceride levels10. In addition,Willett and his colleagues consider fat to be relativelyunimportant because the reduction in weight onceindividuals persist with a lower fat intake is modest. Itis, of course, important to recognise the distinctionbetween primary prevention and secondaryprevention. Bray and Popkin11 have set out an analysisof the data supporting the importance of dietary fat interms of the epidemiology of obesity. This issubstantially supported by animal experiments whichhighlight the selective effect of fat in inducingexcessive weight gain. Many physiological studies inman also demonstrate the propensity for "over-consumption" when individuals have free access to

The interlinking of physical inactivity and dietary effects on obesity and theprogression of disease with industrialisation.

4 BULK,e.g. vegetablestubers, cereals

OBESITY -3 DIABETES ^CHD •*

. Phytoestrogens — • • C A N C E R S : breast,bioactlvate molecules \y endometrium

-*~4 Folate, B6 Homocysteinaemia

Total Fat ©

Thrombosis

_^Jrans fatty acidsn-3 fatty acids

- « - Saturated fats

Fig. 2

-»-Antioxidants-

0

©Atherosclerosis

/




foods of unrecognised high fat content. The moreinactive the individual, the more likely they are toover-compensate for modest physical activity byinadvertently consuming modest amounts of energy-rich foods high in fat12. Astrup, in the workingdocuments for this conference, also sets out howreducing dietary fat does lead to clear weight losseswhich are greater in the overweight. It is also evidentfrom a series of meta-analyses, from longer terminterventions and from national data that whilst theremay be a temporary adverse changes in triglycerideand HDL levels, these do not persist unless thedietary reduction in fat is substantial, e.g. down to 20—25% from 40%13>14. Dietary changes which lead tointakes analogous to those observed in Table 1 have amarked beneficial effect in reducing blood pressure,particularly when there is an ample vegetable and fruitintake (DASH Trial I)15. Further, more extremechanges with a reduction in fat intake to 10% havebeen shown over a five-year period to lead to markedimprovements in blood lipids with a highly significantreversal of arterial thickening16. Therefore although areduction in fat intake has been advocated as part of ageneral strategy relating to cardiovascular disease, it isin practice simply a means whereby one can reducethe hazardous saturated fatty acids but at the sametime bring benefit to individuals by limiting their rateof weight gain or indeed by helping to reduce theirexcess weight.

Attempts have recently been made to compare theeffects of CVD risk factors risks in Finnish men17.This analysis suggested that sedentary living involvingless than three episodes of physical exertion a weekhas a much greater impact on risk than cigarette

smoking, cholesterol levels, high blood pressure oroverweight. These new analyses are indeed valuable inillustrating the need to discriminate the proportionalimpact of different factors. However, they dohighlight how important it is to choose theappropriate optimum diet and activity levels. Inpractice, the high cut-off levels chosen as optimumfor cholesterol, blood pressure and body weight hadthe effect of minimising their contribution. Now,however, there is a new WHO project in which we areattempting to assess the global impact of excessivebody weight and of dietary differences on morbidityand mortality. Already it is clear that excess weightgain accounts for the majority of the increase indiabetes rates across the globe and is a very major riskfactor for high blood pressure and indeed for otherrisk factors in relation to both coronary heart diseaseand stroke.

Figure 3 shows the astonishing differences betweenEuropean countries in the prevalence of adult obesity.These figures have to be treated with caution becausesome of them are not based on nationallyrepresentative data and they also apply to different agegroups. Nevertheless, in crude terms, it is clear thatthe populations of Yugoslavia and Greece now haveexceptionally high rates of obesity despite Yugoslaviaoriginally having perhaps half the fat intake of what itis currently and Greece also having much lower fatintakes. There is now clear evidence of an escalatingepidemic of obesity in Europe and this will enhancethe burden of ill health; the complications of obesitywill emerge over the next two decades as the excessweight gain persists and as the population ages.Another disease, osteoporosis, is also projected to

YugoslaviaGreece

RomaniaCzech Rep.

EnglandFinland

GermanyScotlandSlovakiaPortugal

SpainDenmarkBelgiumSwedenFrance

ItalyNetherlands

NorwayHungary

Switzerland30 20 10 0 10 20

% above BMI >3030 40

)y the IOTF from recent surveys

Fig. 3



346 WPT James

increase, despite benefiting from weight gain;osteoporosis already produces an alarming burden ofhip fractures in Europe and, as the population agesover the next 50 years, there will be a two to three-fold increase in annual fracture rates.

In addition to the major problems of cardiovasculardisease, diabetes, obesity and their associatedproblems of high blood pressure, there is anothermajor cause of death in the EU relating to diet. Anumber of European and global reports have nowemphasised the contribution that diet can make to avariety of cancers. Those cancers which particularlyinvolve the epithelium are affected by diet and anabundant supply of vegetables and fruit is shownconsistently to be protective18. Perhaps a third ofcancers relate to dietary factors but the laboratoryproof is made more difficult by the need to show howdietary factors limit or promote a series of sequentialgene changes which precede the development of thefinal carcinogenic process. Nevertheless, the evidencefrom human studies on risk is sufficient for there tobe a generally accepted policy of attempting to ensurethat children and adults consume throughout life fargreater amounts of vegetable and fruit than arecurrently eaten in most European countries.

Developing integrated population dietary goals

When the analyses of different nutrients and theprincipal public health problems of Europe wereconsidered, it became clear to the Eurodiet group ofexperts that numerous international expert groups hadagreed on a series of specific population goals for dietso it was possible to develop a coherent andintegrated set of nutrient and dietary goals. Almost allof these goals have been developed by recent expertgroups within Europe so there is little conflictbetween the values set out in the table presented bythe first working group and those of most memberstates. Included in the table are detailed notespresented to the conference and which set out someof the issues which concerned individual scientists. Itshould be emphasised that the experts in WorkingParty 1 were not there to develop goals on the basisof their own analysis of appropriate nutrient intakes.Instead they highlighted the issues and considerednovel problems which may not yet have led to aconsensus by the international expert groups of, forexample, cardiologists, diabetologists, cancerspecialists or obesity experts. Despite theseconsensuses , however, there is no doubt that some of

these goals are seen to be controversial by somescientists. Thus the total fat intake, the salt values andthe issue of whether sugar intakes should beexpressed quantitatively have all been much debated.These issues are also, of course, of intense industrialconcern so inevitably there has been a great deal oflobbying and questioning of the detailed evidence.

Current dietary intakes and the development offood based dietary guidelines (FBDG)The second working party set out how best todevelop a step by step approach to food based dietaryguidelines following the original WHO/FAO meetingon this topic19. First it is important to identify whichmajor food sources contribute the nutrients ofinterest and then to see which of these foods providesa substantial proportion of the nutrient intake on apopulation basis. The proposition was made that bylooking at the variation of intake within countries itmight be possible to discern which food groupsshould be highlighted as important when attemptingto improve national diets. One of the problems withthis general approach then emerges because the recentdata from the Institute of European Food Studies onEU food intakes (see Fig. 1 in the Working Party 2Report) shows that few countries in the EU at presenthave intakes of the principal nutrients of concern, e.g.total fat and saturated fat which are close to theoptimum. Indeed, some intakes are far removed fromthe optimum. Therefore some of the national goalshave been developed on a pragmatic national basiswith expert groups recognising that the ideal goalcannot be specified because it is so far from thepopulation mean intake. It is for this reason that thesecond working party highlighted the need to take apragmatic view and to consider carefully what inpractice could be done. When assessing, for example,total fat intake, one could readily identify particularfoods which contributed substantially to fat intakes,but these foods differed markedly in theircontribution across Europe. Therefore, it is unlikelythat a clear food based system can be developed on apan-European basis. So dietary guidelines are bestgenerated on a national basis.

There is a variety of ways of assessing the distributionof intakes of different food groups. The secondworking party highlighted the value of considering thedistribution of food intake in quartiles and assessing




which food groups made the biggest contribution tothe differences between these quartiles. It is alsoimportant to identify the proportion of people whodo not consume particular foods; the proportion ofnon-consumers can vary markedly by country. Thusin Finland 21% of those in the lowest quartile ofnational fruit and vegetable intake do not consumeany fruit at all and 2% do not take vegetables. InBelgium, by contrast, 70% of those in the lowestBelgian quartile fail to eat fruit and 14% do not eat

Public health strategies to implement FBDGs andenhance lifestylesOnce FBDGs are established on a national basis thenthe issue is how best to develop suitable strategies forachieving changes in diet and physical activity. Theseissues were considered extensively by the thirdworking party. It became clear that they had tocontend with a number of myths. First that primaryprevention strategies are not effective; secondly thatthey take too long to have an effect; thirdly that theyinevitably involve telling people what to do: this ismuch resented. Fourthly it is claimed that the foodindustry will suffer. Finally, there is a myth specifyingthat nutritionists can never agree on either the goalsor the preventive strategy so that the whole issue ofdiet and health is too controversial to warrant publicpolicy making.

The recommendations of the Third Working Partywere developed on a sectoral basis because this helpsto make clear who should be considered responsible.The health care sector in Europe needs better trainingin the principles set out in the reports of the fourworking parties. Doctors and their colleagues need tobecome involved in broader community programmesand not simply concentrate on treating individualpatients. It was also recommended that a Europeanforum be established to allow an effective interchangeand assessment of progress in public health strategiesin different parts of Europe. Guidelines for primaryhealth care workers relating to physical activity needto be developed because doctors continue to be, withother health professionals, ignorant about the role ofdiet and physical activity in health. Primary health careservices and developments in health promotion alsoneed to be linked to other regional services which areinvolved in the same activity. Finally the grouphighlighted the need for the health care personnel tochange their own diets and physical activity so that

vegetables. The strategies needed in Belgium andFinland may therefore be very different if one is tryingto increase the intake of fruit and vegetables andpersuade non-consumers to start eating these foods.Other approaches include discriminant analysis ofdifferent food groups in relation to the variety ofnutrients to be assessed. Cluster and factor analysismay also be helpful in highlighting strategies formodifying intakes. These issues are well dealt with in asymposium dealing exclusively with these issues20.

they could, as with smoking, be exemplars ofbehavioural change and appropriate healthy living.

Schools were an obvious focus for change withchanges in the curriculum being needed throughoutthe school age range. Modem concepts of diet and theneed to teach children activity skills should beintroduced to pre-school groups. School meals of anappropriate nutritional standard should be integratedwith other educational changes in school as part of acoherent educational process. Teachers and theirassistants need to be trained to develop a healthyactive school environment which encourages familyand community involvement. Obviously the schoolhealth services need to be seen as an integral part ofthis new development.

When children leave school their adult environmentalso needs to change with employers having not onlyresponsibility but a real opportunity to improve thewell-being of their work force by encouragingintervention programmes and helping with facilities toimprove physical activity and the nutritional well-being of their workers. Management and staff areboth best involved in working out how to undertakethese changes and employer groups based on differentindustrial sectors as well as individual companies canbe selected for particular innovative trials. Obviouslythe food industry itself has a major role to play notonly with its own workers but also in developing andsupporting the provision of healthier diets and foods.New product formulation, labelling initiatives,perhaps even pricing policies and the development ofpartnerships with the health sector are allopportunities for gaining mutual benefit. It istherefore a mistake to think of the food industry as aninevitable problem area when it comes to developinghealthier diets in Europe and achieving major healthgains.



348 WPT James

Major benefits in some European countries fromNational Preventive StrategiesThese proposals might seem routine and similar tothose that have been developed over many years.They are, however, based on national experiencewithin the EU and imply a totally different approachfrom the usual assumption that all one has to do inhealth promotion is to provide better information andeducation. The idea that nutrition education is thesolution to dietary problems is a common fallacy.Experience in Finland has shown that by a systematicfocusing on each component of society whether it isthe health services, pre-school facilities, the schoolenvironment, restaurant and catering facilities oremployee work canteens - the integration of initiativesin all these sectors can have the most dramatic impacton even the average intakes of a country. Thus over a20 year period Finland increased vegetable intakethreefold with a nearly two-fold increase in fishconsumption and a marked fall in full fat milk use.This led to a reduction in saturated fat intake as partof a fall in total average fat intake from about 42% toless than 34% of energy consumed. In associationwith these changes which started in North Karelia,there was a remarkable fall in the prevalence ofcardiovascular risk factors in the population. Thus theaverage blood pressure showed a remarkable 10mmHg drop and the average cholesterol value of theFinnish adults fell by 15%. Such changes would beconsidered remarkable in a tightly controlled clinicaltrial of drugs for hypertension and any dietary changefor lower cholesterol values. This illustrates the factthat in many parts of Europe there is a pessimisticview about intervention strategies and an incorrectassessment of the supposedly limited opportunitiesfor inducing major changes in the risk profile. Inassociation with these falls in risk, there has been aremarkable reduction in mortality rates in North EastFinland from stroke and coronary heart disease withthe observed mortality reductions being close to thosepredicted from the fall in risk factors21. In Finlandthere were also systematic strategies for reducing thesalt, total fat and saturated fat intakes withspecification of the precise nutritional quality neededin schools. Canteens and restaurants were encouragedand rapidly took on the concept of providing a saladbar and vegetables as part of the intrinsic cost of themain meal and a whole variety of policies weredeveloped to set standards of food provisionthroughout society. Interestingly the same reductionin death rates occurred in both men and women

despite the women showing little change in smokingrates or even an increase. This emphasises the factthat although smoking is very hazardous, when itcomes to cardiovascular disease, the impact ofsmoking is substantially dependent on the individual'seating habits being inappropriate22. Law et alPemphasised some years ago that reducing bloodcholesterol by 10% predicts on a long-term basis atleast a 20% reduction in the incidence of CHD. In 40year olds the benefit was for a greater than 50% fall inrisk but even in 80 year olds there was still a 20%benefit. Thus we have underestimated the importanceof improving the diet of Europeans throughout life.

Figure 1 presents the latest analyses of how differentcountries have coped with the recognition of suchdiverse death rates from CHD. The top threecountries in European death rates are Finland, the UKand Ireland but the response is very different in thethree countries. Finland showed the earliest effectsand a dramatic fall whereas the UK showed very littlechange until about 1980, despite many internationalanalyses and policy statements having become well-recognised for 20 years. When we assessed for WHOwhy these differences occurred and whether theyrelated to different approaches by government, wewere surprised to realise that across Europe one couldsee that the changes in death rate were preceded bydietary changes. These dietary changes were not,however, usually induced by novel policy proposals bygovernment, but by major academic groups orindividuals deciding to become major publicadvocates of the need for societal change. Thus inFinland there was a mass movement to improve theappalling death rates whereas in Britain the mediafocused endlessly on the array of experts whodisagreed about the finer points of heart disease andhow it might be caused. Indeed, some major charitiesseemed intent on maintaining the mystery about thebasis for heart disease to keep their research fundsrolling from public appeals. The third country,Ireland, was notable for the lack of a coherentacademic initiative and indeed for academicspromoting controversy on the dietary basis of heartdisease.

Figure 1 also shows that the three countries in the EUwith the lowest rates have shown very differentresponses over the last 30 years. Italian and Frenchcardiovascular rates have been improving whereasGreece is the only EU country with a progressive rise,albeit from a low initial level. Kafatos has emphasisedhow the diet in Greece is changing with an increase in




fat intake and therefore the expected rise in bothchildhood and adult obesity. This problem isincreased by the substantial reduction in physicalactivity. The dietary changes include progressiveincreases in saturated fat in addition to continuinghigh olive oil consumption, so it is not surprising thatCHD rates are rising. Breast cancer and colon cancerrates are also on the increase. Other countries withinEurope have seen appreciable declines in CHD rates,e.g. in Belgium and the Netherlands, but Germany(see Fig. 1) has only modest changes. Again it wouldappear that only recently have German nutritionistsand doctors started to go public on the issues, sothere is still much to do in the medical and nutritionalprofessions.

The third working group therefore highlighted theimportance of academics and public interest groupsbecoming involved in advocating the social andstructural changes needed to support good dietarypractices and an active lifestyle. Academics have aresponsibility to raise the profile of these issues bothin the media and politically and to ensure that theyunderstand what is required in policy developments.They also have a role in changing the politicalspectrum and ensuring that there was appropriateresources allocated to initiating preventiveprogrammes. The value of Nutrition Councilsoperating at a national independent level has alsorecently been highlighted by a UN report24. Finally,the broad policy recommendations of the thirdworking group involve a number of keyrecommendations as set out in Table 2

Policy developments needed

The fourth working group had the unenviable task ofconsidering how best to take forward all these issues

within the context of the EU. After carefuldeliberation they concluded that a number ofmechanisms are needed. First there is a need for theEU to prioritise diet and lifestyles in its analysis of thebasis for the remarkable range in health across theEU. There is a great need to assess the health impactof the numerous EU policies which are beingintroduced, often without any assessment of theirimpact on diet and lifestyles. To promote this moreeffective assessment of current EU developments andthereby help to improve policies, the expert groupadvocated that the EU should establish a newNutrition Committee because hitherto nutritionalquestions of enormous public health significance havebeen neglected. There was indeed a need to revise thecurrent EU recommended dietary allowances,particularly as the US has just produced its own newrecommendations. The group also recognised thatthere is a need to clarify the different responsibilitiesof the EU in relation to national roles but it seemsunwise to think of the Commission becomingengaged in detailed and direct dietary advice to thepublic. Not only are there big differences in nutrientintake across the EU but the. diet and culturaldifferences are often so marked that to be effectiverequires a sensitivity to local circumstances which isnot readily achieved at a Commission level.

Recommendations for EU action

The Eurodiet group highlights the need for acoherent approach to the formal assessment of thestate of health, diet and lifestyles of Europeans on aregular basis, e.g. every five to ten years. At present itis difficult to have any coherent analysis of thedifferent diet and public health issues in Europe.There is indeed a need for a system analogous to that

Table 2 Recommendations on Public Health Strategies

• Tackle inequity and broader determinants of health.

• Develop national strategies with:

• population approach

• multidisciplinary and integrated

• complementary actions

• work at different levels: industrial, community, environmental and policy

• Consistent EU monitoring systems

• All purpose leaflet for integrating different sectors.

• Structured development of diet and activity strategies for different groups

• Professional continuing education.



350 WPT James

undertaken by the Centre for Disease Control in theUnited States. Health based research needs to beprioritised to deal with the real public health issues ofEurope. This would inevitably involve a much morecoherent analysis of dietary issues. EU multi-centrestudies may well be needed on the continuingproblems and there is certainly a need to supportprofessional networks within the EU which can helpconsider the issues relating to diet and health as wellas nutrition education.

On a more legislative basis, it is clear that dietaryaspects of health claims and appropriatecomprehensive food labelling are going to be bigissues, as is the relationship of the EU to CODEXwhere nutrition claims have already been considered.In conclusion, this EU programme of work hashighlighted the intense interest that can emerge once acareful analysis is made of the enormous healthburden in Europe linked to dietary issues. Recent EUanalyses by the Institute of Public Health inStockholm, Sweden suggest that the fraction of thetotal disease burden within the EU that relates to dietis greater than that associated with tobacco use25.Within the top twelve issues tobacco is seen as thetop contributor to ill health, with 9% of the totalburden attributable to it. Alcohol (8.4%), overweight(3.7%), low vegetable and fruit intake (3.5%), physicalinactivity (1.4%) and high saturated fat intake (1.1%)contribute and the percentages cited are allpreliminary estimates of their contributions. There is,however, now a need to re-evaluate these issues,particularly our better understanding of the multi-faceted role of diet in relation to health. The problemis accentuated by the recognition that we may bedealing with very long term effects of changes in diet.Thus dietary changes in pregnancy as well as inchildhood may affect lifelong health.

The dramatic differences in health burden acrossEurope are a vivid display of the opportunities forlimiting the morbidity as well as the prematuremortality of millions of people. The challenge is togain recognition within the EU for these issues. Foodsafety is indeed important and high on the politicalagenda because of the great trade issues involved infood safety. Nutritional problems may, however,become equally politically difficult because advocatingchange in diets is of intense industrial interest. Thehealth benefits that come from an optimum diet havenow been shown for 40 years in Europe to be verysubstantial and it is surprising that we are so slow in

accepting this when, in the United States, NutritionSummits and a series of NIH and Academy of Scienceinitiatives highlight the importance of diet and health.As the EU expands, the challenge is even greater andthe opportunities for benefit, given our currentknowledge, are unprecedented. It is therefore a greatchallenge for us all to ensure that dietary aspects ofhealth become a principal consideration of HealthMinisters in the EU.

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