National coordination: Belgian Heart LeagueContact person: Mr Jean-Pierre WillaertAddress: Rue des Champs Elysées 43

1050 BrusselsBelgium

Telephone: +32 2 649 8537Fax: +32 2 649 2828E-mail: ligue.cardio.liga@euronet.be

National coordination: Danish Heart FoundationContact person: Mr Hans SøndergaardAddress: Hauser Plads 10

DK-1127 CopenhagenDenmark

Telephone: +45 33 931 788Fax: +45 33 369124E-mail: hsoendergaard@hjerteforeningen.dk

National coordination: French Federation of CardiologyContact person: Mr Serge LafayeAddress: 50 Rue du Rocher

F-75008 ParisFrance

Telephone: +33 1 44 90 83 83Fax: +33 1 43 87 98 12 E-mail: slafaye@fedecardio.com

National Coordination: Finnish Heart AssociationContact person: Ms Anna Liisa RajalaAddress: Oltermannintie 8

SF-00620 HelsinkiFinland

Telephone: +358 9 752 752 23Fax: +358 9 752 752 50E-mail: anna-liisa.rajala@sydanliitto.fi

National coordination: German Heart FoundationContact person: Ms Kerstin KopelkeAddress: Vogtstrasse 50

D-60322 Frankfurt/MainGermany

Telephone: +49 69 955 1280Fax: +49 69 955 128 313E-mail: kopelke@herzstiftung.de

National coordination: Irish Heart FoundationContact person: Ms Marie Therese CrottyAddress: 4 Clyde Road

BallsbridgeDublin 4Ireland

Telephone: +353 1 668 5001Fax: +353 1 668 5896E-mail: mcrotty@irishheart.ie

National coordination: Italian Association against ThrombosisContact person: Mr Riccardo PiraniAddress: Via Cesare Correnti 14

20123 MilanItaly

Telephone: +39 02 720 11444Fax: +39 02 720 21776E-mail: trombosi.alt@galactica.it

National coordination: Netherlands Heart FoundationContact person: Ms Karen van ReenenAddress: P.O. Box 300

2501 CH The HagueThe Netherlands

Telephone: +31 70 315 5555Fax: +31 70 383 8752E-mail: k.van.reenen@hartstichting.nl

National coordination: Norwegian Council on Cardiovascular Diseases

Contact person: Ms Kirsti StrandAddress: Postboks 7139 Majorstua

N-0307 Oslo 3Norway

Telephone: +47 23 120 000Fax: +47 23 120 001E-mail: kist@nasjonalforeningen.no

National coordination: Portuguese Heart FoundationContact person: Dr Sofia LemosAddress: Joaquim Antonio de Aguiar,

64 2° D1070-153 LisboaPortugal

Telephone: +351 21 381 5000Fax: +351 21 387 3331E-mail: fpcardio@mail.telepac.pt

National coordination: Spanish Heart FoundationContact person: Ms Beatriz JuberiasAddress: Ntra. Sra. de Guadalupe, 5-7

28028 MadridSpain

Telephone: +34 91 724 2373Fax: +34 91 7242374 E-mail: fec@secardiologia.es

National coordination: Swedish Heart Lung FoundationContact person: Ms Ingrid EngellauAddress: Riddargatan 18

S-11451 StockholmSweden

Telephone: +46 8 566 24217Fax: +46 8 566 24229E-mail: Ingrid.engellau@hjart-lungfonden.se

National coordination: National Heart ForumContact person: Ms Louise SarchAddress: Tavistock House South

Tavistock SquareLondon WC1H 9LGUK

Telephone: +44 207 383 7638Fax: +44 207 387 2799E-mail: louise.sarch@heartforum.org.uk

European Heart Network

Mrs Susanne LøgstrupDirector

Rue Montoyer, 31B-1000 BrusselsBelgium

telephone: +32 2 512 9174fax: +32 2 503 3525e-mail: ehn@compuserve.comwebsite: www.ehnheart.org

European Heart Health Initiative National Coordination

Ms Rosemary CoelhoEHHI European Coordinator

telephone: +32 2 502 1541fax: +32 2 503 3525e-mail: ehhi@compuserve.com

Contact

EUROPEAN HEART HEALTH INITIATIVE

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This European Heart Network acknowledges the financial supportreceived from the European Commission for this project. Neither theEuropean Commission nor any person acting on its behalf is liable for

any use made of the following information.

The mission of theEuropean HeartNetwork is to play a leading rolethrough networking,collaboration andadvocacy in theprevention andreduction ofcardiovasculardisease so that itwill no longer be a major cause ofpremature deathand disabilitythroughout Europe.

www.karakas.be

Quarterly Bulletin of the European Heart Network

HeartMattersHeartMattersJune 2001

CHILD

REN A

ND NU

TRITIO

N CHILDREN AND NUTRITION

This means that every year in the EU almost

150,000 people die from diet-related

cancers and cardiovascular diseases

before they reach the age of 65!

Probably most of these early deaths

are entirely avoidable.

Inappropriate eating habits contribute to

other conditions that shorten life or inter-

fere with the quality of life. For example,

the incidence of diabetes is set to double

in the next 25 years. Besides the compli-

cations caused by diabetes itself, it is also

a contributing factor in heart disease and

stroke. Osteoporosis is also clearly diet-

related, as are many other conditions.

Nutrition for a healthy population

While we welcome the European

Commission’s commitment to establishing

a nutrition action plan for the European

Union and the Council of Ministers’ res-

olution on health and nutrition, we are

concerned that nutritional health is not

taken sufficiently into account in other

Community policies. For instance, good

nutrition should be a major objective

in the remit of the imminent European

Food Authority.

Der Mensch ist was er isst – and he or

she has every right to expect that food is

not only safe but that our politicians are

ready and willing to ensure that it is also

wholesome and nutritious. Our politicians

need to acknowledge that it is necessary

to have structures that monitor eating

patterns so that we can determine the

origin of the excess intake of saturated

fats which we see in particular in northern

Europe. Promoting positive changes in

eating patterns can help ensure a

healthy population.

This year’s Annual Workshop of the

European Heart Network is focusing on

food and nutrition and will agree on ways

forward for a healthier Europe. You will

hear from us again.

HeartMatters

Forming healthy nutrition habitsin childhood

The saying ‘you are what you eat’ is

equally true for children and young

people. In the first edition of Heart Matters,

we looked at the level and pattern of

children and young people’s physical

activity. In this edition we will look at what

they eat. We know that there has been a

considerable increase in obesity among

children and young people in Europe

in recent years, and we learnt from the

first issue of Heart Matters that being

overweight during adolescence appears

to be a more significant predictor of

a range of future diseases than being

overweight as an adult. Therefore, we

have every interest in also looking at

our youngsters’ eating habits and finding

ways of ensuring that they have a good

knowledge and understanding of what

constitutes a balanced, healthy diet.

However, knowledge is not enough.

We also need to ensure that the sort of

food we encourage them to eat is readily

available, affordable and attractive.

In this edition of Heart Matters you will find

a selection of initiatives undertaken by

heart foundations and other organisations

concerned with health promotion that

aim at encouraging healthy lifestyles and

not least healthy eating among our young

people. We are convinced that these

initiatives as well as the information in

the feature article will give you food

for thought.

Safe food, but good nutrition too

Currently, there is a strong focus in Europe

on food safety. Ensuring that food is

uncontaminated by dangerous

substances and safe to eat is clearly of

the utmost importance. In the European

Heart Network we strongly believe,

though, that the highly publicised debate

on food safety should be matched by an

equally publicised debate on what really

creates havoc – namely the nature of

people’s diets.

" The highly publiciseddebate on food safetyshould be matched by anequally publicised debateon what really createshavoc – namely thenature of people’s diets. "

In the European Union (EU) alone around

430,000 people aged 35 to 64 die from

cancer and cardiovascular diseases every

year. It is estimated that about 35% of

deaths from cancers and approximately

one third of deaths from cardiovascular

diseases are caused by unhealthy diets.

editorial

Food for thought by Leslie Busk

Chairman, European Heart Network

By:

‘Der Mensch ist was er isst’ – this famous saying was used recently by two

European Parliament rapporteurs in their respective reports on the European

Commission’s White Paper and proposal on food law. And indeed human

beings, are what they eat.

HeartMatters

1" Every year in the EU almost 150,000 people die from

diet-related cancers and cardiovascular diseasesbefore they reach the age of 65! Probably most ofthese early deaths are entirely avoidable. "

co

nte

nts

1 EditorialFood for thought

3 Feature articleThe next generation:nutrition and health

8 Policy issuesEuropean policy developments

13 Country activities

BelgiumDenmarkFinlandItalyThe NetherlandsSpainSwedenTurkeyUnited Kingdom

19 Contact information

Heart Matters, focusing on cardiovasculardisease prevention, is a quarterly publication relevant to policy makers, public health experts and organisationsinvolved in health promotion, diseaseprevention and public health research.

2

HeartMatters

more usually around 3-8%) (Tang et al.

1998). A recent meta analysis quantified

the relationship between fruit and vege-

table consumption and the incidence

of heart disease. The risk of heart disease

was about 15% lower in the top tenth

of fruit and vegetable consumers,

compared with the tenth who ate least

(Law and Morris 1998). From a meta

analysis of 17 trials, Brunner et al. (1997)

estimated that modifying fat, sodium and

fibre intake could realistically reduce

heart disease by 14%, and stroke by 9%.

Fatty streaks have been reported in the

arteries of young children. Napoli et al.

(1999) looked at the arteries of 156

children who died from trauma and

other causes. The size of lesions correlated

with the conventional risk factors for heart

disease. Lesions had progressed most

in children of mothers with genetically

high cholesterol levels. However, the

relationship between fatty streaks in

childhood and more advanced lesions

is controversial. It has been suggested

that a specific trigger may be needed to

change a fatty streak into an advanced

lesion. There is also evidence that

cholesterol levels in children track into

adulthood (American Heart Foundation

1983; Department of Health, UK, 1994),

with 40% of children with cholesterol in

the highest quarter of the distribution

maintaining this position in adult life.

Obesity increases the risk of cardiovas-

cular disease both directly and indirectly.

In 1998 Gunnell et al. examined the

relationship between body mass index

in childhood and adult cardiovascular

mortality, in a 57-year follow-up of a

cohort of over 2,000 children aged 2-15 in

the UK. Cardiovascular mortality was twice

as high for people in the top quarter of

weight distribution during their youth.

Fat children have a higher risk of growing

up to be fat adults, although it is unclear

how much of this is due to genetics, and

how much to the environment in which

the children grow up. Parsons et al. (1999)

carried out a systematic review of the

childhood predictors of adult obesity.

There was a strong and consistent

relationship between low socio-economic

status in early life and increased fatness in

adulthood. In a companion paper, three

potential explanations were advanced

for this: either over or under-nutrition in

childhood, followed by over-nutrition;

psychological factors, possibly including

emotional deprivation in childhood;

cultural and social attitudes to dietary

restraint and fatness, acquired during

childhood (Power and Parsons 2000).

The other side of the obesity coin is eating

disorders. In a national survey in England

45% of young women with a healthy

body weight said that they were trying to

reduce their weight (Prescott-Clarke and

Primatesta 1998). There are increasing

concerns that this type of ‘restrained

eating’ can itself lead to disordered

eating and overweight. It can also have

short-term health effects as a result of

inadequate mineral and vitamin intakes.

4

3

Imbalances in dietary patterns can affect

health profoundly, both in the short and

long term. Short-term effects in children

include, for example, dental caries as a

result of frequent consumption of sugary

foods, anaemia as a consequence of

eating relatively low amounts of iron

in the diet, and bone health that is

adversely affected by low calcium

intakes.

The aspects that are most relevant to

heart foundations in Europe are the

effects of diet on increasing the risk of

cardiovascular disease, both through the

balance of dietary intake, and through

obesity as a consequence of excessive

calorie intake relative to physical activity.

In the WHO European Region one in

eight men and one in seventeen women

die from cardiovascular disease before

they reach the age of 65 (British Heart

Foundation 2000). The main factors which

increase the risk of cardiovascular

disease, but which can be changed,

are smoking, poor dietary patterns and

inadequate levels of physical activity.

The diet is composed of a complex

mixture of nutrient and non-nutrient

components. We are only just beginning

to understand the roles of some of

these components and the interactions

between them. However, the main

aspects of diet which are closely linked

to cardiovascular disease are: a relatively

high level of saturated fatty acids; a

relatively low consumption and variety

of fruits and vegetables in the diet; and

relatively high amounts of sodium, which

can exacerbate age-related increases

in blood pressure.

Reducing the amount of saturated fat

consumed can result in a reduction in

plasma cholesterol of up to 15%, under

carefully controlled conditions (although

the results of ‘real life’ interventions are

The next generation: nutrition and health

*by Mike Rayner and Lynn Stockley, British Heart Foundation Health Promotion Research Group, University of Oxford, UK

The reasons given for concentrating on

children are extremely cogent. Nutrition

affects health throughout the life cycle,

and it is best to begin to prevent harm

early on. Habits are formed early in life,

and habits are a major determinant of

food choice in later life. It is relatively easy

to reach children through institutions such

as schools. As a society, we have a

responsibility to do our best to protect the

young. All of these reasons are good, and

true. However, they are in stark contrast to

the increasing prevalence of poor diets

and obesity amongst young people.

Changes in children’s diets cannot and

should not be considered in isolation from

other societal changes. Two trends

in particular are worthy of mention in

this regard: the progressive globalisation

of the food supply and the increasing

differentials between rich and poor.

The main streets of many of our cities

and towns across Europe are coming

increasingly to contain the same retail

and fast food outlets. Television

programmes and advertising cross

borders. The aspirations of many young

people are formed by an international

youth culture. Local tradition and culture

play an ever decreasing part in the foods

and meals people eat. In most European

countries average income is rising.

However, there is also an increasing gap

between the incomes of the richest and

poorest in society, exacerbated in many

countries by profound structural changes

over recent years and the migration of

refugees across borders. It is difficult to

consider the impact of these trends on

nutrition and health in any meaningful

way in a short article, but they create

significant tensions that form an important

part of the background for the rest of

this piece.

Children’s diets: the challenge

Nutrition and health

HeartMatters

" Obesity increases the risk of cardiovascular diseaseboth directly and indirectly. "

" Fat children have a higher risk of growing up to be fat adults. "

Time and time again, when the increasing problem of unhealthy diets is discussed, the conclusion is that ‘we need to

focus on the next generation’. It is almost unanimously agreed that an important long-term measure to tackle this is to

try and make sure that children do not repeat the mistakes of their elders. As we all know, from other areas of our lives,

this is far easier said than done.

The two main pan-European surveys that

give insights into what children are eating

are a European Food Information Council

(EUFIC) commissioned study of ‘Children’s

Views on Food’ (Children’s Research Unit

1995), and the World Health Organization’s

report on ‘Health and Health Behaviour

among Young People’ (Currie et al. 2000).

In addition, there are various national

surveys of which one of the most detailed

and recent is the ‘Diets of British School

Children’ (Gregory et al. 2000). Each of

these is summarised briefly below.

The four countries included in the EUFIC

survey were France, Italy, Germany and

the UK. Information was collected on

dietary patterns, and illustrated the

cultural differences between the coun-

tries. In Italy 20% of children did not eat

anything for breakfast, compared with

only 1% in Germany. French and Italian

children consumed the most fruit, and

British children ate fries more often than

young people in the other countries.

Children in France and Italy tended to

drink water rather than soft drinks.

The World Health Organization’s survey

encompassed 28 European countries.

The highest fruit consumption was

reported in Portugal, and the lowest

in Greenland.

With the exception of Latvia, more girls

than boys ate fruit and vegetables.

Another general finding was that the

amount of fruit eaten decreased with

age. The countries of the UK reported

the highest consumption of potato

crisps, and children in Northern Ireland,

Scotland and Israel ate the most fries.

In about 20 of the 28 countries more than

40% of children ate sweets or chocolate

every day, with similar figures for soft

drinks. In all countries more boys than girls

drank soft drinks. There was a relationship

with socio-economic status, with children

from better off families eating more

healthy food.

Whilst these pan-European studies give

interesting information on dietary patterns,

they tell us little about nutrient intakes.

For that we have to look at detailed

national surveys, such as that reported

in the UK (Gregory et al. 2000). In this the

average proportion of food energy from

total fat was around 35%, close to the UK

national recommendations. The average

proportion derived from saturated fats

was just above 14%, compared with

the recommendation of 11%. Refined

sugars provided about 16% of energy,

compared to a recommended average

of no more than 11%. The main source

of these was carbonated soft drinks,

followed by chocolate. Intake of salt

was about twice the recommended

amount. In some of the older children,

particularly girls, there were low intakes

of some micronutrients.

Micronutrient levels per unit of energy

were lower in children from lower socio-

economic households, indicating a

poorer quality diet. The children ate less

than half of the recommended five

portions of fruit and vegetables a day,

with one in five eating no fruit at all. The

picture is thus one of a diet that is

relatively high in sugar and salt, with more

saturated fat than is recommended for

health, and low in fruit and vegetables,

with older girls in particular having low

intakes of some minerals and vitamins.

Over the last hundred years there has

been a trend towards people becoming

taller in most of the countries of Europe,

with a rate of increase of about 10-30 mm

a decade (Cole 2000). Unfortunately, this

growth in height has been accompanied

by an even greater growth in width.

It is difficult to compare rates of obesity

across European countries, because of

the differences in measurements and

definitions that are used. A recently

established pan-European survey on

body weight and physical activity may

provide better relative data in the

future (Sanchez-Villegas et al. 2001).

The information that is currently available

shows that obesity in children is increasing

throughout Europe (Livingstone 2001).

Livingstone reported that in The

Netherlands body weights remained

fairly stable between the 1950s and

1980s, but then there was an increase

in childhood obesity in line with that

observed with adults. Similar trends have

been reported from Switzerland and

France, with the latter reporting increases

in massive obesity. In the UK a quarter of

5 year-olds are overweight or obese.

In Italy, Finland and Austria there is a

higher prevalence of obesity among

boys. The UK, Italy and Spain report

higher levels in girls. Generally speaking

the highest rates are observed in Eastern

and Southern European countries.

5

• Encourage the development of whole

school nutrition policies, for example by

developing healthy school standards,

including indices against which to

measure progress. These policies should

include the integration of food provision,

teaching, school health services, pupils,

staff, parents, and the wider community;

• Have nutritional standards for school

food provision and other institutions that

provide food for children (e.g.

residential homes, childcare facilities);

• Include nutrition in the curriculum from

preschool level to secondary schools;

• Provide appropriate training for

teachers and food providers;

• Develop national and pan-European

networks of best practice;

• Provide positive encouragement for

fruit provision in schools (in the UK a free

fruit scheme has been introduced for

young children);

• Regulate the advertising and marketing

of high-fat and energy-dense foods to

children;

• Develop systems for accrediting food

and nutrition materials used in schools.

Survey after survey shows that young

people are aware of healthy eating.

However, their behaviour, particularly

within the school and in social situations,

does not reflect this. This is partly because

of influences such as peer pressure, but

children themselves also report barriers

such as queuing for food and crowded

dining rooms within schools.

Compared with other settings, there have

been relatively large numbers of studies

carried out in schools to try and work out

the characteristics of those interventions

that are most effective. These studies

have been reviewed systematically by

several authors (Roe et al. 1997; Sahay

2000; Lister-Sharp et al. 1999). The main

conclusions are that in order to be

successful, programmes in schools need

to focus either exclusively on diet, or on

diet combined with physical activity.

The most successful programmes involve

teachers, pupils, parents and the

community, and combine teaching with

changes to the ethos and environment of

the school. In many ways, these charac-

teristics reflect the aspirations of the World

Health Organization’s Health Promoting

Schools Initiative. Lister-Sharp et al. (1999)

specifically reviewed the health promo-

ting schools approach, and concluded

that it was promising and had an impact

on the social and physical environment of

the school, including staff development,

school lunch provision, physical activity

levels, and social atmosphere.

HeartMatters HeartMatters

What can be done in schools?

What can be done through public policy?

" The highest fruit consumption was reported in Portugal,and the lowest in Greenland… more girls than boys atefruit and vegetables. "

" In order to be successful, programmes in schools needto focus either exclusively on diet, or on diet combinedwith physical activity. "

What are children in Europe eating, and just how fat are they?

" Obesity in children is increasing throughout Europe. "

The main recommendations of these policy documents are to:

Interventions are also more effective if they are embedded in supportive public policy. There have been several sets of

recommendations for such public policy, for example those produced by the EU-funded Eurodiet initiative (Stockley, in press)

and in a Children’s Food and Nutrition Action Plan for the UK (Food Commission, in press).

6

References

American Heart Foundation. Blood lipids in children. Prev Med 1983: 12, pp 741-797.

British Heart Foundation. European cardiovascular statistics. BHF. London, 2000.

Brunner, E., White, I., Thorogood, M., Bristow, A., Curle, D., Marmot, M.G. Can dietaryinterventions in the population change diet and cardiovascular risk factors? An assessment of effectiveness utilising a meta-analysis of randomised controlledtrials. Am J Public Health 1997: 87, pp 1415-1422.

Children’s Research Unit. A pan-European survey: Children’s views on food andnutrition. European Food Information Council. Belgium, 1995.

Cole, T., Secular trends in growth. Proc Nutr Soc. 2000: 59, pp 317-324.

Currie, C., Hurrleman, K., Settertobulte, W., Smith, R., Todd, J. Health and healthbehaviour among young people. World Health Organization Europe. Copenhagen, 2000.

Department of Health. Committee on Medical Aspects of Food Policy Report onNutritional Aspects of Cardiovascular Disease. HMSO: London, 1994.

Food Commission. Children’s Nutrition Action Plan. Food Commission. London, in press.

Gregory, J., Lowe, S., Bates, C.J., Prentice, A., Jackson, L.V., Smithers, G., Wenlock, R.,Farron, M. National diet and nutrition survey: Young people aged 4-18 years.The Stationery Office. London, 2000.

Gunnell, D.J., Frankel, S.J., Nanchahal, K., Peters, T.J., Davey Smith, G. Childhoodobesity and adult cardiovascular mortality: a 57-year follow-up study based on the Boyd Orr cohort. Am J Clin Nutr. 1998: 76, pp 1111-1118.

Law, M.R., Morris, J.K. By how much does fruit and vegetable consumption reduce the risk of ischaemic heart disease. Eur J Clin Nutr. 1998: 52, pp 549-556.

Lister-Sharp, D., Chapman, S., Stewart-Brown, S., Sowden, A. Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment 1999: 3, p 22.

Livingstone, M.B.E. Childhood obesity in Europe: a growing concern. Public Health Nutrition 2001: 4 (1A), pp 109-116.

Napoli, C., Glass, C.K., Witzum, J.L., Deutsch, R. Influence of maternalhypercholesterolaemia during pregnancy on progress of atherosclerotic lesions in childhood. Lancet 1999: 354, pp 1234-1241.

Parsons, T.J., Power, C., Logan, S., Summerbell, C.D. Childhood predictors of adultobesity: a systematic review. Int J Ob. 1999: 23(8), pp S1-S107.

Power, C., Parsons, T. Nutritional and other influences in childhood as predictors of adult obesity. Proc Nutr Soc. 2000: 59 pp 267-272.

Prescott-Clarke, P., Primatesta P. Health survey for England: the health of youngpeople ’95-’97. The Stationery Office. London, 1998.

Roe, L., Hunt, P., Bradshaw, H., Rayner, M. Health promotion interventions to promotehealthy eating in the general population: a review. Health Education Authority.London, 1997.

Sahay, T.B., Review of nutrition interventions for cancer prevention. Cancer Care(Report). Ontario, Canada, 2000.

Sanchez-Villegas, A., Madrigal M., Martinez-Gonzalez, A., Kearney, J., Gibney, M.J.,Irala, J. de, Martinez, J.A. Perception of body image as indicator of weight status inthe EU. J Hum Nutr Diet. 2001: 14, pp 93-102.

Stockley, L. Toward public health nutrition strategies in the European Union toimplement food based dietary guidelines and enhance healthier lifestyles. Public Health Nutrition, in press.

Tang, J.L., Armitage, J.M., Lancaster, T., Silagy C.A., Fowler, G.H., Neil, H.A.W.Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subject. BMJ 1998: 316, pp 1213-1220.

In a nutshell, children’s eating patterns

are progressively deteriorating, increasing

risks to both their short and long-term

health. Combined with low levels of

physical activity it seems that the next

generation is likely to be overweight,

at increased risk of chronic disease,

and a liability for health service provision

in all of the countries of Europe.

Although governments have few

inhibitions about interfering in many parts

of our lives, they seem to become coy

and reticent where food is concerned.

The reality is that if resources are not

invested in trying to reverse the trends we

are seeing, and developing supportive

public policies, the outlook for both the

nutritional health of the next generation,

and health care budgets, is bleak.

What next for the next generation? European Policy DevelopmentsThere was a major reorganisation of the

European Commission (the Commission)

in 1998 with a focus on consumer health

and food safety following the BSE crisis.

After the resignation of the whole

Commission in 1999, a further reorga-

nisation took place in 2000, in which

nutrition and food safety were both

placed under the umbrella of the new

Health and Consumer Protection

Directorate General (DG SANCO).

There appears to be increasing recog-

nition that there is a need for action

on nutrition at the European level.

Many existing decisions and policies at

European Union (EU) level already have

an impact on food consumption and

nutrition. Examples include legislation on

food quality, agricultural produce pricing

policies, the management of surpluses,

rules on food labelling and the education

of health professionals. There has also

been an awakening to the potential for

the EU to support the Member States in

promoting healthy nutrition.

The new awakening to the significance

of healthy nutrition has not been limited

to the EU. The World Health Organization

Regional Office for Europe (WHO EURO)

undertook a major initiative to develop a

food and nutrition policy document and

action plan for the European Region,

which includes more than 50 countries, for

the period 2000-2005. In September 2000,

the Regional Committee for Europe

adopted a resolution which endorsed the

Action Plan and recommended that its

member states take steps to carry out

the Plan.

Recent developments in food andnutrition policy in Europe

One sign of an increased commitment

to nutrition within the European context

was the Commission’s January 2000

publication of its White Paper on Food

Safety.1 This document, although largely

concerned with food safety issues, also

contained several commitments relating

to nutrition, including the presentation

of an action plan and the development

of ‘a comprehensive and cohesive

nutritional policy.’2

More specifically, the White Paper

referred to the development of Council

Recommendations for dietary guidelines,

the establishment of appropriate

information tools, the promotion of

nutritional research, and the inclusion

of nutritional factors in Community data

collection systems. Given the extreme

sensitivity of the Commission to food

safety matters at that time, following

the furore over BSE, the inclusion of these

nutrition actions in the White Paper was

surprising to many.

Another key issue signalled in the White

Paper on Food Safety was the intention to

establish a European Food Authority (EFA).

In November 2000, the Commission

adopted a proposal for the Authority.3

The proposed functions of the EFA are to:

• Provide independent scientific opinions

(at the request of the Commission,

Member States, national food bodies or

the European Parliament);

• Advise on technical food issues to

underpin policy and legislation in the

areas of food safety and nutrition, as

well as animal health and welfare,

and plant health;

• Collect and analyse data on dietary

patterns, exposure, risks etc. to monitor

food safety in the EU;

• Identify emerging risks;

• Operate the rapid alert system cover-

ing both food for humans and animal

feeds;

• Communicate clearly to inform the

public on all matters within its mandate.

It is clear that the Commission envisages a

role in nutrition for the EFA in relation

to the provision of scientific advice and

potentially in communication on nutrition

issues. The Proposal includes a recom-

mendation for a Scientific Panel on

dietetic products, nutrition and allergies.

Since the publication of the Proposal,

the Commission has been considering

where the EFA should be located.

However, the European Parliament seems

to be unwilling to include nutrition in the

EFA’s remit unless it has an impact on

food safety; the Parliament wants food

safety to be the paramount concern of

the new Authority and therefore would

prefer to name it the European Food

Safety Authority.4

Throughout 2000, further developments

continued to push nutrition on the EU

agenda, and in December the Council

adopted a Resolution on Health and

Nutrition.5 The Resolution asserted

the importance of nutrition for health

and invited Member States and the

Commission to take action to promote

better nutrition.

The Resolution invited Member States to:

• Promote healthy attitudes and provide

information for informed choice;

• Involve a wide range of parties in the

promotion of nutritional health;

• Draw up and implement dietary guide-

lines;

• Improve the nutritional knowledge of

health professionals;

• Participate in the networks collecting

data on nutrition and physical activity;

• Encourage national experts to

participate in Community activities and

in the production of scientific evidence.

7HeartMatters

8

* Mike Rayner is Director and Lynn Stockley is a Research Associate of the British Heart Foundation Health Promotion Group,

Mike Rayner is also Chair of the European Heart Network’s Nutrition Expert Group.’

The Resolution also invited theCommission to:

• Allow for nutritional health to be taken

into account when drawing up and

implementing any relevant Community

policies, and develop tools for assessing

the health impact of Community

policies;

• Continue to develop tools for monitor-

ing nutritional health and its determi-

nants and work with the Member States

on this issue;

• Support and promote regular exchan-

ges of experience;

• Facilitate the development of scientific

evidence in the area of nutritional

health to provide backing for and to

update national or local dietary

guidelines and consumer information;

• Facilitate the exchange of information

on nutrition-related training courses and

professions;

• Adapt nutritional labelling to the needs

of consumers and develop other means

of providing nutritional information;

• Consider conducting projects to pro-

mote healthy diets (in relation, for

example, to increasing fruit and vege-

table consumption and promoting

breast feeding);

• Consider the use of new information

technologies to improve access to

information for professionals and the

public;

• Plan follow-up to nutrition activities.

The adoption of the Council Resolution

represented the culmination of the

French government’s push to promote

nutrition as a priority theme of its

Presidency of the European Union in

the second half of 2000. The work of the

French Presidency expert group,6 which

included a representative from each

Member State, drew heavily on the work

of the EU-funded Eurodiet project on

Nutrition and Diet for Healthy Lifestyles.7

For the Eurodiet project, four expert

working groups examined:

• The relationships between health and

nutrients;

• How to translate nutrient targets into

meaningful dietary advice (based on

foods rather than nutrients);

• Effective ways to encourage healthy

nutrition and physical activity;

• Barriers and opportunities for promoting

healthy nutrition in the European policy

context.

Following on from these analyses,

Eurodiet experts were able to identify

population goals for nutrients, some

foods, and other lifestyle features for

the prevention of major public health

problems in Europe. The proposed

population goals cover physical activity,

body mass index, dietary fat, fatty acids,

carbohydrates, consumption of sugary

foods, fruit and vegetables, folate from

food, dietary fibre, sodium, iodine and

breast feeding.

The report of the French Presidency

called on the Commission to adopt

these agreed population goals as an EU

Recommendation on dietary guidelines

(which was promised in the White Paper

on Food Safety). Working towards the

population goals in such a recommen-

dation, Member States could then

develop their own dietary guidelines to

take into account their current national

situation and dietary differences.

Other key issues highlighted by the

Eurodiet report and the French

Presidency include:

• Health impact assessment – both

reports called for evaluation of the

potential and actual impact of any

relevant EU policy on nutritional health.

The December 2000 Council Resolution

invites the Commission to carry out

these assessments and to develop

the necessary tools to do so. The main

policy areas which are likely to be

relevant include agriculture, health,

taxation, internal market, consumer

affairs, social policy, education,

environment, customs, industry,

and transport.

• Coordination and follow-upmechanisms – Both reports called for

structural changes to implement and

monitor an action plan on nutrition

and, in particular, improve coordination

of different activities. The French Presi-

dency report suggested the creation

of a nutrition health task force to

coordinate activities, encourage

exchanges and support the process

of health impact assessment. This

task force would be supported by

a nutrition forum bringing together

the principal players, and a special

ministerial debate on nutritional health

policy every four years. The Eurodiet

report recommended the establish-

ment of a new European Standing

Committee on Nutrition to give scientific

and policy advice, oversee the evo-

lution of population dietary goals and

coordinate the monitoring of nutrition,

diet and lifestyles. The report suggested

that this committee could be suppor-

ted by a strengthened nutrition unit

within DG SANCO. Both groups called

for periodic publication of a report on

the state of nutritional health in Europe,

preferably every four years.

European Policy Developments continued

HeartMatters

9HeartMatters

• Consumer information and protection –The EU has an important role in regu-

lating much of the nutrition and health

information provided to consumers

(nutrition labelling, nutrition and health

claims) and supporting Member States’

efforts to provide clear and compre-

hensive dietary information to their

populations. The Commission also

harmonises rules on food fortification,

food supplements and purity criteria.

Various gaps in the current legislation

have been identified, and better

regulation, particularly on labelling, is

essential to enable Europe’s consumers

to choose a healthy diet.

• Promote breastfeeding – Both Eurodiet

and the French initiative highlighted

breastfeeding as an area where the EU

should attach priority to reviewing the

current situation across the EU and

assessing, and if necessary improving,

the effectiveness of relevant EU

legislation, such as the regulations

on breast milk substitutes.

• Increase consumption of fruit andvegetables – The promotion of fruit

and vegetable consumption, which

is recognised as a policy that is widely

supported by public health nutritionists

and would also be supported by pro-

ducers, should be a key component

of any European Food and Nutrition

Policy. The French Presidency report

calls for a study to examine the options

for promoting fruit and vegetable

consumption through the range of

European policies.

Since the publication of the Eurodiet

report and the French Presidency

report, the subsequent adoption of

the Resolution in December and

Commissioner Byrne’s commitment to

try to produce some follow-up before

the end of June 2001, an inter-DG

working group of the Commission has

been drafting an Action Plan on

Nutrition Policy.

The fact that representatives from the

different Directorates General have

been involved in the drafting of the

Action Plan represents a great step

forward and it is hoped that the Action

Plan will contain an analysis of the

various EU policy areas that may have

an impact on nutritional health.

The Commission had initially planned to

adopt the Action Plan as a Commission

Communication in spring 2001.

In light of the developments between

1999 and 2001, it can be seen that some

of the European Heart Network Recom-

mendations in 1998 (see below) are on

their way to becoming reality. It looks

likely, for example, that a food and

nutrition policy for Europe, along with an

Action Plan for its implementation, will be

published within months. Nutrition is now

located within DG SANCO, which has

responsibility for consumer protection

and health, and there may well be a

strengthened support structure for

nutrition within the DG in the near future.

The EHN’s 1998 list included several

recommendations relating to the

promotion of and consideration of

nutrition in other areas of European

policy. There is clearly increased recog-

nition of the impact of other policy areas

on nutritional health now and there does

appear to be the will to tackle other

policy issues in order to promote health.

In practice, however, there is still much

work to be done in assessing the health

impact of other policies in terms of how

the assessment is carried out and how

it then feeds into the decision-making

process. Improvements in the regulation

of food labelling and health/nutritional

claims do seem to be in the pipeline,

although progress has been slow.

The European Heart Network will review

its 1998 recommendations on food,

nutrition and cardiovascular disease

prevention this year and expects to

publish new recommendations in early

autumn 2001 that take into account the

developments since 1998.

10

1 Commission of the European Community. White Paper on Food Safety. COM/99/719,1999.2 Commission of the European Community. White Paper on Food Safety. COM/99/719,1999.3 Commission of the European Community, Proposal for a Regulation laying down fundamental principles and

requirements of food law and establishing a European Food Authority (EFA), 2001. 4 Draft Report on the proposal for a European Parliament and Council regulation laying down the general principles and requirements of food law,

establishing the European Food Authority, and laying down procedures in the matter of food – rapporteur Philip Whitehead – PE 297.2385 Council of the European Union. Resolution of the Council of 14 December on Health and Nutrition, 2000.6 Société Française de Santé Publique Health and Human Nutrition: Elements for European Action. SFSP: Nancy, 2000.7 Eurodiet Report, Public Health Nutrition, V4, 1(A). Special Issue February 2001.

The Finnish Nutrition Council issued thepresent dietary guidelines and recom-mendations in 1998. These include nutrientrecommendations for all age groupsincluding children and young people.

Policy recommendations state thatchildren who spend a whole day in a day care home or nursery should havetwo-thirds of their dietary requirementsfulfilled by the food given in the nurseryand those who spend half a day in thenursery should have one-third of theserequirements satisfied. Each school orcollege meal ought to meet one-third of the dietary requirements.

School meals have been free since 1948 in primary and secondary schools and

even meals for university students havebeen subsidised since 1979.

Present Finnish recommendations relatingto children and young people include‘Recommendations for Infants and Chil-dren, Pregnant and Lactating Women’issued in 1997, the ‘Guide for Trade SchoolCanteens’ (1991) and the newest guide-lines, ‘School Lunch - Health and Habits’(1999). The policy recommendations followthe recommendations given by theNutrition Council.

The Action Plan for Promoting Finnish Heart Health also recognises day care,schools and colleges as important inaffecting children's and young people'sfood behaviour. It states that day care

and school catering encourages healthpromoting diet options and strengthensthem in practice. Communities areresponsible for school catering. Healthyand diversified dietary habits have beenpromoted and the use of products thatsupport the realisation of nutrition recommendations has been increased.More resources must be directed to school catering.

More attention should also be given tocommunication projects such as themedays and to food and health events thatstimulate everyday schoolwork. Nutritioneducation is provided particularly in home economics.

• The content of home economics andnutrition education in primary schoolsshould be developed to meet the needsof heart health for today's youth andtheir current lifestyle. It is recommendedthat the Ministry of Education establish a working group with the task of consi-dering how to promote nutritional issuesto the fullest extent possible and how to improve the transfer of nutritionalinformation to practice in the wholeschool sector. The group should includepedagogy experts, nutrition experts and health promotion experts.

• The goal is that young people will learnpractical food preparation skills, under-stand how to use package labellingwhen selecting products and know how to prepare meals that meet thenutritional recommendations.

• The proportion of nutrition and healtheducation is increased, not only inteacher training, but also in differentstudy plans for different levels.

• In day care the development of thebasis for healthy lifestyles is supported,e.g. by playing and through catering.

At community level the cooperationbetween schools and public health andsport organisations is improved by orga-nising mutual theme events as well as bycarrying out joint projects and campaigns.

The recommendations in the Action Plan in the area of nutrition and children and youngpeople are the following.

HeartMatters

12

Policy recommendations relating to nutritionfor children and young people in Finland

HeartMatters

11

European Heart Network recommendations

In 1998, the European Heart Network proposed eight practical strategies for achieving dietaryrecommendations for cardiovascular disease prevention in the EU. These recommendations were:

• Develop a food and nutrition policy for Europe.

• Specifically include nutrition within the responsibilities of DG XXIV and ensure greater coordination between DG V and DG XXIV on nutrition issues.

• Establish a European Nutrition Committee within DG XXIV.

• Improve mechanisms for auditing the impact of EU policies on the health and nutrition of EU consumers.

• Make provision through the Common Agricultural Policy (CAP) for the promotion of healthy food choices.

• Take more account of nutrition considerations in EU legislation on food labelling and advertising.

• Propose EU Directives on the use of health and nutrition claims.

• Promote a unified approach to the promotion of healthy living in Europe.

HeartMatters

Breakfast is not a major meal in traditionalBelgian culture, so the results of a recentsurvey of breakfast eating habits in youththat was performed on adolescents fromthe ages of 14 to 18 did not come as a complete surprise. According to thesurvey, however, of these secondaryschool students:• 15% never eat breakfast at all, so they

always go to school with a emptystomach;

• 25% have a qualitatively and quantita-tively inferior breakfast;

• ± 50% have an adequate breakfast and • only 10% have a nutritionally valuable

breakfast daily.

Breakfast and youth

Breakfast is an important meal at everyage. For children, however, this meal has a particular importance for physiologicalreasons. Their storage capacity of glycogen(= the form in which sugar is stored in thebody) is very low, and glucose representsthe principal fuel for the human nervoussystem. In the morning, the blood sugarlevel is low and the glycogen reserves are spent. One of the major functions of breakfast therefore is to restore theglycogen reserves after fasting all night,and complex carbohydrates such asfound in bread and other grain foods are particularly important.

Furthermore, scientific studies havedemonstrated that eating breakfastcontributes significantly to improving thephysical and intellectual performance of children and adults in the course of the morning.

A new campaign

For all these reasons, in March 2001 theBelgian Heart League started a newcampaign entitled ‘A Good Start… forPleasure and Health’. This campaign was carried out in collaboration with the Belgian Association of Dieticians and the Belgian Bakery Industry.

We’ve had 250,000 copies of a clearlywritten and attractively presented leafletdescribing the different aspects of ahealthy breakfast and suggesting severalexamples of a healthy breakfast havebeen printed and distributed. Besides arguing in favour of having a meal in

the morning by comparing the humanbody to a battery that needs its energystorage recharged every day, the leafletlists the food groups and portion sizes that make up a good breakfast,depending upon the age of the childrenand youth and the amount of physicalactivity for different age groups. The basic breakfast should consist of the food groups listed below.

These leaflets were distributed primarily bymedical doctors, dieticians and bakeries.

In the next few months an evaluation ofthis campaign will be performed.

News from Belgiumby the Belgian Heart League

A new campaign on eating a “Healthy Breakfast”

A grain product, preferably unrefined Complex carbohydrates, dietary fibre, B vitaminsor not overly refined

A dairy product Calcium, animal protein, vitamins A and D (except non-fat) and B2

One piece of fresh fruit Vitamin C, potassium

A drink - water, tea, coffee, fruit juice Liquids

Foods in a good breakfast Principal nutritional characteristics

13

"6 A Day" Campaign

In September 1998, the Danish NationalBoard of Health issued recommendationsfor the daily intake of fruit and vegetables.The recommendation specifies 600 gramsof fruit and vegetables a day for adultsand 400 grams for children, based onscientific research indicating that a dailyintake of these amounts can decrease therisk for cancer and cardiovascular diseasesby 15-30%.

Currently the Danish people are not eatingnearly 600 grams of fruit or vegetables daily;in fact, a full 96% of the Danes receive lessthan this recommended daily intake offruit and vegetables.

The "6 A Day" campaign is the result ofcooperative efforts between the DanishHeart Foundation, the Danish NationalBoard of Health, Danish Consumer Infor-mation, the Danish Cancer Society, theDanish Veterinary and Food Administrationand the fruit/vegetable trade as well asretail shops. All parties share a greatinterest in an increase in the nationalintake of fruit and vegetables. The partnersinclude governmental departments andorganisations dedicated to the promotionof health and information on nutrition.

The purpose of the campaign is two-fold.First we hope to increase popular know-ledge of the nationally recommendeddaily intake of 600 grams of fruit andvegetables a day for adults and 400grams for children, and at the same timewe intend to double the average Danishdaily intake of fruit and vegetables over a ten-year period.

Set to run from Summer 2000 untilDecember 2002, this multi-faceted projectis targeted at the entire Danish population.Organisations and individuals from boththe public and the private sectors arecooperating to increase Danish awarenessof the need for a varied diet that stressesa higher intake of fruit and vegetables,and to make it easy for people, once they are convinced of the necessity ofchanging their eating habits, to put theirconvictions into practice.

A campaign manager coordinates allactivities concerned with the project.Project activities are varied to reach thepopulation in a number of different ways.

• Mass communication efforts, includingleaflets, posters, television spots etc., aredesigned to raise general awareness,bringing fruits and vegetables topeople’s attention in an effective way.

• Accessibility efforts involve creatingeasier access to fruits and vegetables so that children and adults will easily find the foods that are good for them in their schools and institutions, at theirwork places and in their homes.

• Popular education entails supportingpublic media efforts on local, regionaland national level to underline theimportance of fruit and vegetables in the daily diet and convey easy ways of reaching the recommendedintake amount.

• Web sites convey the messages of thecampaign, that healthy eating meansmore helpings of fruits and vegetablesevery day, and that achieving therecommended amounts can be easyand enjoyable.

HeartMatters

News from Denmarkby the Danish Heart Foundation

Danish campaign working toward dramatic increases in fruit and vegetable consumption

14

HeartMatters

Following the stunning success achievedduring its launching phase last year (31 March and 1 April 2000), the ItalianAssociation against Thrombosis (ALT)repeated and expanded its initiativefocussed on fish this year, on 6 and 7 April2001. The project’s goal is to influence thenutritional habits of the Italian citizens byexplaining the advantages of diets rich in fish consumption to them and handing out fish to encourage people to try out our ideas at home.

In the framework of the European HeartHealth Initiative, this year we set out totarget young children as our priority.Working with our partners the Ministerodella Sanita (Ministry of Public Health);Ministero delle Risorse Agricole e Forestali(Ministry of Fisheries and Agricul-ture);Associazione Piscicultori Italiani (ItalianAssociation for Fish Breeders); and SicilyFish Farm, we made a big splash with ourevent in the city centre of selected urbanareas. All the children approached weregiven a balloon with the ALT logo printedon it, while their parents were providedwith a booklet containing all the basicinformation regarding healthy nutritionand fish consumption.

During the campaign a kilogram of freshfish, together with the aforementionedbooklet of recipes and information oncardiovascular disease (CVD) and CVDprevention, was also given to those whodecided to contribute to research on CVDand to the activities of ALT. The minimumamount of money required in order toreceive the fresh fish was 20,000Lit./10euros. While the pilot project wasimplemented only in Milan, this year twoadditional cities joined, so in the secondphase our members worked together inMilan, Rome and Bologna.

As was the case last year, the initiative was welcomed and well promoted in thenational and local press. The outcome of the initiative was even better than ourforecasts predicted: about 1000 kilogramsof fresh fish and over 14,000 booklets weredistributed. As a result of this success, theproject is likely be expanded in the nearfuture so to include a higher number ofItalian cities for the third phase.

ALT believes that a campaign like our fishpromotion, which encourages people toimprove their nutrition habits by targetinga specific aspect of nutrition and focussingattention on it in several different ways,can turn out to be quite helpful in raising awareness among the generalpopulation concerning CVD risk factorsand CVD prevention.

We are already arranging for future initiatives on the same model. For ourhealthy nutrition promotion, ALT is planning to launch a new campaign on the health benefits of olive oilconsumption, which will take place at the end of November 2001.

News from Italyby the Italian Association against Thrombosis

Un pesce di nome ALT - A fish called ALT

16

Heart Beat - the Rhythm of the Healthprogramme

Primarily aimed at very young children,Heart Beat was the first health educationprogramme in Finland for heart diseaseprevention among children and families.Pre-schoolers and first and second gradersare brought to understand: Inside of mebeats the most important heart in theworld. Children are taught how the heartfunctions, and influenced to adopt hearthealthy diet and exercise, withoutforgetting feelings and love.

Finnish Heart Association’s (FHA) resourcepack in Finnish and Swedish supports thispre-tested and evaluated programmewith materials for teachers, children,parents and catering personnel.

Kids project

The Kids project, already mentioned in thelast issue of Heart Matters, was launchedduring Heart Week in April, with the mottoSmall Deeds Make a Good Heart. Theleaflet A Small Heart - A Big Adventurecontains heart-friendly recipes for thewhole family.

Colourful, tasty, healthy heart-friendly foodcontains a lot of vegetables, tastes otherthan salt, and soft vegetable fats insteadof hard animal fats. Half a healthy plate isvegetables, a fourth is potatoes, pasta orrice, and a fourth is fish, chicken or meatcooked in a heart-friendly way. Whole-meal bread, a light touch of margarineand non-fat milk complete the meal.

The nursery school teacher's guide "HeartMatters to Nursery Schools" presents basicinformation about a heart-friendly dietand suggests a different issue for eachweekday.

Halt the Salt - Half Will Do programme

Halt the Salt, targeted at 13 and 14-year-olds, aims to make them conscious of the harmful effects of a high salt intake.The materials include a teacher's pack, a Salty Stories video and a leaflet ‘Halt theSalt - Half Will Do’ (also available inEnglish). Among discussion topics in theteacher's pack are the history, chemistryand physiology of salt, salt in foods, low-sodium products, intake of salt and hintsfor reducing salt.

Strip Baby project

Strip Baby is a prospective randomisedchild-targeted coronary heart disease risk

factor intervention trial led by Olli Simell,professor in paediatrics at the HeartStation of the University of Turku. Theproject uses regular dietary counselling to reduce children's exposure to theknown environmental atherosclerosis risk factors.

Recruited at the age of five months,between March 1990 and June 1992 thebabies were assigned to an interventiongroup and a control group. The interven-tion families met with a paediatrician, a nutritionist and a nurse at 1-3 monthintervals until the infants were two yearsold and then twice each year. Eight yearsafter it began, there were still 685 childrenin the project.

The families were counselled to reducetheir children's intake of saturated fat and cholesterol, but to supply adequateamounts of energy. At certain intervals thefamilies kept 3-consecutive-day records of their children's food consumption. At each visit the nutritionist suggested thesmall changes in the child's diet thought to be most acceptable to the family,based on the food records. In addition tothe dietary advice, prevention of smokingin the family and the benefits of regularphysical activity were discussed. From theage of seven onwards the children werealso counselled directly. More intensivecounselling on dietary salt reduction startedwhen the children were eight years old.

The children in the control group receivedthe basic health education routinely givenat the Finnish well-baby clinics.

The intervention had a marked effect on serum lipids and lipoproteins. In theintervention group the children hadexcellent cholesterol concentrations. If the change obtained is permanent, it will have a marked effect on cardio-vascular disease incidence in later life. The project will continue through the first20 years of life.1

Kainuu Heart study

Kainuu, an area in north-eastern Finland,has the highest cardiovascular disease(CVD) morbidity rates in the country. Some years ago, to promote heart health,the FHA and its district office in Kainuuestablished the Kainuu Heart study, joined by the University of Oulu. The study aims primarily at reducingchildren's exposure to the known CVD risk factors through health education. A family-oriented CVD preventionprogramme is being developed.

Altogether 515 children from 310 familiesparticipated in the intervention and 768children in two control groups, one ofchildren from high risk families and theother a random sample of Kainuu children.In the autumn of 1997 children in theintervention group met with public healthnurses at school for measurements andhealth counselling. Home visits started inAugust 1998. In three meetings, interven-tion families and a nurse mapped thefamily's health habits and made healthpromotion plans for individuals and thefamily. Health groups and lessons werealso available.

Baseline measurements showed that theKainuu children’s cholesterol level wasequivalent to the average level for Finnishchildren 20 years ago. In the interventiongroup diastolic blood pressure was higherin all age groups than in the control group,and the body mass index was higher thanin the control group in the age group of 10 to 12-year-olds. All the children quitecommonly used butter, fatty cheeses andmilk, but the consumption of vegetables,berries, fish and white meat was low.

Preliminary data shows that during theproject the total cholesterol level amongintervention group children decreased0.22 mmol/l, statistically highly significant.Although the cholesterol level also de-creased in the other groups, the decreasewas higher in the intervention group. The same was true with the levels of HDLand LDL cholesterol.

It is already clear that the health promo-tion programme activates and motivatesfamilies to change life habits whilesimultaneously promoting the children'shealth. The family-oriented model used inthis study works best among childrenunder 14 years old. A different approach is required for older children as peer-groupbehaviour models become more important.

New booklets for weight control

The Association of Clinical and PublicHealth Nutritionists in Finland has publishedtwo booklets for weight control: Mahtavatmuksut (the Great Kids) - solutions to treatobese children aimed at public healthnurses, nutritionists and medical doctorswho treat 10 to12-year-olds, andSuurenmoinen nuori (the Great YoungPeople), solutions to weight control foroverweight young people targeted athealth care personnel treating 12 to 18-year-olds.

News from Finlandby the Finnish Heart Association

Finnish Heart Association's programmes teach goodheart health to children

HeartMatters1 See e.g. Lagström, H., Seppänen, R., Jokinen, E. etal. ‘Influence of dietary fat on the nutrient intake and growth of children

from 1 to 5 years of age: the Special Turku Coronary Risk Factor Intervention Project’, Am J Clin Nutr, 1999, 69:516-23.

Healthy breakfasts: creating healthy nutritional habits young

Because the Spanish Heart Foundation isconvinced that the best way to stopcardiovascular disease (CVD) is by startingwith the youngest population, every yearwe develop a national cam-paign aimedat 6 to 12-year-old children, parentsassociations and teachers, in collaborationwith the Spanish Society of Cardiology andthe Ministry of Agriculture.

In Spain, more than 20% of children go to school every morning without anybreakfast or with an inadequate meal.Therefore, our annual three-monthcampaign in the public schools, with theparticipation of cardiologists and nutritionexperts, covers all the Spanish provinces,even small towns not usually reached bythese kinds of activities.

The activity in each school starts with a presentation on healthy nutrition by a cardiologist, who covers the basic foods children should eat every day andexplains the healthy habits they shouldmaintain. Before the talk the pupils fill out aquestionnaire outlining what they usuallyeat, which helps us study the normalnutritional habits of the Spanish popu-lation. Immediately following the presen-tation, a healthy heart breakfast of milk,fresh fruit, natural juices, olive oil, bread or cereals, honey and milk products isdistributed free to the attendees. Thefollowing day the pupils report on theactivity, with a drawing, in order to focusattention on their healthy breakfast andhelp them remember.

During the eight years this activity hasbeen offered, we have reached morethan 60,000 children. Although a greatdeal of work remains to be done in thisfield, our evaluations show that we haveinfluenced these children’s healthynutritional habits.

Reaching the family cook …

Convincing children to eat a good break-fast is an important step, but we also need to reach the person at the cooker. Working on this side of the equation, wehave developed an activity that teacheswomen, who usually feed and educatefamily members, especially children.

Women must know the key to a healthyand balanced diet to transmit themessage correctly, and for that reason cardiologists spread our message in small towns around Spain, with the hope of keeping traditional healthynutritional habits in the countrysidealthough they have already changed in the urban population.

Carried out in collaboration with theSpanish Housewives Association and the Spanish Society of Cardiology, thismonth-long nation-wide campaign targetsregions with few opportunities for becom-ing informed about CVD prevention.Associations participating in the activitydevelop regional recipes with ingredientsbased on the Mediterranean diet. The best recipes, chosen by a committeethat includes a cardiologist, a nutritionexpert and a well-known chef, are thendistributed to the general public.

and younger cooks, too

In another campaign, the Spanish HeartFoundation offers practice cooking lessonsfor adults, where a nutrition expert and acardiologist teach through easy, colourful,flavourful recipes that people can alsoenjoy good-tasting food at the same timethey take care of their health.

Special attention is paid to children,through cooking classes with well-knownactors from children’s TV programmesfeatured as cook’s assistants. We havealready distributed some hundredbrochures with detailed explanation of the recipes. Children make their funny andcolourful meals and afterwards celebratetheir own delicious creations with a party.

Cholesterol and the heart: not a good match

Unfortunately, and following the trend of other countries, children and youngpeople in Spain are leading unhealthylifestyles, noticeable in their poor nutritionhabits. Together with tobacco, hyper-tension, diabetes, obesity and a sedentarylifestyle, cholesterol is the main cause ofCVD. The average concentration ofcholesterol among the young Spanishpopulation is 173 mg/dl for both sexes,according to various epidemiologicalstudies developed. This is a worrying figure,

considering that in Spain C-LDL values over135 mg/dl among young people arealready considered high.

Therefore, the Spanish Heart Foundation,following its philosophy of spreadingknowledge and information as the onlyway of raising awareness among people,has just published the book Cholesteroland Heart, with practical information onhow to maintain healthy cholesterol levels,especially by introducing minor changes in our cooking habits.

We are distributing more than 300,000 copies free of charge among the population.

Young people in Spain are abandoningthe Mediterranean diet in favour ofindustrial products and fast food, full of calories but low in nutrition, which is contributing to their rising cholesterollevels. A special chapter of the book isdedicated to children and teenagers,teaching them that one key to a healthyadult life is good nutrition, starting in childhood.

"Four Provinces" nutrition study: objectives and design

Spain shows a major variation in thegeographical distribution of ischaemicheart disease and cerebrovascular disease mortality.

The Department of Preventive Medicineand Public Health, the National HealthSchool and the Lipid Unit of the JiménezDíaz Clinic in Madrid are studying thecontribution of environmental factors(nutrition, lipid profile and plasma anti-oxidants) acting in childhood to explaindifferences in cardiovascular mortalityrates between different provinces in Spain.Working with 6 and 7-year-old children, the study covers the two provinces withthe highest cardiovascular mortality ratesand the two provinces with the lowest.

The "Four Provinces" study will provide, for the first time, information about theinfluence of cardiovascular risk factors in early childhood in a Mediterraneancountry. The study will also offer interestingdata about food intake during the schoolyears in four provinces. At the end of Maywe’ll have the first outputs from the study.

News from Spainby the Spanish Heart Foundation

Spanish promote healthy meals for all, starting in childhood

HeartMatters

Encouraging healthy eating habits among12 to 14-year-old students1

Unhealthy eating habits that are related to cardiovascular disease risk factors arecommon among minors in the Nether-lands. For instance, they eat too muchsaturated fat and not enough fruit andvegetables. Moreover, establishing healthyeating habits at an early age may be animportant determinant for diets later in life.Encouragement of dietary change amongminors is therefore important.

Several organisations in The Netherlandsoffer nutrition education programmestailored to the needs of minors, especiallythrough the public schools. Up until thepresent time, such programmes have not been coordinated with other similarprogrammes, and no research has beenperformed to determine whether theprogrammes are effective in modifyingchildren’s eating patterns.

Researching and intervening

Therefore, at Maastricht University’sDepartment of Health Education andPromotion a four-year project started in1999 to develop, implement and evaluatean integrated educational programmetargeted at 12 to 14-year-old students and intended to promote healthy eatinghabits. The programme will be aimed at three specific nutrition behaviours: theyoungsters will be encouraged to increasetheir consumption of fruit, to eat breakfastevery day before school, and to decreasetheir consumption of snacks that are highin saturated fat.

A joint initiative of Maastricht University, The Netherlands Heart Foundation (NHF)and The Netherlands Nutrition Centre, the project also involves representatives of other national organisations such as the Dutch Cancer Society, the RegionalHealth Services and the schools. All thesepartners are participating during thedevelopment phase, which guaranteesthat the optimal use will be made of their knowledge.

Tailoring the campaign effectively

The programme is being developed byusing the ‘intervention mapping’ method.In order to be certain that the interventionprogramme actually changes behaviour, it must be targeted effectively, and theremust be measurable objectives. The firststep in that process is to discover whatdeterminants affect young people’sbehaviour most strongly. If, for example,the campaign is targeted at peer appro-val but in actuality modelling behaviouron media figures is more significant, thenthe campaign will fall wide of the mark.Focus groups of children are helping theresearchers identify the most importantfactors in influencing behaviour throughinterviews, role playing and other activities.Based on the findings in this stage of theproject, the campaign should be effec-tively targeted.

A comprehensive evaluation protocol willdetermine how effective the interventionprogramme is based on (psycho-socialdeterminants of the) nutrition behaviours.

Well advanced in its design phase, thisstudy will work with children in 30 schools,with half of the schools serving as acontrol. The schools have been selectedfrom the less-prosperous, less-educatedpart of the population, as it is felt that thisgroup is most at risk, and therefore most inneed of encouragement to form healthiereating habits. The campaign itself willconcentrate on selected classes from theschools, with researchers working with atleast 2,000 children, half of them in thecontrol group.

Can we reach the young?

In the framework of the European HeartHealth Initiative, the NHF has launched a project on youngsters (ages 12-18).Dramatic lifestyle changes occur in thisage group: a large number of youngsters(depending on school type sometimeseven up to 50%) take up the smokinghabit; physical activity and active sportparticipation drops dramatically; their dietcontains too many saturated fats and theyonly eat about half of the recommendeddaily amount of fruit and vegetables.

This is a very critical age, as future lifestylehabits are strongly influenced by choicesmade during the teenage years. On theother hand experimentation, exploringboundaries and testing limits combinedwith a tense relationship to authoritydominate this period of life. Despite theimportance of health promotion, can this group ever be reached?

Mission impossible?

In the spring of 2000 a project group startedto explore whether youth communicationin order to promote a heart healthy life-style really is a mission impossible. Whatare the motives for behaviour, what is onteenagers’ minds, what do we need to do in order to change current behaviour?To help to find answers to these importantquestions, an expert meeting was organised.

Be clear, be cool

The main conclusion of the experts was:youngsters can be reached by a healthmessage, provided it is simple, clear and cool.

Based on these findings, the NHF is workingon a model in which health organisationsand industry can cooperate in a long-term programme.

News from The Netherlandsby The Netherlands Heart Foundation

Working with young people to promote a healthier lifestyle

HeartMatters

171 For the material on nutrition education, we thank Marloes Martens, Marianne Wind, Patricia van Assema and Johannes Brug of

the Department of Health Education and Promotion, University Maastricht, P.O. Box 616, 6200 MD Maastricht, The Netherlands

First data in from European Youth Heart Study

Sampling cardiovascular disease (CVD)risk factors in children from Denmark,Sweden, Portugal, Norway and Estonia,the European Youth Heart Study (EYHS)1

is an ambitious project aimed atdetermining how personal, environmentaland lifestyle influences interact with regardto CVD risk factors in a large population ofchildren of differing age, sex, culture andethnicity. Ultimately it has the dual goal ofunderstanding CVD risk factors in childrenand providing information that will makepossible the design and implementation ofCVD prevention programmes for children.Food intake is a major part of the study.

Based in schools, the study surveys aminimum of one thousand boys and girlsbetween 9 and 15 years old in each of the five study locations. Six-year follow-updata will be collected in the study’ssecond phase.

To date, the reliability and validity of themethodologies has been checked andthe data has been organised in data-bases. Descriptive data is available andearly analyses have begun. Particularlyalarming for Sweden is the confirmationthat children are not eating nearly enoughfruits and vegetables.

Eating habits of Swedish children

In order to find out what children eat, EYHS researchers used the method of a 24-hour recall interview and a food record.The children were asked to record every-thing they ate during one day, then thenext day they discussed the results one-on-one with the researcher for about 30minutes. With photographs, food modelsand examples, and packages of preparedfoods, the researcher worked with theinterview subject to calculate the amountseaten, using standard food tables.

Chosen because it is easy and quick forboth children and researchers, the 24-hourrecall method was considered especiallyappropriate for the culturally diversesample population with a wide variety ofdiets. Children above the age of 10 canhandle the 24-hour recall without their

parents’ help, but they do need assistancewith weights and measures to estimateamounts. Although the method is unlikelyto be strictly accurate for individualchildren, as it depends on their memoryboth of what they ate and of how much,with this large sample it is consideredadequate for estimating group meansand classifying participants in categories.According to a validity study, the groupmean energy, macronutrient and vitamin and mineral intake estimates areconsidered valid.

Not enough fruits and vegetables!

Since there are no official recommen-dations for fruit and vegetable intake forchildren, the Swedish recommendation of 500 grams per day of fruit andvegetables for the general populationprovides a useful starting point. Averageintake for the children in the study was farbelow this threshold; in fact it did notexceed 300 grams in any case.

The figure below compares boys and girls at the lower and upper ends of thesample, at ages 9 and 15. As the meanvalues show, girls consumed significantlymore fruits and vegetables in all cate-gories. Older girls consumed the most in all categories, but still did not come closeto the amounts we believe necessary forgood health. Compared with the youngerboys, the older boys increased their vege-table and especially their juice consump-tion, but ate lower amounts of fruit, roots,tubers, pulses and beans.

Fruit and vegetable intake (boys)

Fruit and vegetable intake (girls)

Further analysis of the data will look especially at socio-demographicdeterminants. It is already clear, however, that increasing fruit andvegetable consumption among young Swedes is an urgent need.

National guidelines for school meals

In February 2001, for the first time, theNational Food Administration and theCounty Council of Stockholm launchednational guidelines for school meals.Swedish schools have provided all pupilswith a cooked meal every day for a longtime, working with an average of less than1 euro per portion. Offering high qualityfood has always been a challenge withthese scarce resources.

The guidelines are summarised in the box.To encourage children to eat more fruitsand vegetables, preferably 100-125grams/portion, the guidelines recommend that the children pass through the saladbuffet first, before they receive the cook-ed portion of the meal. From the environ-mental point of view, priority should begiven to locally produced food, includingbread, vegetables and potatoes.

Summary of national guidelines forschool meal

•two alternative menus•salad buffet first, with low-fat dressing•cooked dish•bread and light margarine•25-30% of daily calories•33% maximum of calories from fat•33% maximum of fat calories from

saturated fat

HeartMatters

Reaching teenagers in the schools

Promoting a heart-healthy diet has severalcomponents, including weight control,eating a balanced diet with a widevariety of foods, and cutting down on salt,among other things. This year the TurkishHeart Foundation decided to emphasiseadding fibre to the diet. We organisedconferences in various high schools on"Heart Health and Fibrous Nutrition" on 11 and 13 April 2001; we traditionally holdsuch conferences within the context of our education and training programmes in high schools in conjunction with ourAnnual Heart Week in April.

Presented by Associate Professor MahinurGürdai, Ph.D., the conferences wereconducted in collaboration with KurtsanPharmaceutical Inc., Otaci Diet Products,and the faculties of medicine of severaldifferent Turkish universities, as well as withthe cooperation of the Ministries of Healthand National Education. Their majorpurpose was to raise the awareness ofstudents between the ages of 14 and 17,with regard to healthy nutrition.

To that end, lectures concentrated on fibrous food and their benefits; theyhave a major role in weight control andbalancing the blood cholesterol level,which is in turn a significant risk factor incardiovascular diseases. Explanationswere given on how to consume naturalfibres as dietary products and visualtraining materials supported the lecture. At the end of the conferences studentswere given a chance to ask questions on what they wanted to know about this topic and were allowed to taste the flavourful natural fibrous products of Otaci that were displayed at anattractive stand.

A contest to motivate competitiveyoungsters

Again, on 12 April 2001 during the 13thTurkish Heart Week, the Turkish HeartFoundation held a dietary food contest onfibrous products in cooperation with Otaciand Lezzet magazine of cooking and withthe participation of young competitors atthe Ceylan Inter-Continental Hotel.

This contest was organised with an aim of increasing public awareness of theimportance of fibres in healthy andbalanced nutrition. At the same time, the intention was to encourage higherconsumption of foods with fibre content in our daily life.

Creative young contestants competed in three categories, namely soup, main courses and low calorie desserts,preparing their own recipes that they had devised using Otaci fibrous products.Among eleven finalists who competedbefore a jury comprised of distinguishedgourmets, three young people were foundeligible to win an award for their servingsthat had been prepared using Otaci’sprobiotic crackers with rye, wheat, oat,soy and apple fibre content and powderproduct, acting as a substitute for flour,starch and other high calorie ingredients,and enriched with vegetables, fresh or dried fruits, dairy products and different spices.

Among various prizes, the Turkish HeartFoundation offered a free check-up at the Turkish Heart Foundation Health Centeras a special award, while Otaci presentedeach finalist a basket of their products andLezzet magazine gave each one a one-year free subscription to the magazine.

News from Turkeyby the Turkish Heart Foundation

Fibre in the spotlight in high school nutrition programmeand recipe contest for young people

20

News from SwedenBy the Swedish Heart and Lung Foundation

Swedish children need better eating habits

HeartMatters

1 Information about the EYHS is taken from an article, ‘European Youth Heart Study; CVD Risk Factors in Children: The Fruit and Vegetable Intake among Swedish Children,’ supplied by Agneta Yngve, Eric Poortvliet, Ulf Ekelund,Anita Hurtig Wennlöf, Michael Sjöströms, PrevNut at Novum, Karolinska Institutet, Huddinge, 171 57 Sweden.

125

100

75

50

25

0

mean intake (grams)

Grade 3 Grade 9

125

100

75

50

25

0

mean intake (grams)

Grade 3 Grade 9

Fruits and berries

Juice (fruit juice)

Pulses and beans

Vegetables

Roots and tubers

Children are an ideal focus for action ondiet and health, to improve the healthstatus of the population as a whole.Improving children’s nutrition is a causethat everyone can agree on, even if theydiffer on the specific policy measures tobring this about.

A project launched by the UK’s FoodCommission, the leading UK watchdog on food, will help coordinate governmentand NGO action for improving children’snutrition through progressive policy mea-sures. The project also aims to provideinformation and resources that organi-sations can draw upon in concertedaction to improve children’s diets.

A picture of children’s nutrition in the UK

The first phase of this work has been togather and assess information about cur-rent initiatives promoting better nutrition for children. The resulting well-referenceddocument, a draft Children’s NutritionAction Plan, helps paint a broad picture ofwhat’s going on around the UK.Containing information about keyindicators of UK children’s diet and healthstatus, it also collates specific policies thatindividuals and organisations recommendto help improve children’s diets andhealth. Key research that supports thepractical and policy initiatives is flagged.

An assessment of the materials showed aremarkably high level of consensus aboutthe problems facing children and healthpolicy makers, and the policy solutionsneeded to address them. Most of thegroups consulted were worried about the nation’s diet as a whole, but hadidentified children’s diets as of specialconcern – recognising that it is morepossible and politically acceptable tointervene in children’s food choices than in adults’ choices. While differentorganisations focused on different lifestages – for instance, the National HeartForum is working to improve nutritionthrough school meals; the MaternityAlliance is working to improve the diets of pregnant women; the Caroline WalkerTrust is helping nursery school teachers

plan healthier meals – there were severalissues on which general agreement wasevident.

Better nutrition for today and tomorrow

It was generally agreed that what childreneat not only affects their own immediatehealth, but will make a significantdifference to their later health outlook fora whole range of different health issues.There was also evidence to suggest thatimproving children’s nutrition could have apositive impact on the nutritional status ofwhole families.

Organisations pointed to a need for the culture of food to change, as food isthe centrepiece of a broader approachsupporting communities, socialinteractions and a better quality of life.

Concerns were widely voiced about the poor health and nutritional status of young women and children from low-income families, and the inadequacy of state welfare benefits to help thesepeople eat a healthier diet, given the high cost of healthy food.

Controlling the marketeers

Another key concern was about the waychildren are targeted by food marketeersserving up a diet characterised by manyas a ‘nutritional nightmare’. Statistics onthe purchasing patterns of children, andthe marketing budgets of confectioneryand snacks illustrated how the nationaldiet – particularly for children – is beingpushed down a route that almostguarantees a population that will sufferfrom a high level of diet-related ill health.Many health organisations said that theywould like to see restrictions placed on themarketing of unhealthy foods to children,particularly when that marketing takesplace in schools.

These issues were therefore some of thekey themes brought up in a round tablemeeting that formed the second phase of the Food Commission’s children’snutrition project. At the end of March2001, key people whose work has asignificant influence on children’s nutritionin the UK came together from groups asdiverse as the Maternity Alliance, statehealth visitors, the Food StandardsAgency, the UK Department of Health,the British Dietetics Association, SchoolNutrition Action Groups, Action andInformation on Sugars, the CooperativeWholesale Society, the National HeartForum, and the British Heart Foundation.Speakers from these organisations putforward policy proposals to promotebetter food and nutrition for children, and helped contextualise work that isvery often fragmented.

The next phase of the work is to identify,support and/or launch projects to addresssome of the issues that have been sign-posted as of prime importance in ourmutual effort to improve children’s dietsand health status, particularly for childrenfrom low-income families. Many excellentprojects are already under discussion, andwe look forward with great optimism tofuture progress.

To receive a copy of the draft Children’sNutrition Action Plan (free of charge - soonto be published on the Food Commissionweb site: www.foodcomm.org), or to receive further information about this work, please contact: Kath Dalmenyemail: kath@foodcomm.org.ukfax: +44 (0) 20 7837 2250.

News from the United Kingdom

by Kath Dalmeny, UK Food Commission

Concerted action to improve children’s nutrition

HeartMatters

22HeartMatters

Teaching heart functions and healthy eating

The British Heart Foundation (BHF) hasdeveloped Artie Beat's Healthy Cookbookas a resource to support healthy eating fora healthy heart in children. Habits formedin childhood tend to continue into adultlife. Our challenge is to ensure that allchildren understand how their heart worksand how to take care of it so that lifestylechoices early in life promote health inadulthood. Eating the right balance offood is very important for healthy living. By ensuring that children learn to enjoycooking and understand how diet canaffect health, we encourage good healthin this generation and the next.

The cookbook is based on the prizewinning entries from a BHF competition, for which children sent in their favouritehealthy heart recipes, for every kind ofdish including soups and snacks, sand-wiches, main courses, desserts, cakes and bakes as well as drinks. The BHFworked closely with a home economist as well as with a nutritionist when selectingthe tastiest and most nutritious recipes for the cookbook. The competition wassponsored by Kwiksave, a major super-market chain in the UK.

Artie Beat, a fun, heart shaped ballooncharacter designed to educate schoolchildren from the ages of 7 to 11 aboutthe purpose and function of the heart and the habits that make up a healthylifestyle, forms the unifying theme behindthe cookbook. Drawings of Artie Beatappear throughout the book, as thecharacter shares both visual and verbaltips on choosing and preparing foods.

Healthy eating tips available to all youngsters

In order to be available and accessible to all children throughout the UnitedKingdom, the Artie Beat cookbook andprogramme are also linked to all thenational curricula.

Artie Beat’s Healthy Cookbook can bepurchased through the British HeartFoundation shops, Head Office and alsovia the web site found at www.bhf.org.uk.Anyone with queries about this livelyinitiative should not hesitate to contact the British Heart Foundation through theweb site or any of our offices.

News from the United Kingdomby the British Heart Foundation

Promoting healthy habits by starting with the children

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