Food and health in Europe: a new basis for action Food and health in Europe: a new basis for action 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. To ensure the widest possible availability of authoritative information and guidance on health matters, WHO secures broad international distribution of its publications and encourages their translation and adaptation. By helping to promote and protect health and prevent and control disease, WHO’s books contribute to achieving the Organization’s principal objective – the attainment by all people of the highest possible level of health. i Food and health in Europe: a new basis for action ii 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 Te xt editing: Mary Stewart Burgher iii 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 iv 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. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Or- ganization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distin- guished by initial capital letters. The World Health Organization does not warrant that the information con- tained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or edi- tors do not necessarily represent the decisions or the stated policy of the World Health Organization. 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). v 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 vi 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 vii 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 viii 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 [...]... 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... Israel Italy United Kingdom Russian Federation Belgium–Luxembourg Estonia Switzerland Lithuania Netherlands Ireland Germany Poland Austria Latvia Czech Republic Ukraine Slovenia Slovakia a TFYR Macedonia Hungary Croatia Bulgaria Kazakhstan Georgia Turkmenistan Albania Romania Azerbaijan Belarus Armenia Republic of Moldova Kyrgyzstan Uzbekistan 0 50 100 150 200 250 300 Availability (g per person per day)... population targets for healthy eating These targets have become increasingly specific in the last 20 years, moving 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,... 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... the European Region, examines the links between disease and food, and looks upstream at the nature of food supplies It 1 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,... home and at work largely replacing physically demanding manual tasks, and leisure time often being dominated by physically 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 disability and. .. prions), as well as longer-standing 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. .. 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 policies 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. .. 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... 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 Legislative 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 . health. i Food and health in Europe: a new basis for action ii WHO Library Cataloguing in Publication Data Food and health in Europe : a new basis for action (WHO regional publications. European series. Food and health in Europe: a new basis for action Food and health in Europe: a new basis for action 96 WHO Regional Publications European Series, No. 96 The World Health Organization was. 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).