Food and health in Europe:
a new basis for action
Food and health in Europe: a n ew
b asis fo
r actio n
96
WHO Regional Publications European Series, No. 96
The World Health Organization was established in 1948 as a specialized agency of the United Nations serving as the directing and coordinating authority for international health matters and public health. One of WHO’s constitutional functions is to provide objective and reliable information and advice in the field of human health, a responsibility that it fulfils in part through its publications programmes. Through its publications, the Organization seeks to support national health strategies and address the most pressing public health concerns.
The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region embraces some 870 million people living in an area stretching from Greenland in the north and the Mediterranean in the south to the Pacific shores of the Russian Federation. The European programme of WHO therefore concentrates both on the problems associated with industrial and post-industrial society and on those faced by the emerging democracies of central and eastern Europe and the former USSR.
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Food and health in Europe: a new basis for action
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WHO Library Cataloguing in Publication Data
Food and health in Europe : a new basis for action
(WHO regional publications. European series ; No. 96)
1.Nutrition 2.Food supply 3.Food contamination - prevention and control 4.Nutritional requirements 5.Nutrition policy 6.Intersectoral cooperation 7.Sustainability 8.Europe I.Series
ISBN 92 890 1363 X (NLM Classification: WA 695) ISSN 0378-2255
Text editing: Mary Stewart Burgher
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Food and health in Europe:
a new basis for action
Edited by: Aileen Robertson, Cristina Tirado,
Tim Lobstein, Marco Jermini, Cecile Knai, Jørgen H. Jensen,
Anna Ferro-Luzzi and W.P.T. James
WHO Regional Publications, European Series, No. 96
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ISBN 92 890 1363 X ISSN 0378-2255
© World Health Organization 2004 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.
The designations employed and the presentation of the material in this publi- cation do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, ter- ritory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
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Address requests for copies of publications of the WHO Regional Office to publicationrequests@euro.who.int; for permission to reproduce them to permissions@euro.who.int; and for permission to translate them to pubrights@euro.who.int; or contact Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark, (tel.: +45 3917 1717; fax: +45 3917 1818; web site: http://www.euro. who.int).
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Contents
Page Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Editors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Introduction: the need for action on food and nutrition in Europe . . . 1 Overview of the book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 WHO activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1. Diet and disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Diet-related diseases: the principal health burden in Europe . . . . . . 7 Variations in CVD: the fundamental role of diet . . . . . . . . . . . . . . 23 Diet’s role in limiting the development of cancer . . . . . . . . . . . . . . 32 Epidemic of overweight and obesity . . . . . . . . . . . . . . . . . . . . . . . . 35 Type 2 diabetes and excessive weight gain. . . . . . . . . . . . . . . . . . . . 38 Impact of physical inactivity on health . . . . . . . . . . . . . . . . . . . . . . 38 Impaired infant and child development from micronutrient deficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Pregnancy and fetal development . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Feeding of infants and young children . . . . . . . . . . . . . . . . . . . . . . 50 Dental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 The health of the ageing population of Europe. . . . . . . . . . . . . . . . 57 Nutritional health of vulnerable groups . . . . . . . . . . . . . . . . . . . . . 64 Social inequalities and poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2. Food safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Food safety and food control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Causes of foodborne disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Effects of foodborne disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Extent of foodborne disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
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Trends in foodborne disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 The burden of foodborne disease . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Microbial hazards in food. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Chemical hazards in the food chain . . . . . . . . . . . . . . . . . . . . . . . . 112 Risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Food safety, diet and nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Inequality in food safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Emerging food control issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 WHO and food safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
3. Food security and sustainable development . . . . . . . . . . . . . . . . . . 155 Food security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Food production and health policies. . . . . . . . . . . . . . . . . . . . . . . . 156 Food and nutrition insecurity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Current trends in food supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Agricultural policies and diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Policies for food and nutrition security . . . . . . . . . . . . . . . . . . . . . . 196 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
4. Policies and strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 WHO Action Plan on Food and Nutrition Policy . . . . . . . . . . . . . 221 Need for integrated and comprehensive food and nutrition policies 222 Food and nutrition policies in the European Region. . . . . . . . . . . . 230 Nutrition policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Food control policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Food security and sustainable development policy . . . . . . . . . . . . . 270 Mechanisms to help health ministries set priorities for future action 277 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
5. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Annex 1. The First Action Plan for Food and Nutrition Policy, WHO European Region, 2000–2005 . . . . . . . . . . . . . . . . . . . . . . 313
Annex 2. International and selected national recommendations on nutrient intake values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
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Acknowledgements
This publication was prepared by the nutrition and food security and the food safety programmes of the WHO Regional Office for Europe. We, the editors, gratefully acknowledge the financial support provided by the Govern- ment of the Netherlands. We are particularly grateful to the following people for helping us with the conceptual framework: Dr Eric Brunner (University College London, United Kingdom), Dr Raymond Ellard (Food Safety Authority of Ireland, Dublin, Ireland), Professor Tim Lang (Thames Valley University, London, United Kingdom), Professor Martin McKee (London School of Hygiene and Tropical Medicine, United Kingdom), Dr Mike Rayner (British Heart Foundation Health Promotion Research Group, Oxford, United Kingdom) and Dr Alan Lopez (Evidence and Information for Policy, WHO headquarters).
It is impossible to give individual credit for all the ideas and inspiration in- cluded in this book. We give references for the evidence we present, but the thinking and the arguments that allow us to interpret the evidence have come from many sources. We acknowledge the help we have received from a wide array of experts who contributed to individual sections or reviewed the draft text. These generous people have provided information and given their com- ments and support without any question of charge or any attempt to ex- change favours. For this, we and WHO are immensely grateful.
For personal contributions and additional research, we are indebted to (in alphabetical order): Dr Martin Adams (University of Surrey, Guildford, United Kingdom), Dr Brian Ardy (South Bank University, London, United Kingdom), Dr Paolo Aureli (Istituto Superiore di Sanità, Rome, Italy), Dr Bruno de Benoist (Department of Nutrition for Health and Development, WHO headquarters), Dr Elisabeth Dowler (University of Warwick, United Kingdom), Dr Margaret Douglas (Common Services Agency for the National Health Service (NHS) Scotland, Edinburgh, United Kingdom), Dr Robert Goodland (World Bank, Washington, DC, United States of America), Dr Jens Gundgaard (University of Southern Denmark, Odense, Denmark), Dr Corinna Hawkes (Sustain: the alliance for better food and farming, London, United Kingdom), Dr Annemein Haveman-Nies (National Institute of Public Health and the Environment (RIVM), Bilthoven, Netherlands), Dr Anne Käsbohrer (Bundesinstituts für gesundheitlichen Verbraucherschutz und
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Veterinärmedizin (BgVV), Berlin, Germany), Dr Alan Kerbey (International Obesity TaskForce, London, United Kingdom), Dr Marion Koopmans (Re- search Laboratory for Infectious Diseases, Bilthoven, Netherlands), Dr Karen Lock (London School of Hygiene and Tropical Medicine), Professor Jim Mann (University of Otago, Dunedin, New Zealand), Dr Eric Millstone (University of Sussex, Brighton, United Kingdom), Dr Gerald Moy (Depart- ment of Food Safety, WHO headquarters), Dr Joceline Pomerleau (London School of Hygiene and Tropical Medicine, United Kingdom), Dr Elio Riboli (International Agency for Research on Cancer, Lyon, France), Dr Maura Ricketts (Communicable Disease Surveillance and Response, WHO head- quarters), Dr Jocelyn Rocourt (Department of Food Safety, WHO headquar- ters), Dr Katrin Schmidt (Bundesinstituts für gesundheitlichen Verbrauch- erschutz und Veterinärmedizin (BgVV), Berlin, Germany), Professor Aubrey Sheiham (University College London, United Kingdom) and Professor Leigh Sparks (University of Stirling, United Kingdom).
For assistance with reading and commenting on drafts of the text, we ex- press our appreciation and gratitude to (in alphabetical order): Dr Martin Adams (University of Surrey, Guildford, United Kingdom), Dr Carlos Alvarez-Dardet (University of Alicante, San Vicente del Raspeig, Spain), Dr Dieter Arnold (Bundesinstituts für gesundheitlichen Verbraucherschutz und Veterinärmedizin (BgVV), Berlin, Germany), Dr Paolo Aureli (Istituto Supe- riore di Sanità, Rome, Italy), Dr Sue Barlow (Institute for Environment and Health, University of Leicester, United Kingdom), Dr Wolfgang Barth (Cen- tre for Epidemiology and Health Research, Zepernick, Germany), Dr Bruno de Benoist (Department of Nutrition for Health and Development, WHO headquarters), Dr Carsten Bindslev-Jensen (Allergy Centre, Odense Univer- sity Hospital, Denmark), Dr Gunn-Elin Bjørneboe (National Nutrition Council, Oslo, Norway), Dr Zsuzsanna Brazdova (Masaryk University, Brno, Czech Republic), Dr Eric Brunner (University College London, United King- dom), Dr Caroline Codrington (University of Crete, Heraklion, Greece), Pro- fessor Finn Diderichsen (Karolinska Institute, Stockholm, Sweden), Dr Carlos Dora (European Centre for the Environment and Health, Rome, WHO Re- gional Office for Europe), Dr Elisabeth Dowler (University of Warwick, United Kingdom), Dr Guy van den Eede (European Commission Joint Re- search Centre, Institute for Health and Consumer Protection, Ispra, Italy), Dr Raymond Ellard (Food Safety Authority of Ireland, Dublin, Ireland), Dr Maria Ellul (Health Promotion Department, Floriana, Malta), Dr Gino Farchi (Istituto Superiore di Sanità, Rome, Italy), Dr Peter Fürst (Chemical and Veterinary Control Laboratory, Münster, Germany), Professor Igor Glasunov (State Research Centre for Preventive Medicine, Moscow, Russian
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Federation), Dr Robert Goodland (World Bank, Washington, DC, United States of America), Professor Vilius Grabauskas (Kaunas University of Medi- cine, Lithuania), Dr Donato Greco (Istituto Superiore di Sanità, Rome, Italy), Dr Jens Gundgaard (University of Southern Denmark, Odense, Denmark), Dr Elizabeth Guttenstein (WWF European Policy Office, Brussels, Belgium), Dr Ranate Hans (Bundesinstituts für gesundheitlichen Verbraucherschutz und Veterinärmedizin (BgVV), Berlin, Germany), Dr Annemein Haveman- Nies (National Institute of Public Health and the Environment (RIVM), Bilthoven, Netherlands), Dr Serge Hercberg (Institut nationale de la santé et de la recherche médicale (INSERM), Paris, France), Dr Vicki Hird (Sustain: the alliance for better food and farming, London, United Kingdom), Profes- sor Alan Jackson (University of Southampton, United Kingdom), Dr An- thony Kafatos (University of Crete, Heraklion, Greece), Dr Dorit Nitzan Ka- luski (Ministry of Health, Jerusalem, Israel), Dr Ilona Koupilova (London School of Hygiene and Tropical Medicine, United Kingdom), Dr Alan Kerbey (International Obesity TaskForce, London, United Kingdom), Dr Marion Koopmans (Research Laboratory for Infectious Diseases, Bilthoven, Netherlands), Professor Daan Kromhout (National Institute of Public Health and the Environment (RIVM), Bilthoven, Netherlands), Dr Anne Käsbohrer (Bundesinstituts für gesundheitlichen Verbraucherschutz und Veterinär- medizin (BgVV), Berlin, Germany), Dr Denis Lairon (Institut nationale de la santé et de la recherché médicale (INSERM), Paris, France), Ms Hanne Larsen (Veterinary and Food Administration, Ministry of Food, Agriculture and Fisheries, Copenhagen, Denmark), Ms Lisa Lefferts (Comsumers Union, Washington, DC, United States of America), Dr Karen Lock (London School of Hygiene and Tropical Medicine, United Kingdom), Dr Susanne Logstrup (European Heart Network, Brussels, Belgium), Jeannette Longfield (Sustain: the alliance for better food and farming, London, United Kingdom), Dr Fabio Luelmo (tuberculosis consultant, WHO headquarters), Dr Ian MacArthur (Chartered Institute of Environmental Health, London, United Kingdom), Professor Lea Maes (University of Ghent, Belgium), Dr Rainer Malisch (State Institute for Chemical and Veterinary Analysis of Food, Freiburg, Germany)Professor Jim Mann (University of Otago, Dunedin, New Zealand), Professor Barrie Margetts (University of Southampton, United Kingdom), Ms Karen McColl (International Obesity TaskForce, London, United Kingdom), Professor Martin McKee (London School of Hygiene and Tropical Medicine, United Kingdom), Professor Anthony McMicheal (Lon- don School of Hygiene and Tropical Medicine, United Kingdom), Dr Bettina Menne (Technical Officer, Global Change and Health, WHO Regional Of- fice for Europe), Dr Eric Millstone (University of Sussex, Brighton, United
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Kingdom), Dr Gerald Moy (Department of Food Safety, WHO headquar- ters), Dr Paula Moynihan (University of Newcastle upon Tyne, United King- dom), Professor Aulikki Nissinen (National Public Health Institute, Helsinki, Finland), Professor Andreu Palou (University of the Balearic Islands, Palma de Mallorca, Spain), Dr Carmen Perez-Rodrigo (Department of Public Health, Bilbao, Spain), Ms Annette Perge (Veterinary and Food Administration, Min- istry of Food, Agriculture and Fisheries, Copenhagen, Denmark), Professor Janina Petkeviciene (Kaunas Medical University, Lithuania), Dr Stefka Petrova (National Centre of Hygiene, Medical Ecology and Nutrition, Sofia, Bulgaria), Dr Pirjo Pietenen (National Public Health Institute, Helsinki, Fin- land), Professor David Pimentel (Cornell University, Ithaca, New York, United States of America), Dr Joceline Pomerleau (London School of Hygiene and Tropical Medicine, United Kingdom), Professor Ritva Prättälä (National Public Health Institute, Helsinki, Finland), Professor Jules Pretty (University of Essex, Colchester, United Kingdom), Dr Iveta Pudule (Health Promotion Centre, Riga, Latvia), Professor Pekka Puska (Noncommunicable Diseases and Mental Health, WHO headquarters), Dr Mike Rayner (British Heart Foundation Health Promotion Research Group, Oxford, United Kingdom), Dr Allan Reilly (Food Safety Authority of Ireland, Dublin, Ireland), Dr Anton Reinl (Rechts und Steuerpolitik Präsidentenkonferenz der landwirtschaft- skammern österreichs, Vienna, Austria), Professor Andrew Renwick (Univer- sity of Southampton, United Kingdom), Dr Elio Riboli (International Agency for Research on Cancer, Lyon, France), Dr Maura Ricketts (Communicable Disease Surveillance and Response, WHO headquarters), Dr Anna Ritsatakis (former Head, WHO European Centre for Health Policy, WHO Regional Office for Europe), Dr Jocelyn Rocourt (Department of Food Safety, WHO headquarters), Professor A.J. Rugg-Gunn (WHO Collaborating Centre for Nutrition and Oral Health, University of Newcastle upon Tyne, United King- dom), Professor Hugh Sampson (Jaffe Food Allergy Institute, Mount Sinai School of Medicine, New York, New York, United States of America), Dr Jørgen Schlundt (Department of Food Safety, WHO headquarters), Professor Liselotte Schäfer Elinder (National Institute of Public Health, Stockholm, Sweden), Professor Lluis Serra-Majem (University of Las Palmas de Gran Canaria, Spain), Professor Aubrey Sheiham (University College London, United Kingdom), Dr Prakash Shetty (Food and Agriculture Organization of the United Nations, Rome, Italy), Professor Leigh Sparks (University of Stir- ling, United Kingdom), Dr Sylvie Stachenko (former Head, Non-Communi- cable Diseases and Mental Health, WHO Regional Office for Europe), Pro- fessor Elizaveta Stikova (Republic Institute for Health Protection, Skopje, The former Yugoslav Republic of Macedonia), Dr Boyd Swinburn (Deakin Uni-
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versity, Melbourne, Australia), Professor Andrew Tompkins (Institute of Child Health, London, United Kingdom), Professor Antonia Trichopoulou (WHO Collaborating Centre for Nutrition, University of Athens, Greece), Dr Sirje Vaask (Ministry of Social Affairs, Tallinn, Estonia), Professor Paolo Vineis (University of Turin, Italy), Dr Mathilde de Wit (Protection of the Hu- man Environment/Food Safety, WHO headquarters), Professor Alicja Wolk (Karolinska Institute, Stockholm, Sweden) and Dr Gabor Zajkas (National Institute of Food Hygiene and Nutrition, Budapest, Hungary).
For their assistance in the production of this book, we are also very much in debt to staff of the WHO Regional Office for Europe (Ms Sally Charnley, Ms Elena Critselis, Ms Madeleine Nell Freeman, Ms Gillian Holm, Ms Carina Madsen and Ms Nina Roth) and the International Obesity TaskForce (Ms Rachel Jackson Leach, Dr Neville Rigby and Dr Maryam Shayeghi), who have helped in the production of this book.
Aileen Robertson, Cristina Tirado, Tim Lobstein, Marco Jermini, Cecile Knai, Jørgen H. Jensen,
Anna Ferro-Luzzi and W.P.T. James
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Editors
Professor Anna Ferro-Luzzi Head, National Research Institute for Food and Nutrition, WHO Col- laborating Centre for Nutrition, Rome, Italy
Professor W.P.T. James Chairman, International Obesity TaskForce, London, United Kingdom
Dr Jørgen H. Jensen Director, Regional Office for Food Control, Copenhagen, Denmark
Dr Marco Jermini Head, Food Microbiology Department, Cantonal Laboratory, Public Health Division, Department of Social Affairs, Lugano, Switzerland
Ms Cecile Knai Consultant, Nutrition and Food Security, WHO Regional Office for Europe
Dr Tim Lobstein Director, The Food Commission, London, United Kingdom
Dr Aileen Robertson Regional Adviser, Nutrition and Food Security, WHO Regional Office for Europe
Dr Cristina Tirado Regional Adviser, Food Safety, WHO European Centre for Environment and Health, Rome, WHO Regional Office for Europe
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Abbreviations
Organizations, studies, programmes and projects cCASHh Climate Change and Adaptation Strategies for Human
Health (WHO project) CINDI WHO countrywide integrated noncommunicable
disease intervention (programme) DAFNE Data Food Networking (study) DASH dietary approaches to stop hypertension (trial) EC European Commission ECRHS European Community Respiratory Health Survey EFCOSUM European Food Consumption Survey Method (project) EPIC European prospective investigation into cancer FINE Finland, Italy and the Netherlands (study) EU European Union FAO Food and Agriculture Organization of the United
Nations GEMS/Food Food Contamination Monitoring and Assessment
Programme of the Global Environment Monitoring System
GEMS/Food Europe WHO European Programme for Monitoring and Assessment of Dietary Exposure to Potentially Hazardous Substances
IFOAM International Federation of Organic Agriculture Movements
MISTRA Foundation for Strategic Environmental Research SCOOP Scientific Co-operation within the European
Community SENECA Survey Europe on Nutrition in the Elderly: a Concerted
Action UNICEF United Nations Children’s Fund WTO World Trade Organization
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Technical and other terms ANGELO analysis grid for environments linked to obesity
(framework) BMI body mass index BSE bovine spongiform encephalopathy CAP (EU) Common Agricultural Policy CCEE countries of central and eastern Europe CHD coronary heart disease CO2 carbon dioxide CVD cardiovascular diseases DALYs disability-adjusted life-years DDT dichlorodiphenyltrichloroethane DMFT decayed, missing and filled permanent teeth GATT General Agreement on Trade and Tariffs GMO genetically modified organism HACCP hazard analysis and critical control points HDL high-density lipoprotein (cholesterol) IUD intrauterine device LDL low-density lipoprotein (cholesterol) NIS newly independent states N2O nitrous oxide RDA recommended daily allowance PCBs polychlorinated biphenyls PCDDs dibenzo-p-dioxins PCDFs polychlorinated dibenzofurans SD standard deviation STEFANI strategies for effective food and nutrition initiatives
(model) vCJD variant Creutzfeldt-Jacob disease
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Foreword
In 2000, the WHO Regional Committee for Europe requested the Regional Direc- tor, in resolution EUR/RC50/R8, to take action to help fulfil WHO’s role in implementing its first food and nutrition action plan for the WHO European Region. This included presenting Member States with a review of the scientific evidence needed to develop integrated and comprehensive national food and nutri- tion policies. This book fills that need, providing a comprehensive, in-depth analy- sis of the data on nutritional health, foodborne disease, and food safety and public health concerns about the supply and security of food in Europe.
First, this book looks at the burden of diet-related disease in the European Re- gion, discusses the costs to society and asks whether the incidence of these diseases could be reduced. It presents policy options and solutions, along with dietary guide- lines and case studies from different countries.
Just like clean air and water, a variety of high-quality, nutritious, safe food is crucial to human health. Many sectors – the health sector and others, such as agri- culture and food retailing and catering – influence health. Ensuring the availabil- ity of such food is one of the best ways to promote good business while protecting and promoting health. WHO has developed global strategies for nutrition and food safety, and this book makes specific recommendations for the countries in the European Region to ensure consumer confidence while protecting and promoting the population’s health.
Efficient agricultural policies have ensured that most populations in Europe have a secure food supply, so much so that many public health experts no longer understand the concept of food security. This book explains what food security means to the health of Europeans today; it also:
• spells out the health aspects of food production; • examines the forces that shape food consumption patterns; and • explores the opportunities for influencing food policies so that health experts can
better understand what evidence exists and what methods can be used to ensure that health receives due priority.
Fortunately, the solutions for the ethical concerns surrounding food and health are in line with solutions for protecting the environment and promoting sustainable
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rural development. In addition, the book shows how poverty increases food inequalities in every country in Europe, and suggests policy options to reduce them.
Policy on food and nutrition may be a relatively new concept for some public health experts in Europe. This book presents case studies: examples of policies that promote public health (policy concordance) and of those that ignore it (policy dis- cordance). They show why comprehensive food and nutrition policies can only be successful if the policies on food production and distribution are developed along with those on food safety and nutrition.
Food and its central role in improving health should be perceived as an integral part of a primary health service. While health professionals usually lack a sufficient understanding of this role, the general public is becoming very concerned about it. This publication provides correct and consistent information for use by health pro- fessionals. This approach follows the initiatives of WHO and other international bodies to bring human and environmental health and sustainable development into a coherent whole.
Experts working all over Europe contributed technical input to this book. We at the WHO Regional Office for Europe sincerely thank all these people, who are committed to encouraging WHO to develop and promote the scientific evidence that helps governments to implement food and nutrition policies.
The WHO Regional Office for Europe encourages and supports countries in developing and implementing their food and nutrition action plans. The contri- bution of this publication is to strengthen the capacity of health professionals as an efficient investment in improving public health in Europe. Written to provide the scientific evidence for national action plans and the First Action Plan for Food and Nutrition Policy, WHO European Region 2000–2005, this book is one of the first to give a comprehensive review of the effects of the food we eat on the health we have the right to enjoy.
Marc Danzon WHO Regional Director for Europe
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Introduction: the need for action
on food and nutrition in Europe
In the 1950s, Europe was recovering from a devastating war. Food policies were devoted to establishing secure, adequate supplies of food for the popula- tion. Refugees and food rationing were still huge problems, and the European Region relied heavily on countries such as Australia, Canada and the United States to provide its bread, cheese and meat.
By the mid-1970s, strong national and regional measures to support agri- culture had helped ensure better agricultural supplies within the WHO Euro- pean Region, in both the western and eastern countries. In general, there was plenty to eat, and a huge food processing industry had become well established.
Yet all was not well. By the 1980s, policies in western Europe had been too successful, creating problems of overproduction and what to do with the huge amounts of food that were not being eaten. In eastern Europe, the political changes of the late 1980s and early 1990s led to increasing problems with food supply and distribution. In addition, the movement of food increased in the 1990s, in terms of both the quantity transported and the distances trav- elled. Across the Region, there was evidence of increasing rates of disease related to the food being eaten: rising rates of foodborne infectious disease, rising rates of deficiency diseases in pockets of the Region and high rates of chronic, degenerative diseases in which diet plays a key role.
The impact of these diseases – the burden on health services and the costs to economies, societies and families – is beginning to be seen. In particular, health services are becoming conscious of the share of their budgets consumed by food-related ill health. In response, health policy-makers are turning their attention upstream, looking at the early causes of ill health, rather than its diagnosis and treatment. This enables policy-makers to explore possibilities for reducing the burden of disease on the health services and improving the health of the population at large.
This book supports these health policy initiatives. It reviews the current burden of food-related disease in the European Region, examines the links be- tween disease and food, and looks upstream at the nature of food supplies. It
2 Food and health in Europe
shows that policies on food supply and a range of related topics – such as sustainable agriculture and rural development, transport and food retailing and planning – are all linked to the problems of nutrition, food safety and food quality.
In doing this, the book recognizes the very uneven patterns of food pro- duction, food safety problems and diet currently prevailing in the European Region. These patterns vary widely between the Nordic, central and Mediter- ranean countries in the European Union (EU), and even more among the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR. In addition, agricultural policies and sup- port measures differ; food distribution and consumption patterns differ; di- etary disease incidence and prevalence differ. These differences can help to reveal the causes of ill health, and point towards their solution.
This book gives data where the figures are available, and points to areas where they are lacking.1 It shows that knowledge about the links between food production, distribution and consumption and subsequent health pat- terns is now sufficient to enable these elements to be seen as parts of a greater whole. This whole is influenced by past and present food policies, and can in- fluence future policy-making.
Overview of the book This book lays out the available data that show the links between health, nutrition, food and food supplies, as outlined in the First Action Plan for Food and Nutrition Policy, WHO European Region, 2000–2005 (Annex 1). Rising concern about health and consumer issues has led EU countries explicitly to include assessments of the effects on health of other sectors’ poli- cies, in accordance with the Amsterdam Treaty. The Action Plan recommends that WHO Member States within and outside the EU develop cross-sectoral mechanisms to ensure that health policies are integral to non-health sectors. The WHO Regional Office for Europe has expressed its commitment to sup- porting Member States in this task.
Diet and disease Care needs to be taken to distinguish the share of disease attributable to poor diets and that avoidable through better diets. Two assumptions underpin the analysis of the costs and burdens of diet-related ill health: that diet can be a primary cause of disease or cause a reduction in disease, and that the extent of
1 Food and health in Europe: a new basis for action. Summary (http://www.euro.who.int/Information- Sources/Publications/Catalogue/20030224_1). Copenhagen, WHO Regional Office for Europe, 2002 (accessed 3 September 2003).
Introduction: the need for action on food and nutrition in Europe 3
this causation can be measured. Arriving at agreed figures for the extent of cau- sation is not simple. In many diseases, diet is only one of many contributory factors (such as smoking or lack of physical activity), and even the dietary component may vary in different circumstances. Attempts need to be made to tease out the relationships. Chapter 1 looks at patterns of disease and their links to diet.
Fundamental to examining patterns of disease is the notion that they vary between places or over time. These differences allow the suggestion of reasons, which imply causative links, and of remedies, so that people with higher rates of disease may experience the lower rates enjoyed by others.
Chapter 1 reviews chronic noninfectious diseases with links to diet, in- cluding the major causes of death in the European Region (cardiovascular dis- eases and cancer) and those that may not kill but nevertheless are costly to health services, such as dental disease and hypertension. The role of physical activity as an independent and complementary factor reducing the risk of di- etary diseases is highlighted.
Chapter 1 also discusses deficiency diseases, such as those related to iodine and iron deficiency, which are still widespread in parts of Europe, including subpopulations in western European countries, and Chapter 4 considers their implications for food and nutrition policies. Chapter 1 presents nutrition data during key stages in the human life cycle, and considers the possibilities that fetal, infant and childhood nutrition may have long-term implications for chronic diseases in adulthood.
Economic status – expressed as household income, earnings or employ- ment category – appears to be a major determinant of many diseases that are known to have dietary links. As illustrated at the end of Chapter 1, poverty is associated with a higher level of risk for these diseases. Various policy implica- tions can be derived from this, and Chapter 4 highlights such issues as access to healthier foods, their cost, the need to store and prepare them, planning and transport policies, education policies and priorities, advertising policies and the social provision of foods through schools and hospitals.
Food safety Chapter 2 presents short reviews of the links between food safety, health and foodborne diseases. It also looks at toxicological and food safety issues, and considers concerns about the contamination of food with toxic chemicals (such as dioxins), potent microbial agents (such as Escherichia coli 0157) and bioactive proteins (such as protease-resistant prions), as well as longer-stand- ing concerns about the impact on health of agrochemicals and veterinary drugs used to enhance agricultural productivity.
Good evidence links these aspects of food and health – principally food safety and nutrition – in certain circumstances. Each affects the other. On the
4 Food and health in Europe
one hand, nutritional status can determine the risk of infectious disease, and dietary patterns can lower the risk of infection. On the other, foodborne dis- ease can reduce nutrient intake.
Food security and sustainable development The role of food production in generating food-related ill health forms an integral part of this book. Chapter 3 discusses methods of agriculture and food processing, the types of food produced and the increasingly long distances that food commodities travel.
Although production is frequently asserted to follow the patterns of food demanded on the market, there are good reasons to suggest that food produc- tion has become dissociated from market demand and that many factors dis- tort the market. The forms of food production determine not only food prod- ucts’ safety but also their nutritional and dietary value. Food production methods – and the factors that influence them – thus form an integral part of the patterns of food-related ill health.
Environmental issues, especially the need to develop farming methods that are sustainable in the long term, have a bearing on food production. A broad degree of concurrence can be foreseen between the production of food for hu- man health and the production of food for environmental protection. Nutri- tion and environmental policies can thus be developed in parallel, as outlined in the WHO Action Plan.
Food production affects human health in other ways than through food consumption. The nature and sustainable development of the rural economy have implications for rural employment, social cohesion and leisure facilities. These in turn foster improved mental and physical health.
These issues are not mere by-products of sustainable development; they are central to the retention of rural social structures. The wider costs of conven- tional intensive agriculture have been described, and Chapter 3 gives some figures on their economic impact. Any health impact assessments of rural environmental policies and agricultural policies need to consider these largely hidden costs of different farming methods. Chapter 3 explores a model of social capital and social dividends, and different food production methods can be shown to help increase or deplete them.
Hidden costs or externalities (costs that are not directly borne by the production process) affect both agriculture and food processing, packaging and distribution. Transport, for example, has relatively low direct costs, but can have much higher true costs when externalities are taken into account. These hidden costs include pollution and traffic accidents. They not only indicate that the activity is not sustainable in the long term but also di- rectly affect health, and hence place a burden on society and the health services.
Introduction: the need for action on food and nutrition in Europe 5
Policies and strategies Ensuring the safety of food is regulators’ and legislators’ first priority; its health promoting features and its sustainable supply come second. Breaches in food safety can lead to immediate and often fatal outbreaks of food poisoning, and the main thrust of food inspection and control procedures is to ensure that food is safe to be eaten.
Changes in food production methods, discussed in Chapter 3, have led to the changes in food control strategies discussed in Chapter 4, such as the adoption of hazard analysis and critical control points (HACCP) procedures. In addition, as discussed earlier, it is useful to look upstream and ask why con- taminants and hazards find their way into the food supply, rather than relying on minimizing the risks from those that are already present.
Looking upstream at food production is one valuable step, but others also need to be taken. With increasing long-distance distribution of primary and processed products, across national boundaries and around the globe, national regulations are coming under scrutiny, and international agencies (such as the Codex Alimentarius Commission) are increasingly involved in setting safety standards. International standards for the food trade need to be set to protect health, and the health impact of trading policies needs to be assessed.
Chapter 4 discusses nutrition policies from the perspective of improving nutrition at key points during the life-course to maximize opportunities for health in later life. The examples given include exclusive breastfeeding in early infancy to prevent ill health in childhood, and the improvement of women’s nutrition before and during pregnancy to ensure optimum growth of the fetus and infant and the prevention of disease in adulthood.
Chapter 4 also discusses the setting of population targets for healthy eat- ing. These targets have become increasingly specific in the last 20 years, mov- ing from general statements about the need to eat a healthy diet to numerical recommendations for certain nutrients and foods. Such targets as increasing fruit and vegetable consumption and reducing fat, salt and sugar intake have implications beyond the orbit of health educators and public advice, and are of direct concern to agricultural production and the food processing and re- tailing industries.
Population-based nutrition programmes are required to translate popula- tion targets into practice. Such programmes include various measures, ranging from specific initiatives advising on healthy lifestyles to controls over food la- belling, health claims and advertising. Messages on healthy eating need to be consistent, and widely accepted and promoted by all stakeholders.
Nutrition, food safety and food standards are the policy areas that directly affect food-related ill health. As suggested, many other human activities and the policies that govern them have an influence. These activities include the growing, transport, processing, distribution and marketing of food. Policies
6 Food and health in Europe
on these activities can be presumed to have a bearing on subsequent food safety and nutrition, and hence influence health.
Health impact assessment of such policies is being developed in various forms across Europe and elsewhere, and the procedures have many common threads. The methods involve iterative processes, so that initial conclusions can be re-examined and refined and additional material added to the analysis. They have the advantage of providing the basis for a democratic form of decision-making, and can increase the transparency of the processes and of the interests involved in policy-making.
Different forms of intervention need greater analysis to examine their cost–effectiveness and – efficiency. Surveillance, including monitoring and evaluation, is discussed in Chapter 4.
WHO activities Discordant agricultural, industrial and food policies can harm health, the environment and the economy, but harmful effects can be reduced and health can be promoted if all sectors are aware of the policy options. National poli- cies on food and nutrition should address three overlapping areas: nutrition, food safety and a sustainable food supply (food security). The First Action Plan for Food and Nutrition Policy calls for interrelated strategies on all three (See Chapter 4, Fig. 4.1, p. 222).
WHO’s traditional roles – supporting the health sector in the provision of services and training of health professionals, advising it on planning and as- sisting in health programmes – can be extended and developed. The Action Plan outlines a series of support measures for national and regional authori- ties. This book provides a basis for these actions, founded on scientific evi- dence on the causes of food-related ill health.
7
1. Diet and disease
The burden of disease varies widely within the WHO European Region and has changed dramatically in many countries over the last 20 years. Patterns of disease and changes in these patterns have environmental determinants, with diet and physical activity playing major roles.
This chapter assesses the range of major health issues confronting Euro- pean countries and some of the principal determinants of diseases leading to death and disability. Differences and changes in diet explain much of the dif- ferent patterns of ill health observed in children and adults.
Appropriate public health policies can help prevent the nutrition-related diseases discussed here. Chapter 4 presents recommendations on policy, and cross-references are made where applicable throughout Chapter 1.
Diet-related diseases: the principal health burden in Europe The burden of disease has been assessed in terms of disability-adjusted life- years (DALYs). These incorporate an assessment of the years of life lost to different diseases before the age of 82.5 years for females and 80 for males (1) and the years spent in a disabled state (2). Non-fatal health states are assigned values (disability weights) for estimating years lost to disability based on surveys. Years lost (severity adjusted) to disability are then added to years lost to premature mortality to yield an integrated unit of health: the DALY; one DALY represents the loss of one year of healthy life.
Fig. 1.1 shows the contribution of nutrition to the burden of disease in Europe (3), displaying the share of DALYs lost to diseases that have a substantial dietary basis (such as cardiovascular diseases (CVD) and cancer) separately from that to which dietary factors contribute less substantially but still importantly. In 2000, 136 million years of healthy life were lost; major nutritional risk factors caused the loss of over 56 million and other nutrition- related factors played a role in the loss of a further 52 million. CVD are the leading cause of death, causing over 4 million deaths per year in Europe. Dietary factors explain much of the differences in these diseases in Europe. The world health report (4) includes an estimate of the quantitative contribution of dietary risk factors such as high blood pressure, serum cholesterol, overweight,
8 Food and health in Europe
obesity and a low intake of fruits and vegetables. European policy-makers will need to make their own assessments of the relative burden of dietary risk factors in relation to disease prevalence in their own country.
Fig. 1.1. Lost years of healthy life in the European Region, 2000
Source: adapted from The world health report 2000. Health systems: improving performance (3).
Diet as a determinant of health The dietary contributions to CVD, cancer, type 2 diabetes mellitus and obesity have many common components, and physical inactivity is also relevant to all four. The overall effect of each dietary component and of physical inactivity should be calculated and their relative quantitative significance estimated. Unfortunately, only one such assessment of the burden of disease attributable to nutrition in Europe has yet been published (5).
The National Institute of Public Health in Sweden attempted to estimate the burden of disease that could be attributed to various causal factors,
Diabetes mellitus
(5%)
Malignant neoplasm
(32%)
Other neoplasms
(0.2%)
Nutritional deficiencies
(2%)
CVD (61%)
41%
38%
21%
Diseases with major nutritional determinants
Other disorders
Diseases in which nutrition
plays a role
Digestive diseases (9.5%)
Congenital abnormalities
(4.2%)
Nutritional endocrine disorders
(2.6%)
Neuropsychiatric disorders (51.1%)
Perinatal conditions
(8%)
Respiratory diseases (13.2%)
Oral diseases (1.1%)
Respiratory infections
(6.8%)
Maternal condition
(1%)
Infectious and
parasitic diseases (10.5%)
Unintentional injury
(45.9%)
Intentional injury
(21.9%)
Genitourinary diseases
(5%)
Musculoskeletal diseases (19%)Skin diseases
(0.1%) Sense organ
disorders (0.1%)
Diet and disease 9
including dietary factors, in the EU (6), and ranked the leading risk factors contributing to the burden of disease (Table 1.1). Analyses suggest that poor nutrition accounts for 4.6% of the total DALYs lost in the EU, with overweight and physical inactivity accounting for an additional 3.7% and 1.4%, respectively (6). This analysis does not, however, capture the complexity of the situation and is thus likely to underestimate the importance of nutrition. For example, dietary factors interact with other risk factors. Substantial fruit and vegetable consumption seems to reduce the risk of lung cancer among smokers, although smoking is associated with a large increase in the probability of developing lung cancer even among those with the highest consumption. Other dietary components may moderate the impact of alcohol consumption. Taken together, this evidence suggests that improving nutrition could be the single most important contributor to reducing the burden of disease in the WHO European Region.
Table 1.1. Contribution of selected factors to the overall burden of disease in the EU
Source: Determinants of the burden of disease in the European Union (6).
Studies from Australia and New Zealand (7–9) support this finding. In these countries, about 3% of the burden of disease (2.8% in Australia and 2–4% in New Zealand) could be attributed to low consumption of fruits and vegetables. The Australian studies also reported that about 10% of all cancer cases could be attributable to insufficient intake (8,9).
The contribution of various factors to the total burden of disease has been estimated in Australia (8) (Fig. 1.2). The multiple interacting processes by which different dietary factors contribute to the disease burden make these analyses more difficult, and there is no agreement on the extent of synergism or on the relative quantitative importance of the main contributors to different diseases or to public health in general.
Causal factor Contribution (%)
Tobacco smoking 9.0
Alcohol consumption 8.4
Overweight 3.7
Occupational risks 3.6
Low fruit and vegetable consumption 3.5
Relative poverty 3.1
Unemployment 2.9
Illicit drugs 2.4
Physical inactivity 1.4
Diet high in saturated fat 1.1
Outdoor air pollution 0.2
10 Food and health in Europe
Fig. 1.2. Proportion of the total burden of disease (in DALYs lost) attributable to selected risk factors, by sex, Australia, 1996
Source: adapted from Mathers et al. (8).
CVD and cancer cause almost two thirds of the overall burden of disease in Europe. Conservative estimates suggest that about one third of CVD is related to inappropriate nutrition, although the need for more research is widely acknowledged. Cancer kills about 1 million adults each year in the WHO European Region. As with CVD, inappropriate diet causes about one third of all cancer deaths worldwide. A report by the World Cancer Research Fund and the American Institute for Cancer Research (10) estimated that improved diet, along with maintenance of physical activity and appropriate body mass, could reduce cancer incidence by 30–40% over time. Doll & Peto (11) made a widely cited estimate of the diet-related burden of cancer, attributing about 35% of all cancer deaths in the United States to diet (excluding alcohol) and a further 3% to alcohol. They qualified this, however, by also suggesting a range of plausible estimates of between 10% and 70% attributable to diet and a further 2.4% to alcohol. Doll (12) later proposed that the evidence available up to the early 1990s associating diet with cancer had become stronger, and gave a narrower range of 20–60%.
Numerous studies have aimed to identify the components of diet that have the greatest influence on CVD and cancer. Many earlier clinical and epidemiological investigations focused on fat intake. In the early 1990s, a study in the United States suggested that reducing fat consumption from 37% of energy intake to 30% would prevent 2% of deaths from CVD and cancer, primarily among people older than 65 years (13). More recently,
High blood cholesterol
High blood pressure
Lack of fruit and vegetables Obesity
Physical inactivity
Alcohol harm Alcohol benefit
Tobacco Illicit drugs
Occupational
Unsafe sex
– 4 – 2 0 2 4 6 8 10 12 14
Percentage of total DALYs
Males Females
Total = 15%
Diet and disease 11
Willett (14) suggested that replacing saturated and trans-fatty acids in the diet could be more important for preventing CVD than reducing the total amount of fat consumed. For example, replacing 6% of energy intake from predominantly animal fat with monounsaturated fat could potentially reduce CVD by 6–8% (15). Growing evidence also indicates that other dietary factors are associated with CVD and cancer risk. There is an international consensus that an excess of energy (more energy consumed in the diet than is expended) and alcohol are risk factors for certain types of cancer (mouth, pharynx, larynx, oesophagus and liver) and that a high intake of fruits and vegetables protects in part against the agents causing cancers of the mouth, pharynx, oesophagus, stomach and lung (10,16,17). Deficiencies of substances such as vitamin A, other antioxidant vitamins and non-nutrient components of fruits and vegetables have also been linked to an increased risk of both CVD and cancer, although this area remains inadequately researched (10,18).
Joffe & Robertson (19) investigated the potential health gain if vegetable and fruit intake increased substantially within the EU and three countries in the process of joining it. They estimated that about 23 000 deaths from coronary heart disease (CHD) and major types of cancer before age 65 could be prevented annually if low intake of fruits and vegetables were increased to that of the groups consuming the most.
The importance of nutrition in determining or modulating so many major causes of disability and premature death implies that dietary patterns should differ remarkably across Europe and change over time. Fig. 1.3 displays the re- markable variation in estimated national intake of fruits and vegetables in the EU countries, the Czech Republic, Hungary and Poland. There is a general north–south gradient, with higher intake in the south.
The WHO goal for vegetable and fruit intake is at least 400 g per person per day as a national average throughout the year (21). The intake is less than this in most countries in the European Region, although climate and agricultural conditions in southern and central Europe are ideal for producing sufficient fruits and vegetables to feed the whole Region throughout the year. The mean consumption of fruits and vegetables is a poor measure of the distribution of intake within a population. Fruit and vegetable intake is not normally distributed evenly, but highly skewed. Thus, the mean intake values conceal a large proportion of the population within each country with very low consumption. Despite a relatively high mean consumption of 500 g per day in Greece, for example, 37% of the population is below the recommended level (22).
The availability of fruits and vegetables differs vastly at different times of year. Powles et al. (23) found evidence for the importance of seasonality in the role of fresh fruits and vegetables in reducing CVD mortality. This has been
12 Food and health in Europe
suggested as one explanation for the seasonal cycling and severity of CHD in the affected countries (23).
Fig. 1.3. Vegetable and fruit intake (mean g/day) in selected European countries
Source: Comparative analysis of food and nutrition policies in the WHO Europe- an Region 1994–1999. Full report (20).
Not only does fruit and vegetable intake differ surprisingly across Europe, but both the total quantity eaten and the variety and choice have changed re- markably over the last 50 years.
Similar changes and differences apply to the availability of milk fat and fish (according to food balance sheets of the Food and Agriculture Organization of the United Nations (FAO) – Fig. 1.4 and 1.5). Consumption of milk fat is very substantial in north-western Europe and especially in the non-Mediterranean countries. Given its major contribution in inducing high serum cholesterol levels and CVD, it is not surprising that milk-fat consumption predicts the prevalence of CVD across Europe (24).
0 100 200 300 400 500 600 700
United Kingdom (1995)
Ireland (1989)
Austria (1998)
Netherlands (1992)
Germany (1990)
Czech Republic (1997)
Sweden (1989)
Denmark (1995)
Poland (1997)
Belgium–Luxembourg (1982)
Hungary (1997)
Portugal (1980)
France (1996)
Italy (1995)
Finland (1997)
Greece (1997)
Spain (1994)
Intake (g per person per day)
WHO goal
Diet and disease 13
Fig. 1.4. Availability of milk fat, selected countries in the WHO European Region, 1998
a The former Yugoslav Republic of Macedonia.
Source: Food and Agriculture Organization of the United Nations (http://apps. fao.org/lim500/wrap.pl?FoodBalanceSheet&Domain=FoodBalanceSheet&Lan- guage=english, accessed 25 September 2003).
The pattern of fish supply shown in Fig. 1.5 may result from the availabil- ity of fish in the locality unless a country is affluent enough to import sub- stantial quantities. If an intake of at least 200 g fish per person per week is considered reasonable, consumption reaches this level in only about 10% of countries.
6 10 10
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Bulgaria
Ukraine
Latvia
Malta
Romania
Poland
Norway
Greece
Belarus
Germany
Netherlands
Austria
Switzerland
France Iceland
Finland
Ireland
Sweden
Albania
Belgium–Luxembourg
Estonia
United Kingdom
Italy
Czech Republic
Denmark
Portugal
Slovenia
Russian Federation
Kyrgyzstan
Kazakhstan
Hungary
Israel
Croatia
Republic of Moldova
Georgia
Milk fat Butter
Availability (g per person per day)
a
14 Food and health in Europe
Fig. 1.5. Availability of fish, selected countries in the WHO European Region, 1998
Source: Food and Agriculture Organization of the United Nations (http://apps. fao.org/lim500/wrap.pl?FoodBalanceSheet&Domain=FoodBalanceSheet&Lan- guage=english, accessed 25 September 2003).
Government policies and industry initiatives can substantially affect the na- tional consumption of all three categories of food considered here. For in- stance, when eastern Finland and the province of North Karelia were especially affected by CVD, a major comprehensive prevention project was started in 1972, and developed from a demonstration project into national action. Leg- islative and other policy decisions included the development of low-fat spreads, fat and salt labelling for many food groups and improving the quality of meals at schools and in the army. The food industry became involved by de- veloping a cholesterol-lowering rapeseed oil from a new type of rape plant that grows well in the northern climate of Finland. This was in effect a domestic, heart-healthy alternative to butter. As a result, from 1972 to 1997, vegetable
0 50 100 150 200 250 300
Uzbekistan
Republic of Moldova
Belarus
Romania
Turkmenistan
Kazakhstan
Croatia
TFYR Macedonia
Slovenia
Czech Republic
Austria
Germany
Netherlands
Switzerland
Belgium–Luxembourg
United Kingdom
Israel
Greece
France
Malta
Norway
Iceland Portugal
Spain
Finland
Sweden
Denmark
Italy
Russian Federation
Estonia
Lithuania
Ireland
Poland
Latvia
Ukraine
Slovakia
Hungary
Bulgaria
Georgia
Albania
Azerbaijan
Armenia
Kyrgyzstan
Availability (g per person per day)
a
The former Yugoslav Republic of Macedonia.a
Diet and disease 15
intake nearly tripled; fish consumption doubled; the use of full-fat milk fell dramatically (Fig. 1.6) and vegetable oil increasingly replaced butter (Fig. 1.7).
Fig. 1.6. Percentage of men and women aged 35–59 years in North Karelia, Finland drinking fat-containing milk and skim milk, 1972 and 1997
Source: Puska (25).
Fig. 1.7. Percentage of men and women aged 35–59 years in North Karelia, Finland using butter and vegetable oil, 1972 and 1997
Source: Puska (25).
These comprehensive actions were associated with a remarkable fall in CVD mortality, especially CHD mortality, in eastern Finland (Fig. 1.8).
These differences in intake of fruits and vegetables, fish and milk fat can be linked to other nutritional problems. Thus, pregnant women eating more fruits and vegetables have a higher intake of folic acid; this has been linked to fewer small and premature babies and to the prevention of neural tube defects (see p. 47). Women’s consumption of fruits and vegetables limits the likelihood of iron deficiency before pregnancy and of developing anaemia in pregnancy.
0
10
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30
40
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1972
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o f
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y m
ilk (
% )
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1972
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o f
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)
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% )
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1972 1997
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)
16 Food and health in Europe
In addition, the fruits and vegetables eaten by a nursing mother induce higher blood levels of water-soluble vitamins, which readily pass to the breastfed baby.
Fig. 1.8. Predicted and observed mortality from CHD in females aged 35–64, north-eastern Finland
Source: Vartiainen et al. (26).
The consumption of vegetables and fish by young women before and during pregnancy is also crucial to storing omega-3 essential fatty acids in their fat depots, which are called on selectively during pregnancy for channelling to the uterus and the developing fetus. The growth of the fetus and especially the brain of both the fetus and young child crucially depend on having adequate amounts of omega-3 essential fatty acids, which happens only if the mother has been eating an appropriate diet and breastfeeding her child. WHO advocates the gradual introduction of a variety of puréed fruits and vegetables and fish and meats at about 6 months (see Chapter 4, pp. 245–248) (27). Unmodified cow’s milk should not be given as a drink before the age of 9 months but can be used in small quantities in preparing complementary foods for babies aged 6–9 months (see Chapter 4, pp. 245–248).
Fish not only is a good source of omega-3 fatty acids but also modulates immune responsiveness, limits disturbances of fat metabolism and stabilizes
D ec
lin e
in m
o rt
al it
y (%
)
Year 1972 1976 1980 1984 1988 1992
Smoking
Blood pressure
Predicted (all risk factors)
Cholesterol
Observed (all risk factors)
–20
0
20
40
60
80
Diet and disease 17
the excitability of the heart, thereby limiting the risk of sudden cardiac death. Moreover, fish provides an excellent source of zinc, iron and animal proteins that are conducive to the longitudinal growth of the child and the prevention of anaemia.
Given this remarkable interplay between different foods and health, why is the European population not consuming enough of these vital foods at every stage of the life-course? What are the main impediments to their availability and consumption? The precise reasons for poor intake need to be assessed in each country and for each age group, but this book discusses general possibili- ties in the section on social inequality in this chapter (see pp. 66–73) and gives policy options in Chapter 4.
The widely varying dietary patterns across Europe are governed by not only geographical, climatic and agricultural factors described in Chapter 3 (see Fig. 3.5, p. 166) but also societal conditions, including income levels, civil strife, the status of women, urbanization, exposure to marketing and the changing of family and community structures.
The nutrition transition and its effects on health National consumption figures for fruits and vegetables and other dietary ingredients (Fig. 1.3–1.5) and breastfeeding rates (see Fig. 1.23, p. 51) differ remarkably. Consumption levels can change over relatively short periods, as shown by the decline in milk-fat consumption in parts of Finland.
Comparison of dietary patterns with other national statistics, such as gross national product, suggests that consumption patterns for dietary components such as meat, fat and vegetables are linked to national wealth, but these patterns change over time and, at the level of households, may depend on income and food security. At a global level, good evidence indicates a transition in nutrition, in which rising national wealth is accompanied by changes in diet, with an increase in consumption of animal-derived products, fat and oil and a reduction in cereal foods and vegetables. The WHO publication Globalization, diets and noncommunicable diseases (28) describes this transition:
Rapid changes in diets and lifestyles resulting from industrialization, urbaniza- tion, economic development and market globalization are having a significant impact on the nutritional status of populations. The processes of modernization and economic transition have led to industrialization in many countries and the development of economies that are dependent on trade in the global market. While results include improved standards of living and greater access to services, there have also been significant negative consequences in terms of inappropriate dietary patterns and decreased physical activities, and a corresponding increase in nutritional and diet-related diseases.
18 Food and health in Europe
Food and food products have become commodities produced and traded in a market that has expanded from an essentially local base to an increasingly global one. Changes in the world food economy have contributed to shifting dietary pat- terns, for example increased consumption of an energy-dense diet high in fat, par- ticularly saturated fat, and low in carbohydrates. This combines with a decline in energy expenditure that is associated with a sedentary lifestyle, with motorized transport, and labour-saving devices at home and at work largely replacing physi- cally demanding manual tasks, and leisure time often being dominated by physi- cally undemanding pastimes.
Because of these changes in dietary and lifestyle patterns, diet-related diseases – including obesity, type II diabetes mellitus, cardiovascular disease, hypertension and stroke, and various forms of cancer – are increasingly significant causes of dis- ability and premature death in both developing and newly developed countries. They are taking over from more traditional public health concerns like undernu- trition and infectious disease, and placing additional burdens on already overtaxed national health budgets.
Dietary patterns, based on food supply data, can be estimated for national populations, using the FAO database, from 1960 onwards. A pattern of nutri- tion transition can be detected in, for example, southern European countries, which traditionally had diets dominated by plant foods, fish, olive oil and wine. Countries such as Greece, Portugal and Spain show some evidence of moving from Mediterranean-type diets to ones more like those eaten in northern Europe, rich in meat and dairy products.
Simopoulos & Visioli (29) suggest that there is not one type of Mediterranean diet, although countries of the Mediterranean region traditionally all have high intakes of fruits and vegetables and low intakes of saturated animal fat. The region includes varied cultures, traditions, incomes and dietary habits and patterns, all of which are evolving with the impact of economic development and globalization. The food supplies and therefore the diets of Europeans seem to be changing rapidly.
The demographic transition – from rural societies with low life expectancy at birth and families with many children to urban societies with higher life ex- pectancy at birth and fewer children – is well known. The epidemiological transition that follows the demographic transition is also fairly well under- stood: a shift from endemic deficiency and infectious diseases, mostly in early life, to chronic diseases in later life.
Evidence is now sufficient to propose a general theory for these causally and chronologically linked demographic, nutrition and epidemiological tran- sitions. When populations undergo massive social and technological change – as in the NIS, where the level of urbanization is predicted to reach 90% by 2015 – their food supplies and thus disease patterns also change. This pattern
Diet and disease 19
can be traced in more economically developed countries, such as the United Kingdom, between the sixteenth and eighteenth centuries following the agrarian and industrial revolutions. In the CCEE and NIS, such transitions are taking place very much faster and in some cases extremely rapidly. This has immense implications for policy-making in public health.
The nutrition transition is marked by a shift away from diets based on in- digenous staple foods, such as grains, starchy roots and locally grown legumes, fruits and vegetables, towards more varied diets that include more processed food, more foods of animal origin, more added sugar, salt and fat, and often more alcohol. This shift is accompanied by reduced physical activity in work and leisure. Combined, these changes leading to a rapid increase in obesity and its associated health problems.
Consequently, in most countries of the European Region, diet-related dis- eases are gaining in magnitude and effects compared with the effects of spe- cific dietary deficiencies, even though certain micronutrient deficiencies (in, for example, iodine and iron) are still prevalent. If appropriate public policies are not implemented to change the transition patterns, these public health problems are likely to continue into future generations.
Costs to the health care system Information is needed on the cost of diseases attributable to diet and the bur- den they place on society. It can be valuable in risk management (evaluating the benefits and costs of adopting certain risk control measures or health interventions) and in assessing the impact of ill health on national economies and health service budgets.
In the early 1990s, the Federal Ministry of Health estimated the total costs of diet-related diseases to the health service in Germany at about DM 83.5 billion (Table 1.2), equivalent to 30% of the total cost of health care. The costs include both direct costs (medical and health service expenditure) and indirect costs (from workers’ reduced productivity or lost family income). The highest costs resulted from CVD (12% of the total national health care costs), followed by dental caries (7%) and diet-dependent cancer (3%) (30).
In the United Kingdom, Liu et al. (31) estimated that CHD cost £1.65 billion to the health care system, £2.42 billion in informal care and £4.02 billion in productivity loss: a total annual cost of £8.08 billion. This made CHD the most expensive disease in the United Kingdom for which comparable analyses have been done, including back pain, rheumatoid arthritis and Alzheimer’s disease.
Liu et al. (31) also noted considerable variation in both the direct health care costs and the productivity and informal care costs per 100 000 CHD patients in different countries. Unsurprisingly, given the different levels of provision and of unit costs, they observed that the direct health and social care
20 Food and health in Europe
costs of CHD were considerably lower in the United Kingdom than in other countries for which data were available. The direct costs were about 1.2 times higher in the Netherlands, 5.5 times higher in Sweden and 6 times higher in Germany. In contrast, the employment and informal care costs in the United Kingdom were higher than those in Switzerland and were very similar to those in Sweden or Germany.
Table 1.2. Costs of diet-dependent conditions in Germany, 1990s
Source: adapted from Kohlmeier et al. (30).
Kenkel & Manning (32) summarized studies by the National Institutes of Health and by Wolf & Colditz (33) of the costs of illnesses associated with dietary factors and physical activity patterns in the United States. The illnesses included CHD, diabetes, stroke, osteoporosis, gall bladder disease and cancers of the breast, colon/rectum and prostate. The estimates are based on the assumption that dietary factors and sedentary lifestyles contribute to 60% of diabetes cases; 35% of breast, colon/rectum and prostate cancer cases; 30% of gall bladder disease; 25% of arthritis; and 20% of CHD and stroke. The total economic cost of all these diet- and exercise-related illnesses was estimated at US $137 billion (32): more than the economic costs of alcohol abuse and dependence (US $118 billion) or smoking (US $90 billion). The direct costs of diet- and exercise-related illnesses – health care expenditure attributable to these conditions – reached US $67 billion, or about 7% of total personal health care expenditure in the United States.
Also in the United States, Oster et al. (34) suggested that a sustained 10% weight loss among obese people would lead to a lifetime saving of US $2200–
Conditions Estimated costs (DM billion)
Total Direct Indirect
CVD 32.9 15.4 17.6
Dental caries 20.2 20.2 <0.1
Cancer 9.6 1.6 8.1
Diabetes 3.8 2.3 1.5
Alcoholism 3.5 0.7 2.8
Diseases of the liver 3.1 0.4 2.6
Other conditions 2.6 1.4 0.5
Diseases of the pancreas 2.6 1.9 0.6
Lipid metabolism 1.4 1.2 0.9
Food poisoning 1.4 0.3 1.1
Goitre 1.3 1.1 0.2
Diseases of the gallbladder 1.1 0.8 0.3
All diet-related conditions 83.5 47.3 36.2
Diet and disease 21
5300 per person, depending on age, gender and starting body mass index and an increase in life expectancy of 2–7 months. It would cut lifetime incidence of CHD from 12 cases to 1 case per 1000, and the incidence of stroke from 38 to 13 cases per 1000 (34). In Europe, obesity is estimated to account for about 7% of health care costs (35). Obesity has been estimated to account for substantial direct costs to the health budgets in France (36,37), Germany (38), the Netherlands (39) and Sweden (40). The indirect health care costs attributable to obesity are also estimated to be substantial: 3–4% of total health care costs in Germany, for example (38).
Obesity is a highly stigmatized condition in several countries and has been associated with underachievement in education, reduced social activity and discrimination at work (41). Indeed, obese people are often reported to earn less than their lean counterparts because of discrimination or diseases and disabilities caused by obesity (39).
The avoidance of childhood diseases as a result of breastfeeding has been estimated to reduce the economic costs of care to society (http://www.visi.com/ ~artmama/kaiser.htm, accessed 19 September 2003) (42). A study in the United States assessed the potential reduction in costs to society that could be attributed to an increase in breastfeeding from current levels (64% in hospital and 29% at 6 months of age) to those recommended by the Surgeon General of the United States (75% and 50%, respectively). Based on information related to three childhood illnesses (otitis media, gastroenteritis and necrotizing enterocolitis), it was estimated that about US $3.1 billion could be saved by preventing premature death from necrotizing enterocolitis and an additional US $0.5 billion through annual savings associated with reducing traditional expenditure on, for example, visits to physicians or hospitals and laboratory tests. The total estimated savings (US $3.6 billion) probably underestimates the true savings, as the figures reflect savings associated with treating only three illnesses and exclude the cost of over-the-counter medication for otitis media and gastroenteritis symptoms, physician charges for treating necrotizing enterocolitis and savings from reduced long-term morbidity.
In Norway, the National Council on Nutrition and Physical Activity assessed the cost–effectiveness of policies to increase the consumption of fruits and vegetables as a means to reduce cancer (43). It calculated the cost of treating each patient with cancer as NKr 250 000 and estimated that preventing cancer cases could result in savings of NKr 3 million and a delay in cases of 10 years, NKr 1.5 million (using 1997 prices). A similar study in Denmark (44) investigated the economic consequences of an increased intake of fruits and vegetables. In 2000, the average daily intake in Denmark was about 250 g per person per day. Using recent estimates (45), the study showed through modelling that, if the population doubled its intake of fruits and vegetables from 250 g to 500 g, life expectancy would increase by 0.9 years
22 Food and health in Europe
and 22% of all cancer incidence could be prevented (44). The lower number of cancer cases, however, seemed not to affect the aggregate health care costs (a 0.1% change), based on data from 1997. This was the outcome of several offsetting effects. Because there were substantial changes across age groups, the disease-specific mean costs were held constant for each group, but the number of people with cancer, as well as the distribution, changes as the intake of fruits and vegetables increases (44).
Early death or ill health creates not only financial costs to the health care system but also personal costs to the people concerned and their families and friends. For example, many people in Europe provide informal care for relatives suffering from diet-related diseases. In the United Kingdom, about 423 000 people have been estimated to give informal care to people with CHD alone, amounting to about 430 million hours of care in 1996 (46). In addition to limiting their personal freedom, this work forces caregivers to leave paid jobs, which creates financial difficulties.
Although a better understanding of the burden of disease attributable to diet is long overdue, more information is needed on its cost to society. Such information can be valuable when evaluating the costs and benefits of adopt- ing certain risk control measures or health interventions (risk management) and in assessing the effects of ill health on national economies and health ser- vice budgets.
Cost analysis is an important instrument for the health services in evaluat- ing resources used or lost, and estimates of the direct and indirect costs of dis- eases are often used to support the argument that prevention can save money. For most programmes, however, the primary gains from a preventive activity or a change in health habits are increased longevity and improved quality of life rather than reduced lifetime medical expenditures. Only in some cases does an intervention improve health and save money at the same time. This is because paying more is usually necessary to receive better, more valued out- comes in health status, morbidity and mortality. The implications of a partic- ular disease for health policy should not be evaluated solely on the basis of financial cost. Value judgements about health gain and the quality of life remain the principal criteria in deciding about investing in health.
Mortality from diet-related diseases As discussed, CVD and cancer dominate as causes of premature death through- out the Region (Fig. 1.9), and about one third of CVD cases are related to eating a poor diet. CHD is the most common cause of premature death, accounting for nearly 900 000 deaths per year: 16% of all premature deaths in men and 12% in women. Up to the mid-1990s, mortality rates varied widely between the eastern and western countries of the Region. For example, the EU showed a steady fall in deaths from CHD, but most eastern countries exhibited
Diet and disease 23
increased rates. In the CCEE and NIS, CHD mortality is almost double that in the EU and still rising in many countries. Fig. 1.10 illustrates the wide range of death rates from cerebrovascular disease.
In the 1990s, however, mortality rates from diet-related diseases started evolving differently in some countries, especially those moving from a central- ized to a market economy. The east–west divide is no longer a universally applicable image; significant differences are emerging between the NIS and CCEE.
For example, deaths from CVD decreased dramatically in the Baltic countries – and in the Czech Republic, Poland and Slovakia (47) – during the 1990s, while deaths from ischaemic heart disease have continued to increase in Belarus and the Russian Federation (Fig. 1.11). Cancer mortality rates are declining in the CCEE and NIS, falling by 25% in the central Asian republics in only a decade.
Variations in CVD: the fundamental role of diet Countries in the European Region show marked discrepancies in rates of CVD. Fig. 1.12 shows the huge range in death rates from CHD in Europe, and stroke shows a similar pattern. Some of the poorest countries in the Region clearly have the highest CVD mortality. CVD are not a manifestation
Fig. 1.9. Main causes of death in groups of countries in the European Region
Source: European health for all database, WHO Regional Office for Europe, 2001.
EU (1997)
Nordic countries
(1996)
CCEE (1997)
NIS (1997)
0
20
40
60
80
CVD
Cancer
Other diseases
Respiratory diseases
External causes
Ill defined conditions Infectious and parasitic diseases100
Pe rc
en ta
g e
24 Food and health in Europe
of affluence; the wide differences in death rates are remarkably dependent on social inequalities and poverty (see pp. 69–71 and Chapter 3).
Diet-induced increases in serum cholesterol For the last 50 years, a strong relationship has been recognized between the level of total cholesterol in the blood and the risk of CHD. This relationship is seen at all levels of CHD mortality – from the lowest, such as those observed in Japan in the 1950s or rural China in the 1970s, to the highest, observed in north-eastern Finland (48) – and clearly observed in all major prospective studies of CHD. Men are at much greater risk of CHD than women until women have passed the menopause, when their risk increases markedly.
The measurement of total serum cholesterol has been refined with the rec- ognition that one component of the total cholesterol level, low-density lipo- protein (LDL) cholesterol, is the principal factor contributing to atherosclero- sis and that high-density lipoprotein (HDL) cholesterol is protective. HDL is involved in clearing cholesterol from the tissues for disposal and oxidation by the liver. The most effective predictor of risk is the ratio of LDL to HDL
Fig. 1.10. Average age-standardized mortality from cerebrovascular disease in men and women aged 25–64 years, European Region
Source: Mortality indicators by cause, age and sex (database), WHO Regional Office for Europe, 2002.
10
20
30
40
50
60
70
80
90
100
110
120
1970 1975 1980 1985 1990 1995 2000
D ea
th s
p er
1 00
0 00
Year
EU average CCEE average NIS average
Nordic average Central Asian republics average
Diet and disease 25
cholesterol, and smoking, diabetes and high blood pressure amplify the inter- action of the two, especially in middle age.
Several hundred carefully controlled studies have illustrated how diet alters serum cholesterol. The saturated fatty acids in the diet – not dietary cholesterol – are the primary inducers of increases in LDL cholesterol in the blood. These saturated fatty acids vary markedly in their effects. Myristic acid, largely derived from milk fat, is the major stimulus to increased serum levels of LDL. Lauric acid, present in fat and oil from tropical plants and in milk in modest amounts, and palmitic acid, present in animal fat and tropical-plant fat and oil, are also strong stimulators for raising LDL levels, as are some trans- fatty acids (49). A major saturated fat, stearic acid, present in beef fat and lard,
Fig. 1.11. Age-standardized premature mortality from ischaemic heart disease in men and women aged 0–64 years,
Belarus and the Baltic countries
Source: Mortality indicators by cause, age and sex (database), WHO Regional Office for Europe, 2002.
100
150
200
250
300
1980 1985 1990 1995 2000
Year
D ea
th s
p er
1 00
0 00
Belarus Estonia
Latvia Lithuania
26 Food and health in Europe
40 0
30 0
20 0
10 0
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0 20
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Diet and disease 27
does not increase serum LDL cholesterol levels (50), but all the saturated fatty acids have usually been grouped in one category in an attempt to simplify policy-making and educational messages.
Keys originally showed in the 1950s that the intake of saturated fat crudely predicted the rate of CHD in a population. About 40 years ago, this led the Nordic countries and the American Heart Association to call for a reduction in saturated fat intake. A relationship between intake of milk fat and the prevalence of CHD in European countries has been shown repeatedly; this is understandable, given the powerful effect of the myristic acid in milk fat (24). As mentioned earlier, analyses of major public health programmes, such as those in Finland and Norway, have shown that the substantial fall in CHD rates (see Fig. 1.12) is predominantly explained by a 15% fall in average serum cholesterol levels as the consumption of milk fat – in milk, butter and milk products – drops.
Trans-fatty acids Trans-fatty acids are unusually structured fatty acids naturally induced by the bacteria within the rumen, and cattle and sheep therefore have appreciable quantities of these fatty acids in their tissues. In addition, over the last 50 years the food industry has increasingly used a hydrogenation process with liquid vegetable and fish oils to produce hardened margarine and oils with a high concentration of trans-fatty acids. These are especially valuable in producing crisp or firm products that have a long shelf life before becoming rancid.
The trans-fatty acids in such products markedly reduce the intake of polyunsaturated fatty acids and particularly of the valuable omega-3 polyunsaturated fatty acids found in nuts, some vegetables and especially fish. The new chemical species of trans-fatty acids produced by hydrogenation have multiple, unusual structures and have been shown to induce deleterious increases in LDL cholesterol levels and decreases in HDL cholesterol levels.
The epidemic of CHD over the last 70–80 years can be attributed to increased intakes of both saturated and trans-fatty acids, so WHO recommends that this fatty acid constitute less than 1% of total energy (21). Polyunsaturated fatty acids in a non-hydrogenated form can reduce LDL cholesterol and therefore limit the effect of saturated fat. Monounsaturated fatty acids, such as those found in olive and rapeseed oils, have a neutral effect on serum cholesterol levels.
The quality of the fatty acids in the diet – not total fat intake – determines the incidence of CHD.
Essential fatty acids and sudden cardiac death The omega-3 polyunsaturated fatty acids are now recognized to have marked effects not only on brain development in infants and children and on
28 Food and health in Europe
immune system function but also on the risk factors for CHD. An increased intake of these fatty acids raises the level of the beneficial HDL cholesterol and reduces the circulating fatty acids in the form of triglycerides, which are an independent risk factor for CHD. In addition, omega-3 polyunsaturated fat reduces the clotting tendency of the blood and further minimize the thrombotic processes that are part of the mechanisms underlying the develop- ment of CHD. Perhaps one of their most dramatic effects is in stabilizing the reactivity of the neuronal control of the integrated processes governing the heart’s functioning.
Low intake of polyunsaturated fat is linked to a much higher rate of sudden cardiac death. Various careful, placebo-controlled randomized trials have shown a major reduction (45–70%) in the likelihood of sudden death from CHD when intakes of these fatty acids are increased, either by the consumption of fatty fish twice weekly, the provision of fish oils or the inclusion of a Mediterranean-type diet rich in nuts and fish (51). On this basis, the intake of omega-3 fatty acids is a key determinant of CHD rates, acting to reduce the likelihood of sudden death from cardiac arrhythmia in Europe. An analysis of the fatty acids contained in the body fat of patients suffering myocardial infarction showed lower levels of very long-chain omega- 3 fatty acids than in controls (51).
Fruits and vegetables and preventing CVD The more that people consume a variety of fruits and vegetables, the stronger the protection against CVD (52,53). Estimates show that a mean increase in intake of 150 g per day could reduce the risk of mortality from CHD by 20–40%, from stroke by up to 25% and from CVD by 6–22%; the lowest estimates account for the impact of smoking and/or heavy drinking (53).
The precise mechanisms of this protective role are still uncertain. Never- theless, raising fruit and vegetable intake is known to reduce blood pressure and serum cholesterol levels, the increased plasma antioxidants possibly pre- venting lipid peroxidation of LDL cholesterol. Fruits and vegetables are rich in dietary fibre and contain over 100 compounds that may be responsible for their protective effects. These include antioxidants, such as vitamins C and E, carotenoids, flavonoids, folic acid, potassium, magnesium and non-nutritive bioactive constituents, such as phytoestrogens and other phytochemicals.
Zatonski et al. (47) investigated the reasons for the decline in CHD deaths in Poland since 1991, after two decades of rising rates. Having considered the potential role of changes in food availability, smoking, alcohol consumption, stress and medical care, the authors attribute the substantial decline in premature mortality to falls in consumption of saturated fat and to an increased supply of fresh fruits and vegetables (47). Similar dietary changes have taken place in the Czech Republic (54).
Diet and disease 29
Gjonca & Bobak (55) draw attention to the paradox of high adult life expectancy in Albania, despite its position as the poorest country in the European Region. In 1990, age-standardized mortality for CHD in males aged 0–64 was only 41 per 100 000 in Albania, less than half of the rate in the United Kingdom and similar to that in Italy. A detailed analysis of the geographical distribution of mortality within Albania showed that it was lowest in the south-west, where most of the olive oil, fruits and vegetables are produced and consumed. Albania provided unique opportunities to study this relationship because of the almost complete absence of motorized transport, which limits interregional food distribution, combined with the availability of high-quality mortality data. The authors argue that diet is the most plausible explanation for this paradox of high life expectancy in a poor country: low consumption of total energy, meat and milk products but high consumption of fruit, vegetables and complex carbohydrates. This was the diet eaten in Crete in the 1950s, when Keys showed that it was associated with low rates of CHD.
Trials have shown that mimicking a high intake of fruits and vegetables by using dietary supplements containing vitamins C and E, beta-carotene and flavonol is largely ineffective and sometimes even harmful. One exception is folate: new evidence suggests that folate deficiency may lead to an increased risk of CVD (56). Specifically, inadequate levels of folates raise levels of plasma homocysteine (an essential intermediate in folate metabolism), and elevated plasma homocysteine has been associated with an increased risk of CVD. These high levels can be reduced by extra folic acid intake through dietary folates from vegetables; these are only 50% bioavailable, however, and supplements in people at risk are recommended.
CVD and salt Dietary salt intake plays a critical role in regulating blood pressure, and populations with low salt intake, all other things being equal, have a lower average blood pressure level. In addition, accumulating evidence shows that a high salt intake could independently predict left ventricular hypertrophy, although this remains controversial (57,58).
The DASH (dietary approaches to stop hypertension) trial (59) was conducted in people with “high-normal” blood pressure and stage-one hypertension. They were randomly assigned to a control group or one of two groups with a “normal” diet: one rich in fresh fruits and vegetables and the other containing fresh fruits and vegetables and low-fat dairy products. Estimates of sodium intake indicated a modest reduction to an average of about 130 mmol per day. The group receiving the diet with fresh fruits and vegetables and low-fat dairy products had the lowest blood pressure levels, followed by the group assigned to fresh fruits and vegetables and then the
30 Food and health in Europe
controls. These findings support the concept that a high dietary intake of potassium, magnesium and calcium contributes to reducing blood pressure.
A second version of the DASH trial assigned people with blood pressure of 120/80–159/95 mmHg to a control diet or the DASH combination diet, randomized to one of three dietary sodium levels: high (150 mmol per day), intermediate (100 mmol) or low (50 mmol) (60). People on both the control and DASH combination diets showed a stepwise reduction in blood pressure with each level of reduced salt intake. The difference in blood pressure between those on the DASH diet with the highest and lowest sodium intakes averaged 12 mmHg, a response equal to that of potent antihypertensive drugs. The DASH diet had a greater effect in reducing blood pressure on the two higher levels of salt intake than the control diet. As in the earlier DASH trial, no adverse effects of dietary salt reduction were observed.
Little information is available on salt intake in Europe. In Romania, the daily salt consumption per head is estimated to be 14 g (61). On average, about 12% of adults in Romania have hypertension (blood pressure over 140/ 90 mmHg), including 32% of men aged 41–65 years. As in all other
Fig. 1.13. Age-adjusted prevalence of high blood pressure (160/95 mmHg) in men aged 35–64,
selected countries and regions in the European Region
a In Romania, the data are for men aged 41–65 years with blood pressure over 140/90 mmHg (61).
Source: data from a risk factor population survey conducted in demonstration centres of the WHO countrywide integrated noncommunicable disease inter- vention (CINDI) programme, 1999.
0 5 10 15 20 25 30 35 40
Lithuania
Karelia, Russian Federation
Romania
Novosibirsk, Russian Federation
Malta
Belarus
Moscow, Russian Federation
United Kingdom
Bulgaria
Germany
Austria
Portugal
Yugoslavia
Spain
Poland
Hungary
a
Prevalence (%)
Diet and disease 31
European countries, CVD mortality occupies the first place; cerebrovascular accidents caused about 40% of deaths from CVD in 1996, one of the highest rates in the European Region. Fig. 1.13 shows the prevalence of high blood pressure in adult men in some regions and countries in the European Region. The fact that, in countries such as Lithuania, over 40% of adult men in rural areas are hypertensive warrants further studies on salt intake in the Region and renewed emphasis on controlling hypertension by lowering salt intake to less than 5 g per day (18).
The impact of interventions to reduce the daily intake of salt in Norway by 6 g per day was simulated (62). The results suggested that, assuming that the interventions would lead to a reduction of 2 mmHg on average, life expectancy could be increased by 1.8 months in men and 1.4 months in women.
Smoking, stress and CVD Detailed analyses have shown that eliminat