Caballero B. (ed.) Encyclopaedia of Food Science, Food Technology and Nutrition. Ten-Volume Set

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Nutraceuticals See Functional Foods

NUTRITION EDUCATION

S S Deshpande, Central Institute of Agricultural

Engineering, Nabibagh, Bhopal, India

Background

0001 Advances in nutrition research have provided means

of prevention and control of some of the major crip-

pling nutritional disorder with sever socioeconomic

and health repercussions. The next logical step after

the discovery of such solutions will be their propaga-

tion among the concerned community members. It is

here that health and nutrition education has a role

to play. The emphasis in these nutrition education

programs ought to be on the proper use of natural

dietary sources of nutrients and the need for full use

of available health services and health and nutrition

intervention program launched by government and

other agencies.

0002 Nutrition education programs, when properly im-

plemented, have the potential to bring out desired

behavior modifications among the communities. But

for them to be successful, there are several obvious

prerequisites such as the right approach suited to the

community appropriately, motivated change agents,

suitable educational strategies in terms of media,

messages, etc. The ultimate impact of any nutritional

education effort hinges on the extent to which the

above criteria are satisfied.

0003 Nutrition education has been defined as the process

by which beliefs, attitudes, environmental influences,

and understanding about food lead to practices

that are scientifically sound, practical, and consistent

with individual needs and available food resources;

nutrition education should be available to all individ-

uals and families. The fundamental philosophy of

nutrition education is that efforts should focus on

the establishment and protection of nutritional health

rather than on crisis intervention. It is needed, regard-

less of income, location or cultural, social or economic

practices, or level of education. Nutrition education

must be a continuing process throughout the life cycle

as new research brings additional knowledge.

Scope

0004 Education means a change in behavior. It moves the

individual from lack of interest and ignorance to

increasing appreciation and knowledge and finally

to action. Nutrition education offers a great oppor-

tunity to individuals to learn about the essentials of

nutrition for health and to take steps to improve the

quality of their diets and thus their well-being.

0005Nutrition education must continue throughout the

individual’s life in order to accommodate for devel-

opments in nutrition science and for changing eco-

nomic circumstances, health requirements, and the

new food products appearing in the nation’s market.

This requires a greatly expanded use of the mass

media, and the involvement of governmental and

private agencies and universities, as well as the food

industries.

Concept

0006A concept is an idea around which the content of

nutrition education curricula can be built.

What is Nutrition Education?

0007Nutrition education is the process of teaching the

science of nutrition to an individual or group. Health

professionals have a different role in educating an

individual in the clinic, community, or long-term

health-care facility. In these settings, the dietician,

nutritionist, or nurse serves to assist or enable indi-

viduals to incorporate changes in eating patterns and

behavior into their lives. The major focus of this type

of nutrition is not knowledge and facts, but rather the

development of permanent behavioral changes. This

is the art of nutrition education – breaking down a

large body of knowledge into small, individual com-

ponents that are represented to a patient or client at a

rate and level, at which they are able to absorb and

use the information. Effective education is making

nutrition information digestible and usable in an

everyday setting.

Steps Involved in Nutrition Education

0008The development of an organized, coordinated nutri-

tion education program requires a series of steps:

0009Consumer research is needed to determine con-

sumer use of existing information attitudes, know-

ledge, levels of awareness and concern, current

4164 NUTRITION EDUCATION

nutrition practices, and type of education to which

they should be most receptive.

0010 Nutritional surveillance data are needed to deter-

mine the most important public information prob-

lems for determining reasonable objectives to be

used in formulating the nutrition education.

0011 Most appropriate target populations for nutrition

education are determined on the basis of aware-

ness, nutritional status, current knowledge, and

receptivity to nutritional information.

0012 A nutrition education message should be designed

that is appropriate for the needs of the selected

population groups.

0013 The curricula for the nutrition education program

must be well thought out and planned. At every

step, the learner and the educator should work

together to develop goals, objectives, and appro-

priate activities and resources to meet the goal.

0014 Evaluation is crucial to any successful educational

effort.

Why Nutrition Education?

0015 A number of forces have emerged to stimulate in-

creased recognition of the need for a stronger, more

comprehensive and creative effort at nutrition educa-

tion. These factors include:

0016 Many serious as well as less serious health problems

are the result of lifestyles and personal habits, includ-

ing habits of food consumption. Individual modifi-

cations in lifestyles may improve health status.

0017 Food Patterns. Differing forms of food vary in

nutritive value as well as in taste appeal. The aver-

age consumer is often mystified and unaware of

how to make the wisest food choices from such a

variety. Thus, there is a great need for education to

enable consumers to select wisely an appropriate

diet from the vast supply of food available.

0018 Lifestyles are drastically different from those of the

turn of the century. The public must be knowledge-

able about how to meet nutritional needs without

overindulgence in foods.

0019 Nutrition education is also necessary to aid the con-

sumer to make economical food choices, that is, to

save money while getting optimal nutrition. This is

especially important for the low-income consumer.

0020 On a global basis, there is a real possibility of food

shortages. Therefore, the consumer should know

how to provide nutritional substitutes for unavail-

able food items.

What to Emphasize in Nutrition Education

0021 It is very difficult to define the basic knowledge that

should be conveyed to the public about nutrition.

Much will depend upon what the learners already

know, how they evaluate their present dietary habits

and nutritional status, what their present eating habits

actually are, how much they desire to know, and what

changes they are willing or can afford to make.

Nutrition Education Strategies

0022In view of the multifactorial influences on food

habits, there is no one way to persuade people to

change their food choices. Thus, nutrition education

must use a variety of techniques that must be a part of

total family and community environments.

0023In other words, nutrition education involves infor-

mation exchange as well as techniques to motivate

and reinforce improved food habits. Successful nutri-

tion education must include endeavors to make

beliefs, attitudes, values, environmental factors, and

individual ideas about food conducive to nutrition-

ally sound, practical, and acceptable dietary habits.

Nutritional education can be approached in various

ways. What might be termed the rational–empirical

curriculum design is the approach that is typically

used by educators; it is logical and planned, and

it involves behavioral objectives, activities that

are designed to achieve objectives, and evaluation

to determine the discrepancy between planned and

achieved outcomes. The idea of self-responsibility

for health suggests the basic notion that the individual

possesses a dignity, worth, and responsibility to maxi-

mize these characteristics. Self-responsibility assumes

that the individual has the potential and motivation

to make wise judgments about factors that affect their

health status. Another strategy has been termed the

travel metaphor method. The idea is that there is

a body of knowledge, facts, concepts, values and

believes that are known and understood by the edu-

cator. It is the educator’s responsibility to lead the

learner through this body of knowledge and beliefs,

and point out to the learner what is thought to be of

importance. The educator is thus a travel guide whose

job is to provide the student with a set of stimuli and

the opportunity to take advantage and react posi-

tively. It then becomes the responsibility of the stu-

dent to determine how they will make use of the

contacts provided by the educator.

0024Another approach called the garden metaphor ex-

plains how humans grow, develop and flower natur-

ally. The educator has the opportunity to nurture this

environment so that the ‘child’ has the most oppor-

tunity to mature and to learn.

0025Another approach to health and nutrition educa-

tion takes a strategy of social manipulation. The basic

premise is that the matters affecting health are too

urgent, too important, and beyond the individual’s

NUTRITION EDUCATION 4165

power to control on their own. Thus, the role of the

health educator is seen as one of attempting to control

behavior and to shape the desired responses. This

approach is often employed by the mass media.

0026 The manipulative approach is more concerned

with the behavior response patterns rather than the

manner in which the individual reaches these pat-

terns. The approach is an attempt to reach the desired

behavior through a short-cut method and does not

take time to prepare the individual to make fully

informed, wise choices.

0027 The most appropriate and effective strategy for

stimulating improved food habits will depend upon

the knowledge, background, personal characteristics,

and motivation of the audience. It may also depend

upon the size of the target group. Ideally, the

approach should be individualized to the target audi-

ence’s needs, goals, objectives, and other characteris-

tics. A mix of various approaches may be necessary.

Systems Approach to Nutrition Education

0028 The ‘systems’ approach to nutrition education pro-

vides a useful and practical tool to aid the nutrition

educator in deciding what should be taught and how

it should be taught. Simply defined, the systems ap-

proach is a flow of steps needed to achieve the desired

objectives. The approach consists of input, process,

and output.

0029 A successful nutrition education effort must incorp-

orate managerial elements that are crucial to the

success of all program planning. These elements,

which could be termed the input, are essential to an

effective nutrition education process. They include

needs assessment and identification of problems;

study of available resources and alternative strategies

of intervention; determination of objectives and goals;

assignment of resources to implement program; staff

development to implement program, and program

monitoring and evaluation. Crucial to the entire pro-

cess is a firm organization base and administrative and

budgetary support for nutrition education efforts.

Follow-up and Evaluation

0030 Nutritional counseling follow-up, in order to evalu-

ate learning, is an essential factor, which needs to be

included in the plan. After an initial interview, follow-

up is usually planned for some time during the next 1–

2 weeks or perhaps at a later time in the same week.

As clients progress toward a goal, follow-up visits are

generally spaced further and further apart. In a

follow-up session, the client’s progress needs to be

measured against the objectives, and the client needs

to receive positive feedback about their progress. In

the event that no progress has been made or the client

has slipped back into old habits, the counsellor needs

to pursue the problem assertively. The problem needs

to be identified and new goals or methods of achiev-

ing the goals established.

Summary

0031Nutrition education is a broad area; however, the

nutritionists or nurses facilitating it are usually con-

centrated in the acute or long-term care facilities and

community clinics. In all aspects of teaching and

counseling, instructional objectives need to be estab-

lished, the learner’s knowledge assessed, behavioral

objectives written, evaluation tools devised, informa-

tion needs screened and organized, education mater-

ials selected, and instruction critiqued and revised. It

is also essential to keep the learner’s needs in the

forefront and work to maintain a rapport with the

client.

0032Education is not complete until the learning has

been evaluated. Formal and informal tools may be

used to measure learning against established object-

ives. Evaluation helps identify if further teaching

or clarification of information is needed. To some

degree, demonstrating successful learning at evalu-

ation reinforces continuance of new behaviors,

which is the goal of nutrition education.

See also: Community Nutrition; Dietary Requirements

of Adults; Famine, Starvation, and Fasting; Food

Safety

Further Reading

American Dietetic Association (1973) Position paper on

nutrition education for the public. Journal of the

American Dietetic Association 62: 429.

Caliendo MA (1986) Nutrition Education. Definitions and

Concepts in Nutrition and Preventive Health Care,

pp. 410–437. New York: Macmillan.

Deshpande SS (1999) Study of nutritional pattern of some

selected villages around Bhopal with special reference to

soybean consumption. Ph.D. Thesis, Barkatullah Uni-

versity, Bhopal.

Griffin GA (1974) Strategies in Curriculum Development

In: Conference on Education in Nutrition, Looking

Forward from the Post. New York: Columbia Univer-

sity, Teachers College.

Rau P (1982) Experiences in nutrition education. Nutrition

22(2): 3.

Robinson CH, Lawler MR, Chenowth WL and Garwick

AE (1986) Nutrition Problems and Programs in the

Community. Normal & Therapeutic Nutrition, 17th

edn., pp. 355–357. New York: Macmillan.

SNE Concepts for Food & Nutrition Education (1982)

Journal of Nutrition Education 14: 1.

4166 NUTRITION EDUCATION

NUTRITION POLICIES IN WHO EUROPEAN

MEMBER STATES

A Robertson, WHO Regional Office for Europe,

Copenhagen, Denmark

Introduction

0001 In December 1992, after more than 2 years of pre-

paratory work by the member states and the joint

efforts of the World Health Organization (WHO)

and the Food and Agriculture Organization (FAO),

the International Conference on Nutrition (ICN) was

convened in Rome to:

0002 increase public awareness of the extent and serious-

ness of nutrition- and diet-related problems world-

wide

0003 promote effective strategies and actions to address

these problems

0004 encourage the political commitment necessary to

do so

Each of the 159 participating countries and the Euro-

pean Community reaffirmed their determination to

insure sustained nutritional well-being for all people

and committed themselves to achieve this goal by

unanimously adopting the World Declaration and

Plan of Action for Nutrition. The nine action-oriented

strategies of the World Declaration and Plan of Action

for Nutrition are summarized in Table 1. These

provide a framework for national plans of action.

0005 In 1996 a follow-up to ICN (Table 2) was held in

the European region through a FAO/WHO consult-

ation in Warsaw, Poland. Its aim was to assess imple-

mentation of the World Declaration. Representatives

from European member states and Canada, the USA,

the European Commission and the Holy See attended

the meeting along with representatives from the

United Nations Development Program (UNDP), the

United Nations Children’s Fund (UNICEF), nongo-

vernmental organizations (NGOs) and the private

sector.

Methods

0006Member states were requested to prepare a summary

report of their progress for the 1996 follow-up meet-

ing in Poland. Based on the 35 reports received

(response rate of 70%) the WHO Nutrition Unit

compiled an overview of the situation.

0007Member States were grouped into eight geographic

regions: Balkan, Baltic, Central Asian Republics

(CAR), countries of central and eastern European

(CCEE), western Europe, southern Europe, Com-

monwealth of Independent States (CIS), excluding

CAR, and Nordic countries (Table 3). The aim of

this is to facilitate comparative analysis and interpret-

ation and assist in drawing conclusions and recom-

mendations.

Results

0008The country data are presented in tables under the

headings of the strategies of the Plan of Action for

Nutrition adopted at the ICN.

Discussion

Developing Food and Nutrition Policy

0009Around the time of ICN (1992), some member states

in Central Asia, the former Soviet Union and the

Balkan region were not fully independent and so

were unlikely to have information about the ICN.

Thus food and nutrition specialists in some parts of

the WHO European region were probably unaware

of the ICN and so it is hardly surprising that many

countries had not developed national plans of action

according to the ICN objectives.

0010Moreover a few WHO member states are not

members of FAO (1998) and others have only

recently joined. This probably explains why there

were more health than agriculture representatives

present – 66% compared with 27% – at the consult-

ation in Poland in 1996.

0011One of the difficulties when attempting to develop

intersectoral policies is the level of commitment that

tbl0001 Table 1 The nine action-oriented strategies of the plan of

action for nutrition

Incorporating nutritional objectives, considerations, and

components into development policies and programs

Improving household food security

Protecting consumers through improved food quality and safety

Promoting breast-feeding

Caring for the socioeconomically deprived and nutritionally

vulnerable

Preventing and controlling specific micronutrient deficiencies

Promoting appropriate diets and healthy lifestyles

Assessing, analyzing, and monitoring nutrition situations

Preventing and managing infectious diseases (N.B. not included

in this analysis, since not mentioned in any country reports)

NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES 4167

each stakeholder has to public health versus their own

possibly diverging interests (Figure 1). It is improb-

able that intersectoral policies will be implemented,

unless all stakeholders are committed to the process.

However, the long-term interests of the agriculture

sector, the food industry, wholesale and retail repre-

sentatives are dependent on policies which have been

developed in collaboration with the voluntary sector

and consumers. Consumers, the customers of the

food industry, should be more involved in the process

whereby food policy is developed.

Intrasectoral Collaboration within the Health

Sector

0012 Good collaboration between nutrition and food

safety is essential because the public and consumers

perceive food in a holistic way. Consumers do not

compartmentalize food or distinguish between food

safety and nutrition – consumers want good whole-

some food they can enjoy without fear. There appears

to be far more collaboration between the nutritionists

and food safety specialists working in central and

eastern Europe compared with those in western

Europe.

0013There may be several reasons for the stronger col-

laboration in central and eastern Europe. Nutrition is

a relatively new science and in eastern parts of Europe

its evolution seems to be closely linked to ‘hygiene’

and the sanitary–epidemiology system. In eastern

Europe nutrition and food hygiene have evolved

from the same postgraduate specialization, usually

as a specialization of medicine. In former socialist

countries food safety is traditionally under ministries

of health, whereas in some western European

tbl0003 Table 3 Member states of the World Health Organization European region, 1996

Balkan Baltic CARandTurkey CCEE WesternEurope Southern Europe CIS Nordic

Albania Estonia Kazakhstan Bulgaria

Austria Greece Armenia Denmark

Bosnia and Herzegovina Latvia Kyrgyzstan

Czech Republic Belgium

Israel Azerbaijan Finland

Croatia Lithuania Tadjikistan

Hungary France Italy Belarus Iceland

Federal Republic of

Yugoslavia (Serbia

and Montenegro)

Turkey

Turkmenistan

Uzbekistan

Poland

Romania

Slovakia

Germany

Ireland

Luxembourg

Netherlands

Switzerland

Malta

Monaco

Portugal

San Marino

Spain

Georgia

Republic of

Moldova

Russian

Federation

Ukraine

Norway

Sweden

Former Yugoslav Republic

of Macedonia

Slovenia

No report submitted (Finland was added later).

CAR, Central Asian Republics; CCEE, countries of central and eastern Europe; CIS, Commonwealth of Independent States.

Public health specialists

in food control and

nutrition

Public health specialists

collaborate with public

interest groups

Agriculture, food industry,

and health specialists

collaborate with public

interest groups

The health sector

develops

its food policy

The health sector

seeks alliance with

consumers

Create a sustainable

market for the food

industry

fig0001 Figure 1 From intra- to intersectoral policy development food priorities for health.

tbl0002 Table 2 Member states at the International Conference on Nutrition follow-up consultation, Poland, September 1996

Total no. of FAO/WHO

memberstatesinvited

Total no. of

countries present

Total no. of

representatives

Percent of health and agriculture

representatives from European region

Total no. of reports

submitted (Europeanregion)

57 40 62 66% health 35

27% agriculture

7% others

FAO, Food and Agriculture Organization; WHO, World Health Organization.

4168 NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES

countries only nutrition is under ministries of health

and the responsibility for food legislation and en-

forcement may be with ministries of agriculture or

trade in the west. However this is changing, especially

in some European Union (EU) member states, where

ministries of health are taking a much more proactive

role in protecting consumers and their health.

0014 Coordination between public health specialists

working in food safety and nutrition is important

for many other reasons. One is that from time to

time food control authorities may issue warnings

about food, e.g., chicken that contains Salmonella,

or fish and vegetables which are contaminated.

Meanwhile, as part of national campaigns, nutrition-

ists promote the consumption of vegetables, fish, and

poultry. Public health specialists must deliver consist-

ent and reliable information to avoid public confu-

sion. Closer cooperation between nutritionists and

food safety specialists can prevent the promotion of

conflicting messages.

Intersectoral Collaboration

0015 Public health specialists dealing with food safety and

nutrition should strengthen their collaboration with

other sectors dealing with food, e.g., agriculture, food

industry, wholesalers and retailers, voluntary sector

and public interest groups representing consumer

interests. Consumers have a vested interest in

supporting the supply of safe food of good quality

that is nutritionally healthy and the food industry has

a vested interest in supplying healthy consumers.

There is an opportunity for the health sector to

strengthen health alliances with public interest groups

working in the voluntary sector.

0016 Surprisingly, in the country reports, there was very

little mention about the importance of collaboration

with consumer agencies except by Hungary, Norway,

Poland, and Sweden. In these countries there is an

understanding that the food industry can profitably

increase the availability of vegetables and fruit, low-

fat milk, and lean meat, on condition that it is assured

a market.

Assessing the Nutrition Situation

0017 Almost all countries reported a need to improve

nutrition information systems. According to DAFNE

(Network of the Pan-European Food Data Bank

Based on Household Budget Surveys: countries par-

ticipating are Belgium, Denmark, Greece, Germany,

Hungary, Ireland, Poland, Portugal, Spain, and the

UK), some had no information, while some use sec-

ondary data or access nutrition information from

household budget surveys. Some had information

from one-off surveys that were sponsored through

international cooperation. The Nordic countries and

the UK seem to have established the most comprehen-

sive surveillance systems that provide information on

food consumption and nutritional status on a routine

basis. Clearly it will take time for some countries to

achieve this level of sophistication but ultimately

these data are essential to facilitate food and nutrition

policy development.

0018It seems unlikely that, at least in the near future,

nationally representative nutrition surveys will be

carried out on a regular basis; therefore other strat-

egies have to be found: members of DAFNE extract

nutrition-related data from household budget surveys;

in Italy secondary data sources were used to develop a

national policy. Mortality data are available from the

WHO Health For All database which is accessible

through the internet from the WHO website. These

data allow comparison of mortality statistics between

different countries. FAO food balance sheets provide

data such as the percentage energy coming from

carbohydrate, fat, protein, and alcohol and the quan-

tity of vegetables and fruits available nationally. These

data are directly accessible from the FAO website.

0019In the future the EU may encourage its member

states, and those wishing to join, to develop standard

information systems. This will allow comparison of

data on food intake, nutritional status, and diet-

related behavior in different EU member states and

so facilitate the development of cost-effective strat-

egies that enable countries to save money on treating

preventable diseases.

Improving Food Security

0020After the Second World War the main aim in Europe

was to increase the supply of food, especially animal

products, e.g., meat and milk. However the postwar

policy was too successful (Table 4) and in the 1980s

until the present time Europe has surplus stocks of

butter, meat, and milk.

0021Since the Second World War, new scientific

evidence has led to the level of recommended daily

protein intake being reduced. For example the level

of protein intake recommended by the FAO, WHO,

and the United Nations University (UNU) in 1986

was 0.75 g kg

1

day

1

. This new level resulted in

many countries reducing the level of their national

recommended protein intakes for adults from 120 g

to around 50 g per person per day. There is now some

evidence suggesting that excess intake of some sources

of protein, especially from red meat, could be associ-

ated with ill health.

0022Various hypotheses exist to explain how meat con-

sumption may contribute to chronic diseases such as

heart disease and certain cancers. Meat intake is as-

sociated with an increased intake of saturated fats

NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES 4169

which are linked to an increased risk of cardiovascu-

lar diseases and breast and colorectal cancer. Exces-

sive protein intake may be associated with increased

excretion of calcium and so possibly exacerbate the

prevalence of osteoporosis. Excess intake of protein is

associated with increased risk of renal disease, espe-

cially in infants, since the kidneys have to excrete

excessive solute loads and so excess protein intake is

perhaps linked to the risk of developing high blood

pressure later in life. It is advisable that ministries of

health review their national recommended intakes to

insure that these are in line with current international

recommendations.

0023 Lessons learned over the past 50 years suggest

future food policies should insure that:

0024 cereal and potato production should be geared to

supply > 50% energy

0025 vegetables (excluding potatoes) and fruit produc-

tion should be geared to supply a consumption of at

least 400 g per day per person

Given the recommendations, contained in most diet-

ary guidelines, ‘to protect, promote and support the

consumption of cereals, potatoes, vegetables and

fruit,’ it is surprising that there was no mention of

the need to increase the production of these foods in

the country reports. Without a food policy which

guarantees food security in the form of cereals, pota-

toes, vegetables, and fruit, it is difficult to see how

national targets for a healthy diet can be achieved.

0026 One of the reasons why families living in countries

undergoing economic transition (CEE and CIS) are

not suffering from protein/energy deficiency is

because many produce a large percentage of their

own potatoes, vegetables, and fruit. In Russia, town

dwellers produce 88% of their potatoes, 43% of their

meat, 39% of their milk, and 28% of their eggs on

urban household plots. This important share of pro-

duction is generated on plots of 0.2–0.5 ha which

together constitute only 4% of the total amount of

agricultural land in Russia. In addition, imports from

abroad have supplemented national food production

and currently 50% of chickens and 30% of meat

consumed in the Russian Federation is imported. In

the short term, imports are essential during times of

hardship and economic transition, but in the long

term agricultural polices should promote sustainable

production and protect local food production to

insure national food and nutrition security.

0027In eastern Europe the agriculture sector forms a

much higher percentage of national gross domestic

product compared with western Europe. Almost 30%

of the population in some CEE countries are employed

in agriculture compared with only 1 or 2% in western

Europe. Many economists are concerned about the

impact when more countries join the EU because the

Common Agriculture Policy (CAP) is not sustainable.

The CAP receives almost half the EU budget and in

1995 it cost EU taxpayers 39 billion ECU. During the

CAP reform process, health recommendations and

dietary guidelines should influence the reformed

policy in addition to concerns about national employ-

ment and the national food security of the EU acces-

sion countries.

Protecting Health Through Food Safety and Quality

0028In some reports there was no mention of the import-

ance of food safety, especially in the countries of

southern Europe. As mentioned in the introduction,

it is vital to strengthen the collaboration between

food control and nutrition agencies. Some western

governments are already attempting to bring these

two disciplines under one food authority and three-

quarters (27 out of 35 countries) did include food

safety in their ICN reports. Close collaboration be-

comes even more essential as the line between food

safety and nutrition becomes more and more blurred

with the introduction of precooked foods; functional,

novel, and special dietary foods; and supplements.

Moreover, with the introduction of food into global

trade, the public’s need for information will be

immense. To provide reliable information, both food

safety specialists and nutritionists need data on food

intake patterns. More effective use could be made of

resources if joint surveillance and risk management of

food intake are carried out together.

0029Foodborne diseases are among the most wide-

spread health problems in the contemporary world.

tbl0004 Table 4 Food policy in the twentieth century

1950s 1960s 1970s 1980s 21st century

Food insecurity and perceived

nutrient deficiency, especially

protein

Increased food

production and

consumption,

especially of animal

protein and fat

Surplus stocks of

food, especially

animal products

Links identified between

mortality from NCDs and

diets high in animal fats

and low in vegetables

and fruit

The opportunity to

change food

policy to meet

health and

environmental

recommendations

NCDs, noncommunicable diseases.

4170 NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES

In rich and poor countries alike they impose substan-

tial health burdens, ranging in severity from mild

indispositions to fatal illnesses. The emergence of

new foodborne diseases is an ominous trend. Epi-

demics due to newly identified pathogens such

as Campylobacter jejuni, Listeria monocytogenes,

Escherichia coli 157:H7 and bovine spongiform en-

cephalopathy (BSE) have hit industrialized countries.

Salmonella outbreaks are one of the main causes of

epidemics in Europe. Global trade will make it

more difficult to contain foodborne diseases within

national borders and enforce national food laws. In

addition, chemical contamination, toxic materials,

pesticides, veterinary drugs, and other agrochemicals

require constant surveillance to insure their safe use.

Similarly, the use of food additives can improve the

quality of the food supply but appropriate controls

are necessary to insure their proper use.

0030 Most regions included in their country reports the

need to harmonize their national food legislation with

the EU and World Trade Organization (WTO). Many

countries stated they are lining up to join either the

EU or WTO (12 countries) and so intend to harmon-

ize their national legislation with international direct-

ives set by the EU or Codex Alimentarius. It is

essential that health professionals, especially those

working in public health, become more informed

about international agreements on global food trade

and take a full part in the WTO Committee on Sani-

tary and Phytosanitary Measures (SPS Committee).

Only if public health specialists, from both food

safety and nutrition, participate can they hope to

influence future food policies.

Promoting Breast-Feeding

0031 Clearly there is a lot to be done in the European region

to promote breast-feeding. More than one-third (13)

of the 35 member states made no reference to breast-

feeding in their country report. This does not neces-

sarily mean that there are no active breast-feeding

programs in the country (e.g., Romania) but it does

mean that there is probably little coordination be-

tween those responsible for nutrition policy and

those responsible for promoting breast-feeding.

Perhaps this is because breast-feeding is regarded as a

clinical issue dealt with by midwives and primary

health care workers. However, public health nutri-

tionists and hygienists in CCEE and the CIS do have

an important role and should be active in the develop-

ment of national policies to promote breast-feeding.

0032 National breast-feeding initiatives will only be

successful if policies are developed and enforced

according to guidelines from the Baby-Friendly

Hospital Initiative (BFHI) and the International

Code for the marketing of breast milk substitutes.

It is necessary to national and regional trends

(marketing strategies and breast-feeding levels) to

interpret the national situation and make recommen-

dations to policy-makers.

0033The BFHI jointly launched in 1991 by WHO and

UNICEF, aims to enable women to choose and prac-

tice breast-feeding as the primary source of nutrition

up to about 6 months by minimizing obstacles which

make it difficult or prevent women from exercising

their right to breast-feed and to insure the cessation of

free and low-cost infant formula supply to hospitals.

The BFHI targets maternity services and hospitals,

particularly health workers and those responsible

for policies to help mothers succeed in breast-feeding.

To become a baby-friendly hospital every facility

providing maternity services and care for newborn

infants should implement the Ten Steps to Successful

Breastfeeding outlined in the joint WHO/UNICEF

statement entitled Protecting, Promoting and Sup-

porting Breastfeeding: The Special Role of Maternity

Services and should end free and/or low cost supplies

of breast milk substitutes.

0034There is clearly a vital need to increase the number

of Baby-Friendly Hospitals in Europe and develop

and enforce national legislation which is based on

the International Code of Marketing of Breast Milk

Substitutes.

0035In some countries there may be conflict between

nutritionists, hygienists, and new breast-feeding

policies. Some hygiene standards and decrees in the

former Soviet countries, such as the recommendation

that mothers should be separated from their babies

after birth, contradict the current UNICEF and WHO

recommendations to promote the ‘rooming-in’ of

babies with their mothers. In addition, National Nu-

trition Institutes involved with research and develop-

ment of breast milk substitutes and weaning foods

may unintentionally interfere with breast-feeding

promotion.

0036Complementary feeding (weaning) was not dis-

cussed in detail in any report and only mentioned

very briefly in two country reports, those of Albania

and Italy. Perhaps this is because the categories listed

in the World Declaration of ICN do not specifically

include complementary feeding, only breast-feeding.

This was perhaps an oversight by the ICN committees

since it is clearly important that all member states

address their policies on infant and young child feed-

ing. It is around the age of 6–24 months when mor-

tality and morbidity levels are at their highest. It is

likely that the high prevalence of anemia seen in some

parts of the European region is due to poor feeding

practices, such as the early introduction of foods and

drinks, especially cows’ milk and tea, before the age

of 6 months.

NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES 4171

Caring for the Deprived and Vulnerable

0037 In the region around 70% of the population is

suffering from physical and mental exhaustion as

people cope with increasingly uncertain conditions

related to very rapid economic and social change.

This is especially true for the countries of the former

Soviet Union where policy-makers are not used to

developing safety nets for vulnerable groups. The

transition to a market economy has resulted in

soaring consumer prices due to a reduction in subsid-

ies while salaries have remained low. In addition there

is rising unemployment as a result of industrial

restructuring and the new monetary polices have hit

vulnerable groups in particular. Mechanisms must be

developed to identify and protect the vulnerable

groups in society.

0038 Caring for vulnerable groups was mentioned in

almost three-quarters (22) of the country reports.

Many initiatives were related to the physiologically

vulnerable, such as children, pregnant women, or

the elderly. In addition, welfare safety nets, aimed

at insuring a minimum family income by setting

minimum wages, pensions, and unemployment bene-

fits, were considered necessary for economically

vulnerable groups such as the poor, low-income, un-

employed, and refugees or immigrants and those with

large or one-parent families.

0039 The gap between the rich and poor is increasing in

many countries in Europe, and as a phenomenon of

the economic transition in central and eastern

Europe, unemployment has appeared in many. If

this trend continues, the food intake and nutritional

status of vulnerable groups should be monitored

closely in order to develop safety nets and prevent

food insecurity. Among European industrialized

nations the UK was exceptional in the pace and extent

of the increase in inequality in the 1980s and by 1990

the level of inequality was almost back to 1930 levels.

0040 Poverty is a growing concern in Europe, especially

for those with incomes below societies’ poverty lines.

In 1994 it was estimated that 13.5% of the Polish

population (about 5 million) had average monthly

expenditures lower than the relative poverty line. In

1995, 4 million children in the UK lived in families

with incomes below 50% of average earnings. Lack

of food is associated with poverty, which can be

measured by estimating the percentage of disposable

income spent on food: in Romania the average figure

is around 60%; and in Poland around 40%, com-

pared with 22% in the EU.

0041 Coping within a limited budget often means that

healthier, safer foods are not affordable. In Lithuania

increased food prices have caused socially deprived

people to consume cheaper, less nutrient-dense foods

which are more likely to be contaminated. In Poland

the prevalence of nutrient deficiencies is highest

amongst the unemployed and low-income families

with many children. Poor people in the UK consume

much lower quantities of vegetables and fruit.

0042There is growing evidence for the protective effect

of vegetables and fruit against chronic diseases such

as cancer and coronary heart disease. This suggests

that the low intakes of vegetables by poor people

may directly increase their risk of these diseases.

Inadequate diets also have adverse consequences on

a child’s health, education, and future employability

and there are demonstrable costs to society in each

instance.

Micronutrient Deficiencies

0043There is no doubt that, in the European region of

WHO, the most prevalent health problems related

to diet are noncommunicable diseases such as cardio-

vascular diseases and cancers and not deficiency

diseases. Nevertheless, micronutrient deficiency does

exist in certain European countries under certain

circumstances.

0044Iodine One of the most prevalent nutrient deficien-

cies is iodine. Iodine deficiency disorders (IDD) are

prevalent throughout Europe and only six countries

have no IDD (Finland, Iceland, Norway, Sweden,

Switzerland, and the UK). Although this problem

has been largely eliminated in some countries in west-

ern Europe, it is reemerging in some countries in CEE

and the CIS. For example, in Albania and Tadjikistan

iodine deficiency is severe and in some other countries

the prevalence of IDD is increasing.

0045The main public health strategy recommended to

solve this problem is universal salt iodization. This

means insuring that all the salt used by the food-

processing industry, the mass catering sector, and

households is iodized. In some countries there is no

universal iodization and only table salt is iodized

(Italy, Poland). This could be a problem, especially

in western Europe where most of the population get

their salt from processed food products and not from

home-cooked food to which salt is added during

cooking or eating. Therefore nutritional epidemiolo-

gists should monitor the source of a population’s salt,

and so iodine.

0046In addition to insuring that iodized salt is used in

food processing and mass catering, policy-makers

should consider the need to include a recommenda-

tion to feed iodized salt to animals (cows). In the

Nordic countries and the UK iodine is given to cows

in the form of ‘salt-lick’ and so milk and milk prod-

ucts supply around 40–70% of the iodine intake in

humans. In addition to insuring elimination of iodine

4172 NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES

deficiency, this has the added benefit of limiting the

amount of salt consumed by the population.

0047 In CCEE and the CIS, cardiovascular diseases are

responsible for 68% of all premature deaths, while in

the rest of Europe this figure is only 43%. Moreover,

proportionally, cerebrovascular diseases are mark-

edly higher in CCEE and CIS. Because of the strong

link between high salt intake and cerebrovascular

disease, the WHO recommends a salt intake of no

more than 6 g per capita per day. In Italy a campaign

on the role of salt in the diet was launched. This

campaign aims to eliminate IDD through the promo-

tion of iodized salt, but at the same time preventing

hypertension and vascular diseases through limitation

of salt intake.

0048 Iron The other main nutrient likely to be deficient in

European countries is iron. Iron deficiency was men-

tioned as a problem by one fourth (9) of 35 member

states. Prevalence studies show that anemia is wide-

spread in central Asia and the Caucasus. For example,

in Kazakhstan and Azerbaijan up to 70% of children

younger than 2 years of age have low hemoglobin

levels. In addition, 20–30% of women of child-

bearing age also have low hemoglobin levels. These

problems may not be related solely to iron deficiency

in the diet. For example, it has already been men-

tioned that early introduction of cows’ milk is a

major cause of iron deficiency in the young. Anemia

in adults is associated with the presence of iron-

absorption inhibitors in the diet, such as tea and

coffee, which is frequently consumed in eastern Euro-

pean countries; or lack of absorption enhancers, such

as vitamin C from vegetables and fruit.

0049 Folate Folate deficiency is associated with neural

tube defects. Denmark, Poland, and the UK men-

tioned national strategies related to solving this prob-

lem. Folate may also play an important role in the

prevention of coronary heart disease by helping to

reduce levels of homocysteine. The main food sources

of folate are Brussels sprouts, asparagus, spinach,

broccoli, cabbage, cauliflower, parsnip, iceberg let-

tuce, beans, peas, and beef and yeast extracts – yet

another reason why national food and nutrition po-

lices and dietary guidelines should promote vegetable

production and consumption.

0050 Other micronutrients There may be situations when

the only solution to solve micronutrient deficiency is by

food fortification of bread or salt, for example (such as

for iodine deficiency), or, more rarely, by supplements

(during emergencies). However, generally, where pos-

sible, WHO promotes primary prevention strategies

such as increasing vegetable consumption rather than

advocating consumption of nutraceuticals, food sup-

plements, or multivitamin tablets. Population strat-

egies advocating the use of vitamin supplements are

not the solution to micronutrient deficiencies in

Europe. Vitamin supplements may have many disad-

vantages: side-effects; nutrient imbalances; toxicity;

malabsorption; long-term dependence and lack of

confidence in locally produced foods, and, finally,

supplements are an unnecessary expense.

Appropriate Diets and Lifestyles

0051Countries of the CARs and the CIS must pay more

attention to the link between diet and noncommunic-

able diseases (NCD), such as cardiovascular diseases,

certain cancers, diabetes, hypertension, and obesity.

Some of the country reports focused too much on

deficiency of protein and micronutrients. In focusing

on deficiency the link between premature mortality

from NCD and a diet high in fat, salt, fatty red meat,

and fatty/sugary foods and simultaneously low in

vegetables and fruit is neglected.

0052Some countries in the CIS and central Asia men-

tioned the need to increase the teaching of dietology/

dietetics. There is still a tendency in some countries to

prescribe many different types of diets for different

disorders. Many of these dietary prescriptions have

not been scientifically proven. In addition, many of

the individuals referred for dietary treatment are

suffering from obesity, diabetes, heart disease, high

blood pressure, and other conditions related to un-

healthy lifestyles. These cases should be treated using

the healthy nutrition principles developed for the

population. Dental caries is also widespread in many

European countries and there can be little doubt that

this is related to frequent high intakes of sugar as well

as poor oral hygiene.

0053Some countries, such as Albania, Israel, Kazakh-

stan, Latvia, Romania, Slovakia, the Republic of

Moldova, Ukraine, and Uzbekistan made no mention

of the link between diet and NCDs. Moreover, only

one-third (12) of 35 member states mentioned obesity

(Austria, Azerbaijan, Czech Republic, Denmark,

Estonia, Hungary, Lithuania, Luxembourg, Malta,

Poland, Turkey, and the UK), despite the fact that

the prevalence of obesity is high and appears to be

increasing in every country in Europe. For example,

the Russian Federation has one of the highest preva-

lences, where 55% of the female population is over-

weight. Little mention of obesity probably reflects the

lack of data on body weight and height and illustrates

the need for countries to collect anthropometric data

as part of their health information system.

0054Physical activity and obesity Obesity is a chronic

medical problem caused by a combination of an

NUTRITION POLICIES IN WHO EUROPEAN MEMBER STATES 4173