A sign of deprivation, stunting increases the risk of morbidity, impaired cognitive development and poor school performance in childhood and reduced work productivity in later life (163,164). Stunting is a sensitive measure of poverty and is clearly linked with low birth weight (165). In the European Region, levels of stunting in young children are low in western countries but high in eastern ones, especially the central Asian republics. Fig. 1.26 shows that in Tajikistan, for example, over half the children under 5 years of age are stunted (http://www.who.int/nutgrowthdb/intro_text.htm, accessed 25 September 2003) (80–82,109). In Uzbekistan, 31% of preschool children are stunted and 14% of these are severely stunted (166). Fig. 1.26. Prevalence of stunting in preschool children, selected European countries, 1990s Sources: WHO Global Database on Child Growth and Malnutrition (http:// www.who.int/nutgrowthdb/intro_text.htm, accessed 25 September 2003), Kazakhstan demographic and health survey (DHS), 1999 (80), Turkey demographic and health survey (DHS), 1998 (81) and Kyrgyzstan demographic and health survey (DHS), 1997 (82). Stunting is usually more pronounced in rural than in urban areas. This suggests that hygiene and environmental conditions partly determine stunting (166). Kazakhstan (80), Kyrgyzstan (82) and Yugoslavia (http://www.who.int/ nutgrowthdb/intro_text.htm, accessed 25 September 2003) all report about twice the rate of stunting in rural as in urban areas. The exception to the pattern is Uzbekistan, where stunting was reported to be slightly higher in urban areas (109). Croatia (1995–1996) Armenia (1998) Czech Republic (1991) Hungary (1980–1988) Yugoslavia (1996) Romania (1991) Kazakhstan (1999) Turkey (1998) Russian Federation (1993) Azerbaijan (1996) Albania (1997) Kyrgyzstan (1997) Uzbekistan (1996) Tajikistan (1996) Prevalence (%) 0 10 20 30 40 50 60 Diet and disease 55 While stunting is most common in the central Asian republics, less than optimal growth patterns may be found among poorer groups in relatively wealthy countries, such as the United Kingdom. Gregory & Lowe (167) have shown that the average height of children from the wealthiest households (with over £600 weekly income) is 10 cm over that of children from the poorest households. Dental health Dental caries is a process of enamel and dentine demineralization caused by various acids formed from bacteria in dental plaque. The DMFT (decayed, missing and filled permanent teeth) index is a universally accepted measure of dental health. The score for any individual can range from 0 to 32 and represents the number of teeth affected (168). Caries is caused by acids produced mainly from the interaction of specific bacteria with dietary sugar: the bacteria do not produce enough acid to demineralize enamel without sugar. Fluoride is the main factor altering the resistance of teeth to acid attack. Fluoride reduces caries by reducing demineralization of enamel, by remineralizing enamel and by altering the ecology of dental plaque to reduce bacterial acid production (168). Fig. 1.27 shows DMFT scores in children in Europe (169). Even in the countries with relatively low DMFT scores, 65% of children have had dental caries in their permanent teeth (170). The CCEE and NIS continue to have significantly higher caries levels than other European countries; these levels are well above the European average and the WHO target of a population average of 3 or fewer DMFT (169). In addition, caries affects the vast majority of people in eastern countries from an early age; in most of western Europe, it is concentrated in certain groups. Further, the percentage of untreated caries lesions in 12-yearolds has been reported to be 11% in the Czech Republic, 29% in France, 45% in the United Kingdom, 46% in Hungary and 53% in Poland (169). Dental care is expensive. Table 1.2 shows how dental caries accounted for the largest proportion of all direct costs to the health care service in Germany in the 1990s and the second-largest share of total costs. In older people, oral health status is especially important and influences nutritional status. Dental caries, traditionally considered a problem of childhood, progresses throughout life and may accelerate with old age (168). Periodontal disease increases with age. As a result, older people have fewer natural teeth, are more likely to be toothless (edentulous) and are also vulnerable to dietary restrictions for other reasons such as disability and medical or social conditions. Chewing problems are relatively common in older people. They can cause dietary restrictions and thus compromise nutritional status and wellbeing 56 Food and health in Europe 6 5 4 3 2 1 0 Denmark Finland Norway Iceland Austria Belgium (Flanders) France Germany (eastern) Germany (western) Netherlands Switzerland United Kingdom Greece Italy (Venice region) Portugal Spain Albania Slovenia Lithuania Czech Republic Hungary Poland Romania Slovakia DMFT 1982–1988 1989–1995 Fig. 1.27. Average number of DMFT in children, European Region, 1982–1988 and 1989–1995 Source: Marthaler et al. (169). Diet and disease 57 (171,172). Wearing dentures limits dietary intake and nutritional status, as it may alter food choices, which may result in lower intakes for key nutrients such as iron and fibre (173–176). Tooth loss is associated with a lower intake of hard-to-chew foods such as apples and carrots, and edentulous people consume fewer fruits and vegetables, less fibre and carotene, and more cholesterol, saturated fat and energy than people who have retained their teeth (175). In older people living in their own homes, intakes of most nutrients, fruits and vegetables were significantly lower in the edentulous. In the United Kingdom, raw carrots, apples, well done steak or nuts were difficult for many edentulous older people to eat: for about 20% of those living in their own homes and over 50% of those in institutions. The daily intake of fruits and vegetables, non-starch polysaccharides, protein, calcium, non-haem iron, niacin, vitamin C, intrinsic and milk sugars and plasma ascorbate and retinol were significantly lower in edentulous people. Plasma ascorbate was significantly related to the number of pairs of teeth at the back of the mouth that are capable of chewing fruits and vegetables (177). The health of the ageing population of Europe The population of Europe is ageing, and within the EU alone, the number of people aged over 80 years is estimated to increase by about 30% over the next 50 years (178). Because life expectancy is increasing across the European Region, despite the differences (see Fig. 1.28), an increasing proportion of the population is older. This means that the overall disease burden can be expected to rise sharply, which will tend to offset the benefits of good preventive measures. For a variety of physical, social and psychological reasons, older adults are considered to be at risk of nutritional problems, either as a result of impaired food intake or reduced nutrient utilization. Both cross-sectional and longitudinal studies in older people show a decline in energy intake with age (179,180). Several of the health problems and bodily changes they experience have long been attributed to the normal ageing process but are increasingly being linked to lifestyle, socioeconomic or environmental factors (181). For example, four fifths of pensioners in Romania have incomes below the official subsistence limits (67). Diet and morbidity and mortality among older people The FINE (Finland, Italy and the Netherlands) study investigated the association of dietary patterns and mortality in more than 3000 men aged 50–70 years in the three countries. Of the 59% of men who died during the twentyyear follow-up, mortality was highest in eastern Finland and lowest in Italy. The national differences were striking in that Finnish men with healthier diets had higher mortality rates than Italian men with more unhealthy diets (182). 58 Food and health in Europe Other detailed studies on older people in Europe have emphasized the importance of an appropriate diet in determining mortality and morbidity rates as well as mental functioning (183). From 1988 to 1999, the Survey Europe on Nutrition in the Elderly: a Concerted Action (SENECA) found evidence of deficiency in 47% for vitamin D, 23.3% for vitamin B6, 2.7% for vitamin B12 and 1.1% for vitamin E (184). There is evidence that plasma homocysteine levels in many older people are related to inadequate intake of folic acid (185–187). Homocysteine levels relate not only to lower levels of plasma folate but also to estimates of folate intake, and have been associated with an increased propensity to CVD and especially thrombosis. The association of high homocysteine levels with poor mental functioning may therefore reflect the impact of a series of small cerebral thromboses. Detailed studies in Italy have revealed that low folate levels are especially evident among older people living at home, with higher rates among men and among those who drink more alcohol and take a variety of drugs, which reduce the bioavailability of dietary folate. Thus, those taking drugs for a variety of medical conditions have 2–3 times the prevalence of low folate deficiency. Other European studies have shown that about 75% of older Fig. 1.28. Trends in the proportion of the population 65 years or older in the WHO European Region, 1970–1998 Source: European health for all database, WHO Regional Office for Europe. 4 6 8 10 12 14 16 18 1970 1975 1980 1985 1990 1995 2000 EU average CCEE average NIS average Nordic average Central Asian republics average Proportion (%) Year Diet and disease 59 people have abnormally high homocysteine levels, which are correlated inversely with both plasma and dietary folate (188). Fat-soluble vitamins, such as vitamins A, E and D, are important for older people. Studies in Italy show a clear decline in vitamin A status with age as food intake falls (189), and a higher level of vitamin E in the plasma lowers the likelihood of marked atherosclerosis among older people (190). It is therefore not surprising that vitamin E status, as well as the adequacy of intake of B vitamins, has been linked to a higher survival rate and lower mortality. The SENECA study shows a high prevalence of vitamin E and B6 deficiency among older people in Europe. An appreciable proportion of the poor mental functioning of older people in Europe may therefore prove to be preventable. As older people reduce their food intake in response to decreasing physical activity, iron intake falls. Any difficulty in chewing food because of dental loss reduces the intake of iron-enhancing vegetables and meat (173–176). In a follow-up to the SENECA study, Martins et al. (191) reported that, of people in Portugal aged 81–86 years, 49% of men and 73% of women consumed less than the lowest European recommended dietary intake. Anaemia rates, however, are not unusually elevated, except in the central Asian republics, where iron availability is severely compromised or intestinal parasitism or other intestinal disease limits iron absorption. The modest prevalence of frank anaemia among older people needs to be distinguished from the much higher prevalence of anaemia among people who are ill and depend on nursing and other help with food, either at home or in institutions. Many well recognized techniques identify older people at risk, such as those living on their own, having difficulty in moving and shopping or displaying poor appetite and poor dental health (192,193). The importance of a healthy lifestyle in later life The decline of the vitamin status of older people in Europe is of serious public health concern and is related not only to the marked decline in physical activity but also to the often poor quality of the diet among very old people, many of whom are either edentulous or have serious dental problems (168). This suggests that the quality of the diet needs to be improved. The general importance of adequate vitamin status in older people was assessed in a double-blind placebo-controlled trial. Giving the equivalent of the recommended daily allowances of vitamins and some minerals to apparently healthy older people not only markedly improved their immune status but also led to a halving of intercurrent illnesses in the subsequent year. How much the health of older people can be generally improved – by either improving the quality of the diet or simply increasing their physical activity so that they increase their intake – is uncertain. Nevertheless, the importance of increasing physical activity in older people has certainly been 60 Food and health in Europe underestimated. Detailed studies in the Netherlands have shown that the greater the physical activity of older men, the lower the subsequent mortality rate. Thus, the rate among the most active third of older people was more than halved (194). This surprisingly strong effect of physical activity may reflect not only improved nutrition but the well recognized impact of even modest physical activity in reducing CVD mortality (195). In older people, physical activity is also likely not only to maintain better bone structure and greater power in better maintained muscle mass but also to limit the adverse metabolic effects of obesity. Intervention studies encouraging older people to take up even modest physical activity markedly improved their flexibility and sense of wellbeing (196). This is a neglected area of public health in Europe. Fig. 1.29. Adjusted hazard ratios of the individual and combined effects of diet, nonsmoking and physical activity on mortality in a sample of European men and women born between 1913 and 1918 Note: The ratios were adjusted for age at baseline, region and the number of chronic diseases. HQ diet = high-quality diet; LQ diet = low-quality diet. Source: Haveman-Nies et al. (197). 3.50 2.57 1.70 1.25 2.80 2.06 1.36 1.00 1.0 2.0 3.0 4.0 Hazard ratio Low activity High activity Low activity High activity HQ diet LQ diet Smokers Men 1 unhealthy behaviour 2 unhealthy behaviours 3 unhealthy behaviours 3.88 3.08 2.21 2.21 1.76 1.75 1.00 1.0 2.0 3.0 4.0 5.0 Hazard ratio Low activity High activity Low activity High activity HQ diet LQ diet Smokers Nonsmokers Women 1.26 Nonsmokers No unhealthy behaviour Diet and disease 61 The SENECA study highlighted the interaction between a good diet and physical activity by investigating their effects on the survival of older people individually and in combination with nonsmoking. The study population, aged 70–75 years, consisted of 631 men and 650 women from cities in Belgium, Denmark, Italy, the Netherlands, Portugal, Spain and Switzerland. A lifestyle score was calculated by adding the scores of the three lifestyle factors. Each factor and the total lifestyle score were related to survival in these European populations (Fig. 1.29). Combining types of unhealthy behaviour increased the risk of death: men and women with three unhealthy types of behaviour had a three- to fourfold increase in mortality. These results (197) emphasize the importance of a healthy lifestyle, including multiple lifestyle factors, and maintaining it with advancing age. Healthy behaviour is related not only to a higher chance of survival but also to a delay in the deterioration of health status. Ideal healthy ageing is described as a situation in which people survive to an advanced age with their vigour and functional independence maintained and with morbidity and disability compressed into a relatively short period before death (198). Fig. 1.30 shows the effect of healthy behaviour on life expectancy and health status. The health status of survivors of the SENECA birth cohorts with healthy and unhealthy lifestyles is presented, with hypothetical extrapolations from the age of 82.5 years. During the ten-year follow-up period, the health status of the survivors with healthy lifestyles declined less quickly. Fig. 1.30. Effect of healthy lifestyles on healthy ageing in a sample of Europeans born between 1913 and 1918, including hypothesized effects after 2000 Source: adapted from Haveman-Nies et al. (197). Age (years) 72.5 82.5 Healthy survivors (%) Healthy lifestyle Unhealthy lifestyle Hypothetical 62 Food and health in Europe In conclusion, healthy behaviour increases the chance of survival and delays the onset of illnesses. Although the SENECA study could not determine the net effect of these two relationships on the process of healthy ageing, postponing the onset of major morbidity is likely to compress morbidity into a shorter period. The burden of osteoporosis Osteoporosis means that the amount of bone per unit volume decreases but the composition remains unchanged. It occurs progressively after people reach peak bone mass as young adults. The two nutrients essential for bone health are vitamin D and calcium. Vitamin D deficiency is common among elderly people, often caused by poor nutrition and/or inadequate exposure to sunlight (199). Subclinical deficiency of vitamin D, known as vitamin D insufficiency, may increase the risk of bone fractures if osteoporosis is already present. The yearly incidence of osteoporotic hip fractures in the EU is projected to more than double, from over 400 000 (80% in women) to almost 1 million, by 2050 (Fig. 1.31). Fig. 1.31. Projected numbers of yearly incident hip fractures in EU countries, 1995–2050 Source: adapted from Report on osteoporosis in the European Community – action on prevention (200). Osteoporotic fractures have an overall mortality of 15–30% (201,202). They are associated with considerable morbidity and often require 0 200 400 600 800 1000 Fractures (thousands) Total Women Men 1995 2000 2010 2020 2030 2040 2050 Diet and disease 63 hospitalization, rehabilitation and home care. The economic burden of osteoporosis is considerable. For example, the total cost of hospitalization for hip fractures in the EU was ECU 3.6 billion in 1995, and is expected to rise with the number of fractures (203). Fig. 1.32 shows the direct estimated costs; these include surgery and postoperative stay, but not longer rehabilitation. For Sweden and the United Kingdom, for which data are available for the indirect costs of hip fracture (such as primary care, outpatient care and institutional care), the total amount is 2.5 times the direct hospital costs. Fig. 1.32. Estimated total direct hospital costs arising from hip fractures in 13 EU countries, 1996 Note: No national data were available for Luxembourg or Portugal. The figures for Austria are based on the costs in Germany. Source: adapted from Report on osteoporosis in the European Community – action on prevention (200). Physical activity plays a well established role throughout the lifespan in maintaining the normal structure and functional strength of bone. Specifically, physical activity can prevent or slow down the bone loss that begins occurring in women as a normal process after menopause (204). In summary, while most chronic diseases manifest in later life, the quality of life needs to be maximized until death. Adopting health promoting behaviour, such as physical activity and healthy diets, provides clear benefits to ageing individuals and populations. As the proportion of older European increases, interventions will influence an even greater number of people. In 0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 Germany France United Kingdom Spain Italy Netherlands Austria Belgium Sweden Denmark Greece Finland Ireland Costs (ECU million) 64 Food and health in Europe turn, improved health results in less dependence and reduces the cost of health care and institutional care (see Chapter 4, pp. 237–239, for policy recommendations). Nutritional health of vulnerable groups Refugees and internally displaced people In the midst of major socioeconomic and political transition, and in part as a result of the severance from traditional trade and financial links with the former USSR, many of the NIS and CCEE are not maximizing their industrial and agricultural potential and some are further crippled by natural disaster and political strife. These conditions continue to damage food security and the nutritional status of the affected populations. For instance, the three-year conflict in Bosnia and Herzegovina jeopardized the health and nutritional status of older people. By January 1994, 15% had a BMI below 18.5. Because the vegetable supply was poor, so were plasma carotenoid levels and plasma 25-hydroxyvitamin D3 levels in 65% of older people, most likely because of poor exposure to sunlight after months of siege (205). Protein and energy undernutrition was not a widespread public health problem, however (110). In 1999 in Kosovo, 11 000 children older than 5 years were estimated to be acutely malnourished and about 17 000 would be affected by stunting. Over 5% of the surveyed mothers had a BMI below 18.5 and more than 10% were obese (206). Other examples are Tajikistan and Uzbekistan, where both drought and civil conflict have increased the frequency of both wasting and stunting. Migrant groups, refugees and travellers constitute minorities residing – sometimes temporarily – within populations. Surveys of dietary patterns and nutritional status among these groups are sparse. As of 1 January 2002, the United Nations High Commission for Refugees classified nearly 5 million people in Europe as persons of concern, including refugees and asylum seekers (http://www.unhcr.ch/cgi-bin/texis/vtx/home?page=statistics, accessed 25 September 2003). Transient populations such as the Roma, an ethnic minority group of northern Indian origin that is especially numerous in the CCEE and western NIS, suffer additional strains on their health, as they are often stigmatized. More than 5 million Roma live in the CCEE. They are estimated to account for more than 5% of the population in Bulgaria, Hungary, Romania and Slovakia (207). With few exceptions, members of groups such as the Roma have low socioeconomic status. A study of Romany children aged 9–13 years in the Czech Republic found inadequate consumption of vegetables (19% of the recommended daily allowances (RDAs)), fruit (20% of RDA), milk and Diet and disease 65 milk products (32% of RDA), cereal foods (63% of RDA) and fish, meat, poultry and eggs (on average, 78% of RDA) (208). The children were consuming more than four times the recommended amounts of various snack foods containing fat and sugar. Compared with Czech children, Romany children typically consumed half the amounts of fruit, vegetables, milk and milk products. Yet when asked what foods they liked, 90% of Romany children mentioned fruit of various types. Their low consumption may reflect the constraints on choice arising from low income (209) and lack of access to fruits and vegetables because of high seasonality in rural areas (210,211). This highlights the need to address availability and expense rather than concentrating only on education and information campaigns. These results may also help explain the reports of elevated obesity rates in Romany children (211). Children who are especially vulnerable to food insecurity and poor diet tend to grow and develop more slowly than others of their age (208). In Azerbaijan, anaemia rates were consistently higher among internally displaced populations (http://web.azerweb.com/NGO_and_International_Organization_Reports/1996/CDCsurvey.html, accessed 25 September 2003). In Kazakhstan, the Kazakh ethnic group has a higher rate of anaemia than the Russian ethnic group (212). People in hospital Evidence shows that some patients in European hospitals are undernourished and that undernutrition may increase during hospital stay. The prevalence of underweight (BMI < 20) among hospital patients is 20–30%. This problem has been described in Denmark (213), Germany, Italy (214), Norway (215), Sweden (216), Switzerland (217,218) and the United Kingdom (219). Good nutritional care for patients provides clear benefits, but several factors have prevented its adequate provision in Europe (see Chapter 4, pp. 242– 243, for recommendations on nutrition in hospitals): • unclear responsibilities in planning and managing nutritional care; • insufficient education on nutrition for some staff groups; • patients’ lack of influence and knowledge; • insufficient cooperation between staff groups; and • inadequate involvement of hospital managers. Some patients who have little fat-free mass could be undernourished despite having a normal BMI (218). Most of the studies assessing the nutritional status of patients have excluded those who are most ill and hence most likely to be undernourished (213,220). Finally, obese patients could become undernourished while losing weight (221). 66 Food and health in Europe The prevalence of undernutrition is much higher among some patient groups, such as gastrointestinal patients, than among others, such as people admitted for obstetric services or elective surgery. In addition, undernutrition is higher among old patients (213,219,222–224). The prevalence has been suggested to be slightly higher among medical than surgical patients (219), among women (225,226) and among patients in teaching hospitals than those in district general hospitals (220,227). A survey of hospitalized children under 5 years in Kosovo found that 44% were fed vegetables and 84% fruit; 58% of the children were anaemic (18% severely and 40% moderately), possibly in part because tea was given to 80% of infants. The average age at which tea was introduced into their diet was 5 months. In 68% of hospital cases, children had not been breastfed for 6 full months, and 63% of the children had been given cow’s milk before reaching 6 months of age. Many studies have shown that the risk of undernutrition increases during hospital stay (228–232). For example, of 112 patients with all kinds of diagnoses hospitalized for more than 1 week, 64% had lost weight when discharged (mean weight loss: 5.4%), including 75% of those initially most undernourished. In contrast, 20% gained weight, including only 12.5% originally classified as undernourished. None gained sufficient weight to allow them to be reclassified as having normal weight (219). A reduced length of stay in hospital and decreased complication rates benefit both the patient and the health services. Improving hospital nutrition may bring the services substantial savings: at least £330 per surgical patient according to one estimate (233). A study in Denmark suggested that nutritional support could save the health services €133 million for every 100 000 patients (221). A study in the United Kingdom estimated that the National Health Service could save £266 million per year through nutritional support, based on the assumption that 10% of patients would benefit (234). A study in the United States (235) suggested that appropriate and timely nutritional support could save a typical large hospital over US $1 million per year. Social inequalities and poverty Various studies have surveyed the dietary patterns of different socioeconomic groups in Europe using a variety of indicators, such as household income, occupational class or the educational level of the head of the household (see Chapter 3, pp. 158–168). The DAFNE (Data Food Networking) study looked at household food purchases made by different socioeconomic groups based on educational attainment levels in Belgium, Greece, Hungary and Poland in 1990 (236). Diet and disease 67 The study found that dietary patterns differ considerably between countries, possibly reflecting different phases of the nutrition transition. These differences were generally greater than the differences found between socioeconomic groups, although the latter showed certain patterns. In general, lower socioeconomic groups tend to consume more meat, fat and sugar, although not necessarily the lowest socioeconomic groups, who may be partly excluded from more commercialized food supplies. The groups with the highest educational level appeared to consume more fruits and vegetables, although in some countries the groups with the lowest educational level, who may be growing their own produce, consumed a great deal. De Irala-Estevez et al. (237) and Roos et al. (238) support these findings; they examined dietary survey data for several western European countries and showed large socioeconomic differences in fruit and vegetable intake, with the higher socioeconomic groups usually consuming more fruits and vegetables (Table 1.4). Table 1.4. Difference in fruit and vegetable consumption among groups with high and low education in selected European countries and regions, 1980s and 1990s Source: Roos et al. (238). These figures are based on surveys made in the 1980s and 1990s. A more recent examination of fruit and vegetable consumption in Spain (239) suggested that the patterns of fruit and vegetable consumption now reflect those of northern Europe, with people in higher educational groups having higher intakes than those in lower educational groups. Among over 3000 Norwegian adults, those with higher educational and occupational status ate more fruits and vegetables and more dietary fibre and less fat (240). People living in cities also had healthier diets than those living in rural areas, although other data indicated that farmers in Norway tended to Country or region Difference (g per 10 MJ consumed per day) Fruits Vegetables Finland +55 +30 Sweden +18 +23 Norway +26 – 3 Denmark +46 +43 United Kingdom +31 +33 Germany +16 +14 Netherlands +52 +19 Spain Navarra +14 + 9 Catalonia + 6 –19 Basque Country –97 +31 68 Food and health in Europe have a lower-fat diet, lower serum cholesterol and less CHD than people in urban areas (Gunn-Elin Bjørnboe, National Council on Nutrition and Physical Activity, Oslo, Norway, personal communication, 2000). The United Kingdom has a long history of monitoring dietary patterns related to income levels, and annual food purchasing surveys have shown that household income is consistently related to certain dietary patterns. Families living on low incomes tend to consume less fruit and vegetables (Fig. 1.33) (241), fish and whole-grain cereal foods and more refined cereal foods, sweet foods, fat and oil (242). As a result, the intake of essential nutrients shows a marked social gradient from poorer to richer households (Table 1.5). Fig. 1.33. Relationship of income to consumption of fresh fruits and vegetables and the share of income spent on food in the United Kingdom Source: Department for Food, Environment and Rural Affairs (241). Further surveys in the United Kingdom have shown that vulnerable groups – including older people, children from manual social classes, families claiming state benefits and children from lone-parent families – have lower intake and lower blood levels of many vitamins and minerals than others in the population (111,167,243). Intakes of vitamin C, folate, iron, zinc and magnesium are well below reference levels in households with incomes below £180 a week (the lowest income cut-off) or in households with more than three children or headed by a lone parent (241). Among the poorest fifth of families, the intake of some nutrients declined over a period of 15 years: vitamin C by 23% and beta-carotene by 47% (244). Consumption (g per person per day) Income spent on food 1 2 3 4 5 6 7 8 9 10 400 300 200 100 0 0 5 10 15 20 25 30 Share of income (%) Consumption (g) Deciles of net family income (per head) a 1 = lowest incomes; 10 = highest incomes. a Diet and disease 69 Table 1.5. Household income and average levels of consumption of several essential nutrients in the United Kingdom Source: Ministry of Agriculture, Fisheries and Food (241). Studies of socioeconomic status and breastfeeding suggest that, in more affluent countries, the frequency and duration of breastfeeding are greatest among higher-income groups. In the United Kingdom, for example, mothers in the highest-income group are twice as likely to be breastfeeding during the first week after a baby’s birth than mothers in the lowest group, and the socialclass differences grow over subsequent weeks (Table 1.6). Table 1.6. Breastfeeding rates in high and low socioeconomic groups in the United Kingdom, 1999 Source: Nelson (245). Inequality and diet-related diseases The dietary patterns described above may go some way in explaining the different disease patterns experienced by different social groups. A survey of more than 15 000 adults in the United Kingdom found significant differences in the prevalence of disease factors across different social classes defined by occupation (Table 1.7). The short-term effects on disease of inequality between social classes can be illustrated among individuals who change social class during their adult lives. A study in Oslo found that people who moved from lower to higher income or vice versa showed mortality rates that approached but did not equal those of the class to which they had moved (246). Income decile (%) Beta-carotene (µg/day) Folate (µg/day) Vitamin C (mg/day) Iron (mg/day) Zinc (mg/day) 0–10 1.175 204 43.2 8.3 6.6 10–20 1.601 231 50.8 9.5 7.3 20–30 1.631 245 54.7 10.0 7.8 30–40 1.742 250 56.7 10.2 7.8 40–50 1.773 253 60.7 10.3 7.9 50–60 1.914 257 63.2 10.5 8.1 60–70 1.921 256 62.3 10.5 8.0 70–80 1.984 266 69.4 10.8 8.2 80–90 1.937 269 73.4 11.0 8.3 90–100 2.075 273 80.8 11.2 8.3 Time Breastfeeding rates (%) Social class I Social class V At 1 week 84 40 At 6 weeks 73 23 At 4 months 56 13 70 Food and health in Europe Table 1.7. Social class and ill health: prevalence of diseases and risk factors in adults in the United Kingdom, 1994 Source: Colhoun & Prescott-Clarke (117). Cancer rates can show a similar change in pattern: after Turkish migrants move to Germany, their disease rates rise towards the levels prevailing there (247). This implies that changing lifestyle – including food and diet – can affect the health experience of the groups being assimilated and can therefore explain some of the inequality in disease rates among these populations. As shown in Table 1.7, lower-income groups in the United Kingdom tend to have higher heart disease rates, and many countries in Europe show a similar relationship. The cause is likely to be multifactorial, including smoking, physical activity, stress, occupational factors and other psychosocial factors (248), as well as nutrition. Nevertheless, the same pattern may not be found among populations adhering to diets more like those traditionally eaten in southern Europe. Kunst et al. (249) examined data on socioeconomic status and heart disease mortality in several European countries. Although data sources were not perfectly compatible, and data for some groups were unobtainable, the figures fairly consistently show that lower socioeconomic status and heart disease are most strongly associated in northern Europe and among younger populations. In contrast, the association tended to be reversed among older populations in southern Europe (Table 1.8). The analysis was based on data from longitudinal and cross-sectional studies using national population censuses of 1981. For most of the longitudinal studies, follow-up covered the period from 1980 to 1989. The trends shown in Table 1.8 may result from several factors, but diet will play a part. A transition from the heart-protecting diets (rich in fruits, vegetables and fish) eaten traditionally in southern Europe to diets rich in animal products and refined carbohydrates will increase the risk of heart disease. Diseases and risk factors Social class Highest Intermediate non-manual Lowest Men Women Men Women Men Women Ischaemic heart disease (%) 5.1 1.8 6.0 5.2 6.4 7.2 Stroke (%) 1.3 0.5 1.7 2.3 2.1 2.5 Mean blood pressure (mm/Hg) 136/76 130/72 138/76 136/73 139/77 141/75 Cholesterol > 6.5 mmol/l (%) 26 26 27 35 26 36 Haemoglobin < 13 g/dl (%) 3 9 5 12 5 13 Obesity (BMI > 30) (%) 9.9 11.8 13.7 15.0 14.0 22.6 Physically inactive (%) 14 15 15 17 21 22 Diet and disease 71 The fact that such a transition in diet has occurred to a greater degree among poorer populations and has affected younger more than older members of a population needs further investigation. Obesity, physical activity and inequality Inequality in disease experience may also be related to energy expenditure and physical activity (see Chapter 3, pp. 165–167). A fitness survey in England found that people who had more education or owned their homes tended to engage in more physical activity (250). Unemployed men, and to some extent unemployed women, tended to be more sedentary than those in employment (251). Professional people were twice as likely as unskilled manual workers or economically inactive people to take part in sports or other leisure physical activity. In addition, a survey of over 15 000 adults in the United Kingdom found that physical inactivity in both men and women increased as social class decreased. Socioeconomic status and obesity have often been found to be inversely related among women in Europe (Fig. 1.34) (252). The relationship among men, although less clear in earlier reviews (253), seems to be similar to that among women. In the consumer survey of the entire EU, in which BMI was calculated from subjects’ self-reported height and weight, levels of obesity and social class were strongly associated, with social class being defined variously by household income, occupation or educational level (252). The survey involved over 15 000 people aged over 15 years in the member states of the EU. In 1997–1998, the WHO Health Behaviour in School-aged Children study found consistent links between greater family affluence and more selfreported exercise among 15-year-olds surveyed in several European countries (98). Exercise was more common among more affluent children in Austria, Table 1.8. Relative riska of heart disease for men in manual versus non-manual occupations in selected countries in western Europe a >1 = elevated risk; <1 = lower risk. Source: adapted from Kunst et al. (249). Country Relative risk in men aged: 30–44 years 45–59 years 60–64 years Sweden 1.80 1.38 Not available United Kingdom (England and Wales) 1.68 1.50 1.26 France 1.18 0.96 Not available Italy 1.35 1.08 0.85 Portugal 0.82 0.76 Not available Norway 1.77 1.35 1.26 72 Food and health in Europe Denmark, Germany, Hungary, Latvia, Portugal, the Russian Federation and the United Kingdom, but not in Norway. A consumer survey in the EU suggested that adults with less education are more likely to have physically active jobs and are more likely to spend time in sedentary leisure when not working (254). Those who were older and had only primary education were the least likely both to take part in physical exercise and to consider such activity necessary for health. Lifestyle and choice In countries where undernutrition and poor child growth are still relatively common, there is evidence that obesity and underweight may coexist. Studies carried out in Kyrgyzstan, the Russian Federation and Tajikistan (255) show that 30–60% of households with underweight individuals also had overweight individuals: typically an underweight child and an overweight adult. The causes may be complex, but some evidence suggests that, the more rapid the nutrition transition, the more likely that both under- and overweight problems will coexist in the same household (256). The data reviewed here show wide variation between countries in the WHO European Region. More economically advanced countries show a posttransition pattern, in which people who are poorer in material or social conditions are likely to eat less healthily and take less exercise. These unhealthy lifestyles in turn generate the inequality observed in morbidity and mortality from CVD and a wide range of other causes. In countries with limited access to commercialized food supplies, dietary patterns may be more like a subsistence diet, relying on staple cereal crops, Fig. 1.34. Prevalence of obesity among adult men and women according to economic status (measured by household income or occupation) in the EU Source: adapted from Martinez et al. (252). 0 2 4 6 8 10 12 14 16 Men Women Prevalence (%) Middle–upper Middle Middle–lower Lower Diet and disease 73 some vegetable foods and limited amounts of animal products. Health indicators such as infant mortality rates may be high, but rates of CVD and other adult noncommunicable diseases may be low, indicating that such diets may contribute to better adult health. As discussed elsewhere in this book, factors such as fetal nutrition, birth weight, child growth and subsequent obesity and disease experience are shaped by environmental and material circumstances that may be far beyond the individual’s control. In such situations, efforts to improve health by exhorting members of the population to improve their lifestyles may have only limited impact: as Dowler (257) points out: The implication is that people are able to exert personal choice over what they eat, or whether they walk/cycle or undertake active exercise, rather than leading a sedentary life, and that the role of those implementing health promotion is to encourage or enable them to make “the right” choices … In practice, choices in relation to food and activity are not solely individual matters, unconstrained by family, neighbourhood or material conditions. 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