Food-Based Dietary Guidelines - development of a conceptual framework for future Food-Based Dietary Guidelines in Europe: report of a Federation of European Nutrition Societies Task-Force Workshop in Copenhagen, 12-13 March 2018.

Identifying a need for developing a conceptual framework for the future development of Food-Based Dietary Guidelines (FBDG) in Europe, The Federation of European Nutrition Sciences established a Task Force for this purpose. A workshop was held with the specific objective to discuss the various dimensions considered as particularly relevant. Existing frameworks for FBDG were discussed, and presentations from various countries illustrated not only several commonalities but also a high degree of heterogeneity in the guidelines from different countries. Environmental aspects were considered in several countries, and dimensions like food safety, dietary habits and preparation were included in others. The workshop provided an overview of the use of FBDG - both in developing front-of-pack nutrition labels and for reformulation and innovation. The European FBDG dimensions were described with examples from the close connection between FBDG and European Union (EU) policies and activities and from the compilation of a database of national FBDG. Also, the challenges with communication of FBDG were discussed. Considering the current scientific basis and the experiences from several countries, the Task Force discussed the various dimensions of developing FBDG and concluded that environmental aspects should be included in the future conceptual framework for FBDG. A change in terminology to sustainable FDBG (SFBDG) could reflect this. The Task Force concluded that further work needs to be done exploring current practice, existing methodologies and the future prospects for incorporating other relevant dimensions into a future Federation of European Nutrition Societies conceptual framework for SFBDG in Europe and working groups were formed to address that.

Nutrition in the context of the Sustainable Development Goals.

The 2030 Agenda for the Sustainable Development Goals (SDGs) represents a common framework of international cooperation to promote sustainable development. Nutrition is the key point for the SDG 2 'End hunger, achieve food security and improved nutrition and promote sustainable agriculture' and is an essential component for achieving many of the other targets: overall, the nutritional aspects of the SDGs aim to promote healthy and sustainable diets and ensure food security globally. While undernutrition is of minimal concern in the European Union Member States, trends in childhood obesity are still alarming and far from any desirable target. European food production systems have improved over the last years, with immediate impact on several environmental aspects; however, a comprehensive regulatory framework to fulfil the environmental and climate targets is still lacking. Policy actions at multinational level are needed to achieve global nutrition targets designed to guide progress towards tackling all forms of malnutrition while preserving the environment through virtuous food production and food systems.

'Du bist was du isst': challenges in European nutrition policy.

Food cultures have developed in communities as according to the produce of local farms in the vicinity. The industrial revolution resulted in large cities and towns becoming reliant on farm produce from the neighbouring countryside; this stimulated development of farming, which itself became industrialized. However, although local diets in Europe differed markedly, the 'healthiness' of all diets was unquestioned until recently. Early in the 20th century, academic departments studying nutrition were established, but it is only since the 1980s that much interest in the 'healthiness' of our food began to be of concern outwith academia. At about this time it was becoming clear that existing patterns of farming and food production were having negative effects on the environment. Since the 1990s, environmental, farming and nutritional sciences have each progressed, but in parallel, and there has been all too little effort to unite them. However, it is clear that, in general, production of foods associated with 'unhealthy' nutrition is also the most damaging from an environmental viewpoint.This article summarizes the evidence on current European diets, analyses costs and benefits in transitioning to healthy and sustainable diets, identifies sustainable dietary guidelines as the way forward and discusses the role of public health in achieving dietary reform in the interests of improved nutrition and environmental protection.

Collecting standardised urban health indicator data at an individual level for adults living in urban areas: methodology from EURO-URHIS 2.

Background: An aim of the EURO-URHIS 2 project was to collect standardised data on urban health indicators (UHIs) relevant to the health of adults resident in European urban areas. This article details development of the survey instruments and methodologies to meet this aim. 32 urban areas from 11 countries conducted the adult surveys. Using a participatory approach, a standardised adult UHI survey questionnaire was developed mainly comprised of previously validated questions, followed by translation and back-translation. An evidence-based survey methodology with extensive training was employed to ensure standardised data collection. Comprehensive UK piloting ensured face validity and investigated the potential for response bias in the surveys. Each urban area distributed 800 questionnaires to age-sex stratified random samples of adults following the survey protocols. Piloting revealed lower response rates in younger males from more deprived areas. Almost 19500 adult UHI questionnaires were returned and entered from participating urban areas. Response rates were generally low but varied across Europe. The participatory approach in development of survey questionnaires and methods using an evidence-based approach and extensive training of partners has ensured comparable UHI data across heterogeneous European contexts. The data provide unique information on health and determinants of health in adults living in European urban areas that could be used to inform urban health policymaking. However, piloting has revealed a concern that non-response bias could lead to under-representation of younger males from more deprived areas. This could affect the generalisability of findings from the adult surveys given the low response rates.

Differences in adults' health and health behaviour between 16 European urban areas and the associations with socio-economic status and physical and social environment.

Background: With a growing proportion of the European population living in urban areas (UAs), exploring health in urban areas becomes increasingly important. The objective of this study is to assess the magnitude of differences in health and health behaviour between adults living in urban areas (UAs) across Europe. We also explored whether and to what extent such differences can be explained by socio-economic status (SES) and physical or social environment. Data were obtained from a cross-sectional questionnaire survey, performed between as part of the European Urban Health Indicator System Part 2 (EURO-URHIS 2) project. Using multi-level logistic regression analysis, UA differences in psychological distress, self-assessed health, overweight and obesity, daily smoking, binge drinking and physical exercise were assessed. Median Odds Ratios (MORs) were calculated to estimate the extent to which the observed variance is attributable to UA, individual-level SES (measured by perceived financial strains, education level and employment status) and/or characteristics of physical and social environment. The dataset included 14 022 respondents in 16 UAs within 9 countries. After correction for age and gender, all MORs, except that for daily smoking, indicated statistically significant UA health differences. SES indicators (partly) explained UA differences in psychological distress, decreasing the MOR from 1.43 [95% credible interval (Cr.I.) 1.27-1.67, baseline model], to 1.25 (95% Cr.I. 1.14-1.40, SES model): a reduction of 42%. Accounting for the quality of green areas reduced the MOR for psychological distress by an additional 40%, to 1.15 (95% Cr.I. 1.05-1.28). Our study showed large differences in health and health behaviour between European UAs. Reducing socio-economic disadvantage and improving the quality of the neighbourhood's green spaces may reduce UA differences in psychological distress.

Determinants of self-rated health in elderly populations in urban areas in Slovenia, Lithuania and UK: findings of the EURO-URHIS 2 survey.

Background: Ageing imposes extra financial burdens on social and health services in developed countries. Self-rated health (SRH) is considered to be both a reliable measurement of overall health status including morbidity and mortality and an important predictor of hospitalization, functional impairment and greater demand for health-care services in the elderly. Our aim was to identify factors associated with poor SRH in elderly populations and investigate possible differences between urban areas in Slovenia, Lithuania and UK. Data were obtained from population-based surveys from the European Urban Health Indicator System Part 2 project. The stratified representative sample (41% men and 59% women) consisted of a total of 2547 respondents aged ≥65 from the urban areas in the three countries. The prevalence of poor SRH was highest in Lithuanian urban areas. The strongest factors associated with poor SRH were low education [OR (odds ratio) 4.3, 95% CI (confidence interval) 2.5-7.3, P < 0.001], restriction of activities attributable to a chronic disease (OR 2.6, 95% CI 2.2-3.0, P < 0.001), inadequate physical activity (OR 1.7, 95% CI 1.2-2.5, P = 0.007) and poor mental health (OR 1.1, 95% CI 1.1-1.2, P < 0.001). The main factors associated with poor SRH by country included the following: living alone (Slovenia) (OR 2.0, 95% CI 1.1-3.7, P = 0,023), female sex (Lithuania) (OR 2.0, 95% CI 1.0-4.2, P = 0.058) and inadequate physical activity (UK) (OR 2.2, 95% CI 1.3-3.6, P = 0,003). Despite different levels of poor SRH, the factors associated with poor SRH were similar for the urban areas of the three countries. Factors associated with poor SRH in the urban areas could also reflect either cultural differences or specific situations for elderly in that country, which need further research.

Collecting urban health indicators from routinely available sources: development and piloting of a tool for the collection of existing data for EURO-URHIS 2.

Introduction: EURO-URHIS 2 aimed to collect comparable health indicators across a large number of urban areas (UAs) across Europe and Vietnam using four data collection tools. This paper outlines the process for the selection of indicators to be collected from routinely available sources, and the piloting of the data collection tool. A long-list of indicators potentially collectable from routinely available sources was generated by the EURO-URHIS 2 consortium. Key contacts from each UA completed an e-mail survey reporting for each indicator whether it could be collected using the given definition, an alternative definition or not at all. Additionally participants listed the 20 leading causes of death for their UAs from the Eurostat 65. Results were compiled to inform indicator selection for the main data collection phase. Responses were received for 25 of 28 eligible UAs. Of the 29 proposed indicators, 55.1% ( n = 16) were accepted without change, 24.1% ( n = 7) were re-allocated to other data collection tools and 17.2% ( n = 5) were accepted after a modification of the EURO-URHIS 2 definition. This scoping exercise and piloting phase for the 'existing data tool' for the project was useful and informative. It provided detailed information on what could be collected, and an opportunity to modify indicator definitions to maximize response rates. These results are only applicable to those UAs returning results and cannot be generalized. Detailed interrogation of definitions is essential to this sort of data collection, and the process described was designed with cross-national comparability in mind.

Developing a European urban health indicator system: results of EURO-URHIS 1.

Introduction: More than half of the world's population now live in cities, including over 70% in Europe. Cities bring opportunities but can be unhealthy places to live. The poorest urban dwellers live in the worst environments and are at the greatest risk of poor health outcomes. EURO-URHIS 1 set out to compile a cross-EU inventory of member states use of measures of urban health in order to support policymakers and improve public health policy. Following a literature review to define terms and find an appropriate model to guide urban health research, EURO-URHIS Urban Areas in all EU member states except Luxembourg, as well as Croatia, Turkey, Macedonia, Iceland and Norway, were defined and selected in collaboration with project partners. Following piloting of the survey tool, a the EURO-URHIS 45 data collection tool was sent out to contacts in all countries with identified EUA's, asking for data on 45 Urban Health Indicators (UHI) and 10 other indicators. 60 questionnaires were received from 30 countries, giving information on local health indicator availability, definitions and sources. Telephone interviews were also conducted with 14 respondents about their knowledge of sources of urban health data and barriers or problems experienced when collecting the data. Most participants had little problem identifying the sources of data, though some found that data was not always routinely recorded and was held by diverse sources or not at local level. Some participants found the data collection instrument to not be user-friendly and with UHI definitions that were sometimes unclear. However, the work has demonstrated that urban health and its measurement is of major relevance and importance for Public Health across Europe. The current study has constructed an initial system of European UHIs to meet the objectives of the project, but has also clearly demonstrated that further development work is required. The importance and value of examining UHIs has been confirmed, and the scene has been set for further studies on this topic.

Collecting standardized urban health indicator data at an individual level for school-aged children living in urban areas: methods from EURO-URHIS 2.

Background: Measuring health and its determinants in urban populations is essential to effectively develop public health policies maximizing health gain within this context. Adolescents are important in this regard given the origins of leading causes of morbidity and mortality develop pre-adulthood. Comprehensive, accurate and comparable information on adolescent urban health indicators from heterogeneous urban contexts is an important challenge. EURO-URHIS 2 aimed to develop standardized tools and methodologies collecting data from adolescents across heterogenous European urban contexts. Questionnaires were developed including (i) comprehensive assessment of urban health indicators from 7 pre-defined domains, (ii) use of previously validated questions from a literature review and other European surveys, (iii) translation/back-translation into European languages and (iv) piloting. Urban area-specific data collection methodologies were established through literature review, consultation and piloting. School-based surveys of 14-16-year olds (400-800 per urban area) were conducted in 13 European countries (33 urban areas). Participation rates were high (80-100%) for students from schools taking part in the surveys from all urban areas, and data quality was generally good (low rates of missing/spoiled data). Overall, 13 850 questionnaires were collected, coded and entered for EURO-URHIS 2. Dissemination included production of urban area health profiles (allowing benchmarking for a number of important public health indicators in young people) and use of visualization tools as part of the EURO-URHIS 2 project. EURO-URHIS 2 has developed standardized survey tools and methodologies for assessing key measures of health and its determinants in adolescents from heterogenous urban contexts and demonstrated the utility of this data to public health practitioners and policy makers.

Defining the urban area for cross national comparison of health indicators: the EURO-URHIS 2 boundary study.

Introduction: Despite much research focusing on the impact of the city condition upon health, there still remains a lack of consensus over what constitutes an urban area (UA). This study was conducted to establish comparable boundaries for the UAs participating in EURO-URHIS 2, and to test whether the sample reflected the heterogeneity of urban living. Key UA contacts ( n = 28) completed a cross-sectional questionnaire, which included where available comparison between Urban Audit city and larger urban zone (LUZ) boundaries and public health administration areas (PHAAs). Additionally, broad health and demographic indicators were sought to test for heterogeneity of the EURO-URHIS 2 sample. Urban Audit city boundaries were found to be suitable for data collection in 100% ( n = 21) of UAs where Urban Audit data were available. The remainder ( n = 7) identified PHAA boundaries akin to the 'city' level. Heterogeneity was observed in the sample for population size and infant mortality rate. Heterogeneity could not be established for male and female life expectancy. This study was able to establish comparable boundaries for EURO-URHIS 2 data collection, with the 'city' area being selected for data collection. The homogeneity of life expectancy indicators was reflective of sub-regional similarities in life expectancy, whilst population estimates and rates of infant mortality indicated the presence of heterogeneity within the sample. Future work would trial these methods with a larger number of indicators and for a larger number of UAs.

Food and Agriculture Policy in Europe.

Diet includes many risk factors for the most common non-communicable diseases (NCDs), but diets consumed in Europe and in other parts of the developed world are not being modified sufficiently to take account of health priorities concerning, in particular, the prevention of NCDs, while much excess mortality and morbidity could be prevented by government actions to regulate appropriately both the agricultural and food industries, and to apply appropriate taxes and subsidies to promote healthier nutrition. In Europe, the Common Agricultural Policy (CAP) continues to promote production of saturated fat rich foods and sugar, with scarce attempts to promote increased production of fruit and vegetables. Meanwhile, the food industry continues to market secondary food products rich in sugar, salt and saturated fats. Powerful lobbies seek to block reform; however, necessary reforms are indicated in the interests of improved nutritional health.

Effects of docosahexaenoic Acid supplementation on blood pressure, heart rate, and serum lipids in Scottish men with hypertension and hypercholesterolemia.

To investigate the effects of daily supplementation with docosahexaenoic acid (DHA) on coronary heart disease risks in 38 middle-aged men with hypertension and/or hypercholesterolemia in Scotland, a five-week double-blind placebo-controlled dietary supplementation with either 2 g of DHA or active placebo (1 g of olive oil) was conducted. Percent composition of DHA in plasma phospholipids increased significantly in DHA group. Systolic and diastolic blood pressure and heart rate decreased significantly in DHA group, but not in placebo group. High-density lipoprotein cholesterol (HDL-C) increased significantly, and total cholesterol (TC)/HDL-C and non-HDL-C/HDL-C ratios decreased significantly in both groups. There was no change in TC and non-HDL-C. We conclude that 2 g/day of DHA supplementation reduced coronary heart disease risk factor level improving blood pressure, heart rate, and lipid profiles in hypertensive, hypercholesterolemic Scottish men who do not eat fish on a regular basis.