Introduction
The fi rst survey of food and nutrition policies was published by the League of Nations, a predecessor of the United Nations, in 1937–1938 (League of Nations 1938). It was proposed that every country should form a national nutrition committee and report annually on the state of nutrition in their country. The main focus at that time was nutritional adequacy and diseases associated with nutritional defi ciencies. Since then much has changed, but the need for food and nutrition policies is undiminished.
With rising prosperity and the associated abundance of food, nutrition-related health risks have changed considerably (World Health Organization 2009). Traditional risks such as undernutrition or unsafe food and water have largely been replaced by problems related to unbalanced diets and inadequate physical activity, which are important contributors to the chronic diseases, such as ischaemic heart disease and diabetes, that currently dominate morbidity and mortality patterns in Europe. The major food-related risk factors for chronic diseases in Europe today are high blood pressure, overweight and obesity, high blood cholesterol, high blood glucose and low intake of fruit and vegetables (World Health Organization 2009). If physical inactivity is also included, these risk factors together explain 57% of all cardiovascular deaths, 25% of all premature deaths and 12.6% of the total disease burden in Europe, all of which is preventable. Table 4.1 summarizes the food- and nutrition-related burden of mortality in Europe, and shows that these risk factors are important across Europe, not only in the high-income countries.
For several decades, governments have been engaged in defi ning nutritional recommendations and formulating food and nutrition policies in response to these health challenges, a process continuously supported and monitored by the WHO (WHO Regional Offi ce for Europe 2000, 2006a, 2008; World Health Organization 2004; Andersson et al. 2007). A food and nutrition policy may
be defi ned as a ‘specifi c set of decisions with related actions, established by a government and often supported by special legislation, which addresses a food or nutrition problem or set of problems’ (Johns Hopkins Bloomberg School of Public Health 2012).The terms ‘food’ and ‘nutrition’ have slightly different meanings, with food referring to the substances that we eat, and nutrition to the actual provision of nutrients needed for life. We will use the general term ‘food and nutrition policies’ to refer both to policies dealing with the supply of food, and to policies seeking to modify the demand for specifi c foods. In general, available instruments in health policy are education, legislation/regulation and fi scal measures, which may be used to a varying extent depending on the political context and the scientifi c evidence.
Up until the 1970s, the focus of European food and nutrition policies was to ensure nutritional adequacy. Concurrently with the rise in food availabil-ity and knowledge on the links between diet, health and disease, the focus of nutrition and food policies started to change during the 1970s. A striking development in Europe after the Second World War has been the initial rise in cardiovascular morbidity and mortality followed by a dramatic decline in most European countries during the period 1970–2010 (see Chapter 1). In recent times there has also been a steady rise in obesity. Formulation of food and nutri-tion policies has occurred in response to these changing disease patterns, defi n-ing the policy objectives in relation to the risk factors such as unhealthy diet and physical inactivity. However, policies on paper are not always implemented as intended and an adequate evaluation of policy implementation is lacking in most countries. Furthermore, policy implementation often is a ‘natural experi-ment’ without control groups and, therefore, cause and effect cannot easily be established.
Ta ble 4.1 Attributable mortality by nutrition-related risk factor in Europe, 2004
Risk factor Deaths (in 1000s)
Total High income Low and middle income
High blood glucose 748 258 490
High blood pressure 2491 740 1752
High cholesterol 926 242 684
Iron defi ciency 8 4 4
Low fruit and vegetable intake 423 77 346
Overweight and obesity 1081 318 763
Physical inactivity 992 301 691
Suboptimal breastfeeding 36 2 33
Underweight 28 0 27
Vitamin A defi ciency 10 0 10
Zinc defi ciency 5 0 5
Total deaths (all causes) 9493 3809 5683 Source: World Health Organization 2009
Nevertheless, favourable changes in people’s diets have occurred during the past four decades. This chapter will start by looking at iodine defi ciency, an old problem that has never been completely eradicated in spite of knowledge of how to do so. Efforts to tackle nutrition-related risk factors for cardiovascular diseases will then be considered. A general overview of food and nutrition policies, by country, is presented in Appendix table 4.A1.
Tackling iodine defi ciency
The European continent has a long history of iodine defi ciency because of its iodine-defi cient soils, with endemic goitre as its main clinical manifestation.
Brain damage and irreversible intellectual impairment have been and still are major health consequences of this micronutrient defi ciency, which all European countries except Iceland have experienced to a greater or lesser degree (World Health Organization 2007).While cretinism, the most extreme expression of iodine defi ciency disorders, has become very rare, more subtle degrees of intellectual impairment associated with iodine defi ciency are of considerable concern, leading to poor school performance and impaired work capacity (Hetzel 2004). Iodine defi ciency remains a major threat to health and development around the world, particularly among preschool children and pregnant women, and it is the greatest single cause of preventable brain damage (de Benoist et al. 2008). Worldwide it is estimated that 2 billion people suffer from iodine defi ciency, of which 20% are in Europe.
The most costeffective and sustainable strategy to reduce iodine defi -ciency is iodization of salt. The fi rst country to apply this countermeasure was Switzerland, which succeeded in completely eliminating goitre through sus-tained implementation and monitoring of a programme of salt iodization.
After this remarkable success, legislation on iodized salt was passed in many European countries, and iodine defi ciency was no longer considered to be an important public health problem (Delange 2002). However, in the 1980s, it gradually became clear that iodine defi ciency had reappeared in many European countries where it was thought to have been eliminated (Vitti et al. 2003; World Health Organization 2007).
Four factors have led to this situation. First, in some countries political and social changes have interrupted the salt iodization process and quality control measures that had previously been in place. Second, the formation of common markets along with increasing globalization have led to increased movement of foods across national borders, some processed with iodized salt but some not.
Third, a diminishing amount of salt is consumed as table salt while a greater proportion is ‘hidden’ in processed foods, which are not covered by legislation in many countries. Finally, partly because of concern about hypertension, salt consumption has gradually declined, although it remains high (World Health Organization 2007).
In the 1990s the situation became particularly serious in eastern Europe.
In 1997, a meeting held in Munich revealed the recurrence of goitre, and occasionally of endemic cretinism, in some countries in eastern Europe after the interruption of their salt iodization programmes. Many had good salt
iodization coverage prior to 1990 but saw a drastic drop in iodine status during the 1990s after the break-up of the USSR. The former USSR began iodizing salt in the 1950s, and by 1970 most of the iodine defi ciency disorders had been eliminated. However, as a result of relaxation of monitoring and less stringent enforcement, non-iodized salt started to reappear, again increasing the prevalence of iodine defi ciency disorders in the region. For example, cases of goitre increased dramatically in certain oblasts in Ukraine and Belarus (Rokx 2003). Since then, an improvement in the availability of iodized salt has been brought about through partnerships formed by United Nations Children’s Fund (UNICEF), with the help of other organizations. Unfortunately, the two major salt-producing countries in the region, the Russian Federation and Ukraine, have been slow in achieving universal salt iodization. Only 12 and 37%, respectively, of salt is iodized in these countries. Major challenges in the region include reintroducing the iodization technology in the now private salt producers, engaging with small salt producers, introducing and enforcing existing regulations and controlling the trade in illegal salt (Rokx 2003).
The problem is not limited, however, to eastern Europe. In 2002, only 28% of households in Europe as a whole used iodized salt (Delange 2002), and iodine defi ciency is still common throughout Europe. Until 1990, goitre prevalence was used as an indicator of iodine defi ciency, but today urinary iodine is used (de Benoist et al. 2008). Iodine defi ciency is considered a public health problem in countries where the median urinary iodine concentration is <100 μg/L.
Estimations from 2010 show that, of all the WHO regions, the European Region has the highest proportion of insuffi cient iodine intake. This affects 44% of all schoolchildren and 44% of the general population (Table 4.2).
The number of countries with insuffi cient iodine intake in the WHO European Region has decreased from 23 in 2003 to 14 in 2010, among them several central and eastern European countries. The list of countries that still have insuffi cient iodine intake includes Albania, Belgium, Estonia, France, Hungary, Ireland, Latvia, Lithuania, the Republic of Moldova, Norway, Portugal, the Russian Federation and Ukraine; this shows that the problem affects countries throughout the region (Zimmermann and Andersson 2011).
This long list of countries that still have insuffi cient iodine intake is an indication that the problem is not taken seriously enough, perhaps because governments still equate iodine defi ciency with goitre and are unaware of the
Table 4.2 Prevalence of iodine defi ciency in the WHO European Region, 2003–2007 Year Countries with
insuffi cient intake
Total number, millions (%)
School-age children General population
2010 14 28.6 (43.6) 359.9 (43.9)
2007 19 38.7 (52.4) 459.7 (52.0)
2003 23 42.2 (59.9) 435.5 (56.9)
Source: Zimmermann and Andersson 2011
adverse effects of iodine defi ciency on reproduction and brain development (Zimmermann and Andersson 2011). Even though most countries in the region monitor urinary iodine and/or total goitre prevalence in the population at irregular intervals, much more needs to be done to eradicate iodine defi ciency disorders in Europe. The WHO recommends implementation of effective control and surveillance programmes, public information campaigns, and legislation or regulation on universal salt iodization. The last is particularly impor-tant for processed foods, which constitute a growing proportion of people’s diets. Until universal iodization is achieved, iodine supplementation for the most vulnerable groups, such as pregnant women and young infants, should be considered in regions where there is insuffi cient iodized salt (Andersson et al. 2010).
Tackling nutrition-related risk factors for cardiovascular diseases
Effectiveness of food and nutrition policies
As noted in the introduction, the rise of cardiovascular diseases after the Second World War has bought new nutrition-related risk factors into focus. In the 1970s, the Seven Countries Study reported positive correlations between deaths from ischaemic heart disease and total fat intake, and later between ischaemic heart disease mortality and saturated fat intake (Keys et al. 1986). Other nutrition-related risk factors for ischaemic heart disease that have been identifi ed include high blood pressure (which partly refl ects high salt content of foods), low intake of fruit and vegetables, and intake of trans-fatty acids (TFAs; Mente et al. 2009).
In the 1990s, overweight, obesity and diabetes type 2 emerged as serious public health threats in Europe and elsewhere, caused by a rising consumption of an energy-dense diet high in added sugar and fat and low in fruit and vegetables, in combination with a sedentary lifestyle.
The recognition of these risk factors has led to a range of dietary intervention studies in the community and in the workplace (James et al. 1997). The main dietary components targeted were fat quality, fruit and vegetable intake and salt. The results have been summarized in systematic reviews showing that it is possible to modify nutrition-related risk factors, and that modifying these risk factors reduces the risk of cardiovascular diseases. Intensive support and encouragement to reduce salt intake has led to a reduction in the amount of salt eaten, and also to lower blood pressure, although with mixed success (Hooper et al. 2004). Replacing some saturated (animal) fats with plant oils and unsaturated spreads reduced the risk of cardiovascular events (Hooper et al. 2011). Dietary advice on the reduction of salt and fat intake and an increase in the intake of fruit, vegetables and fi bre lead to modest improvements in cardiovascular risk factors, such as blood pressure and cholesterol levels (Brunner et al.
2007). Obesity prevention programmes, however, often lack effectiveness. For example, programmes to improve physical activity and nutrition in children do improve these behaviours, but only some of these studies show an effect on children’s body weight (Waters et al. 2011).
Several international agreements have been drawn up in the fi eld of nutri-tion with the aim of strengthening nanutri-tional policy acnutri-tion, such as the Global Strategy on Diet, Physical Activity and Health (World Health Organization 2004), the European Charter on Counteracting Obesity (WHO Regional Offi ce for Europe 2006b), the European Action Plan for Food and Nutrition Policy 2007–2012 (WHO Regional Offi ce for Europe 2008), and the 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases (World Health Organization 2008). Following these initiatives, a monitoring mechanism has been set up by the WHO Regional Offi ce for Europe to help countries to evaluate progress towards their commitments in the international agreements. A 2006 survey on food and nutrition policies revealed that 48 out of 53 countries in the WHO European Region had established national policies. The latest survey in 2011 showed that all 27 EU Member States had a national food and/or nutri-tion policy either as a stand-alone policy or included in the public health policy (Bollars 2011). These data are reported to the WHO Regional Offi ce for Europe by national focal points. On the basis of the country data, an overview of the policy development stage in the WHO European Region has been produced (Appendix 4.1). However, in order to draw conclusions about policy implemen-tation, more in-depth assessment at country level is needed, and this is not yet available. Consequently, for this chapter, three case studies are presented fi rst that are well documented in the scientifi c literature and illustrate how govern-ments have committed themselves, on the basis of evidence, to improving diets in the population and the effects on health. Trends in nutrition-related risk factors and ischaemic heart disease mortality in Europe will then be reviewed.
Finland’s comprehensive nutrition policy
In the 1960s, Finland had the highest death rate from ischaemic heart disease in the world (Pietinen et al. 2001) and was one of the fi rst countries to take action by reducing risk factors. The Finnish diet at that time was characterized by a high fat intake (40–45% of energy intake), particularly a high saturated fat intake (>20% of energy intake), and salt intake (15 g/day), plus a low intake of fruit and vegetables (Prattala 2003). A comprehensive community health promotion intervention, the North Karelia Project, was initiated by Finnish researchers in 1972. The aim was to reduce mortality and morbidity from car-diovascular diseases by reducing established risk factors, such as smoking, high serum cholesterol and blood pressure, and improving the diet (Vartiainen et al.
1994). The main dietary targets were saturated fat, salt and fruit and vegetables.
Activities included media campaigns, health education, primary health care measures, environmental measures, collaboration with the food industry and the agricultural sector to develop healthier products, collaboration with non-governmental organizations, legislation and community activities in super-markets and catering services, among others. A large detection and treatment programme for high blood pressure was also started in 1972. After the fi rst fi ve years, the programme was extended to the rest of Finland and the goals were broadened to prevention of all chronic diseases. Concurrently, a comprehensive monitoring system was developed, including regular population surveys on risk
factors for cardiovascular diseases, including diet, every fi ve years (Pietinen et al. 2001).
As a result, full-fat milk was to a large extent replaced by low-fat milk. Butter was replaced by margarines based on vegetable oils, and the percentage of Finnish men using butter decreased from 90% in 1972 to < 5% in 2009 (Puska 2009). This resulted in a substantial increase in the ratio of polyunsaturated to saturated fats, leading to lowering of serum cholesterol in the population (Vartiainen et al. 1994). This trend has been sustained and, in 2009, the mean intake of saturated fat in Finland in the working population was 12.9%
of energy intake, which is at the lower end of the European range (8.8% in Portugal to 26.3% in Romania; Elmadfa 2009). Daily vegetable consumption among men went up from 16 to 28% during the same period (Prattala 2003), corresponding to a three-fold increase between 1972 and 2001, made possible through increased availability, mainly through the workplace and schools, and lower prices (Pietinen et al. 2001). Blood pressure decreased as a result of better medical treatment, a lowered salt intake in the population and, possibly, through an increase in the intake of polyunsaturated fat from vegetable origin.
Anti-smoking legislation was also enacted.
As a result, cardiovascular mortality, including from ischaemic heart disease and stroke, decreased faster in North Karelia than in the rest of Finland during the fi rst fi ve years of the intervention; after 1977 the trend was the same all over Finland (Pietinen et al. 2001) (Fig. 4.1). Today cardiovascular mortality is 80%
lower than at its peak, which is a remarkable achievement. Most of this decrease has been explained by the fall in serum cholesterol brought about by dietary change (Puska 2009). Furthermore, life expectancy in Finland has increased during this period by almost ten years.
The developments in Finland provide an interesting example of how research on the links between blood lipids, diet, smoking and heart disease was translated into community action in 1972 and fi nally to health policy in 1978, when the Finnish National Nutrition Council made its proposal for Finland’s fi rst food and nutrition policy. In 1987, the Council published recommendations for improving health and diet, emphasizing the role of fat, salt and dietary fi bre.
Two years later, in 1989, a multisectoral action plan including the whole food sector was released. In 1995, the Finnish Nutrition Surveillance System was established and in 1997 there was a consensus meeting regarding a programme to reduce cardiovascular diseases. Today, health services, schools and voluntary organizations share responsibility for implementing nutrition and health education (Puska 2009). Even though the health trends in Finland have been paralleled by similar developments in other countries, nowhere else have health gains been as large as in Finland.
Denmark’s ban on industrially produced trans-fatty acids Milk and dairy products contain low amounts of TFAs (Micha and Mozaffarian 2008), but the major source in the diet today is industrially produced partially hydrogenated vegetable oils, which are used in bakery products, deep fried and frozen foods, packaged snacks and margarines. These contribute 2–4% of
energy intake in many countries. Some groups in the population may have even higher intakes, particularly those who consume large amounts of fast foods and snacks. The WHO recommends a maximum TFA intake corresponding to 1% of daily energy intake (Nishida and Uauy 2009). This can be accomplished by the elimination of partially hydrogenated vegetable oil in the human food supply.
Observational studies have linked a high intake of TFA to unfavourable effects on blood lipids, increased systemic infl ammation, endothelial dysfunction and
Observational studies have linked a high intake of TFA to unfavourable effects on blood lipids, increased systemic infl ammation, endothelial dysfunction and