APJCN

In terms of the ancestral genome of Homo sapiens, 90% of our genetic adaptation has come in the context of various hunter-gatherer settings, in which food variety was diverse and balanced between the Animal and Plant Kingdoms, and life-expectancy was short. Only recently, during the past century, when the human life-span began to elongate, have "long-term" health concerns truly been important. Reproductive health and child-rearing skills were the primary primeval concerns of evolutionary humans. With the number of persons over 60 years of age increasing at a rapid rate, chronic diseases threaten to cause suffering and disability for an increasing segment of the population while bankrupting health-care systems with the costs of therapeutic and custodial care for the elderly. How a society eats from birth and throughout the lifespan has a major determining effect for either more or less health and function. The meat-based fare of the caveman is probably not the recommended food pattern for healthy aging and compression of mortality, but neither is heavy exposure to the newer foods (dairy foods; cereals; refined sugars; vegetable oils; alcohol; salt; and fatty meats) which the agricultural and technological revolutions have made abundantly available. Taken in a lifespan perspective with an assumption of median survival through seven decades, a micronutrient-dense, but primarily plant-based intake reduces the risk of non-transmissible diseases. A concern going forward is how governmental policies and food-industry practices can contribute to making the most healthful diets and physical activity patterns accessible, available and appealing to persons throughout both the affluent and developed and the low-income and developing societies of the world.

Epidemiological studies as well as randomised dietary trials suggest that Mediterranean diet may be important in relation with the pathogenesis (and prevention) of coronary heart disease (CHD). For instance, a striking protective effect of an alpha-linolenic acid (ALA)-rich Mediterranean diet was reported in the Lyon Diet Heart Study with a 50 to 70 % reduction of the risk of recurrence after 4 years of follow-up in CHD patients. According to our current knowledge, dietary ALA should represent about 0.6 to 1 % of total daily energy or about 2g per day in patients following a Mediterranean diet, whereas the average intake in linoleic acid should not exceed 7g per day. Supplementation with very long chain omega-3 fatty acids (about 1g per day) in patients following a Mediterranean type of diet was shown to decrease the risk of cardiac death by 30% and of sudden cardiac death by 45% in the GISSI trial. Thus, in the context of a diet rich in oleic acid and poor in saturated and not high in omega-6 fatty acids (a dietary pattern characterizing the traditional Mediterranean diet), even a small dose of very long chain omega-3 fatty acids (one gram under the form of capsules) might be very protective. These data underline the importance of the accompanying diet in any dietary strategy using fatty acid complements.

Secondary prevention of coronary heart disease (CHD) usually focuses on risk reduction in patients with established CHD who are at high risk of recurrent cardiac events and death from cardiac causes. Because complications such as sudden cardiac death (SCD) and associated syndromes are often unpredictable, occur out of hospital and far from any potential therapeutic resources in the majority of cases, and account for more than 60% of total cardiac mortality in most countries, they should be the priority of any secondary prevention program. As a conclusion of this article, we propose a minimum clinical priority dietary program based on the idea that many patients (and their families) find it difficult to fully and immediately adopt a very effective cardioprotective diet. The clinical priority program provides a list of simple dietary recommendations that the patient and his/her attending physician will try to follow or not, according to their own choices and possibilities.

The aim of this project was to improve clinical nutrition practice amongst Australian general practitioners by offering of web-based learning as a medium for integrating clinical nutrition into general practice. Eleven nutrition units were developed in conjunction with nutritionists at www.healthyeatingclub.org and offered as part of an existing comprehensive online continuing professional development program comprising 400 educational units and offered free to Australian General Practitioners. Pre- and post-assessment questionnaires and eva-luations were collected over a 19 month period and the results collated. The experience of providing online continuing professional development to general practitioners within an integrated comprehensive primary care curriculum demonstrates that they are both interested and able to integrate clinical nutrition into practice. Since 2002, 1437 (28% of participating general practitioners) have voluntarily selected and completed clinical nutrition units as part of their learning programs. Effective educational modalities are case-based learning and peer group discussion supported by resource material and clinical tools to take learnings into practice. Educational outcomes include increased confidence to undertake counselling for weight management, increased used of anthropometric measurements, increased understanding of and use of dietary intake evaluation tools, especially the food variety score. Sustained change in clinical practice was measured by the use of clinical nutrition tools with 59% of participants making modifications to practice. A further 34% indicated an intention to review their practice and/or take up the clinical nutrition practice tool kit. Web-based nutrition education programs can be designed to be both modular and flexible, and are able to adapt to the different learning needs and styles of the different practitioners within Australia. They are an effective way of increasing knowledge, skills and confidence of general practitioners in nutrition counselling.

The prevalence of obesity in the Australian adult population has increased from 8.1% in 1981 to 18% in 1995 and 20.5% in 2000. Similarly, the estimated cost of obesity has risen from $840 million in 1992/93 to $1,520 million in 2003. This cost includes both the direct health care costs and the indirect costs associated with lost production due to premature death and absenteeism. There are a number of options available in the fight against obesity. One proposal is for a Government policy that supports weight reduction programs. Another method that is likely to gain public support is the use of weight loss pills. This study shows that the weight reduction programs proposal is superior in terms of both economic and budget impacts. Weight reduction programs, such as Weight Watchers, could be supported with a government rebate. This proposal was previously analysed by Econtech in a report of July 2003 and the results are reviewed here. New weight loss pills could be supported through their listing on the PBS. This report analyses this proposal for the first time. For weight reduction programs, the expected social (or total) benefit per enrolment of $623 is greater than the expected social cost of $195, implying a social net benefit of $428, and a social benefit to cost ratio of 3.2. So weight reduction programs easily pass a cost-benefit test. As a point of comparison, for weight loss pills, the expected social benefit per patient of $397 to $953 compares with expected social cost of $840, implying a social net benefit of between -$443 (net loss) and $113 (net benefit), and a social benefit to cost ratio of between 0.5 and 1.1. So even using optimistic assumptions, weight loss pills only barely pass a cost-benefit test. So weight reduction programs are for more economic than weight loss pills - the balance between social benefits and costs is much more favourable. This is because while both approaches are expected to deliver broadly similar benefits, weight reduction programs are far cheaper than weight loss pills. Government budget impacts were also estimated for the two alternative policies. For the rebate for weight reduction programs, the estimated annual gross cost to the budget is $52 million to $80 million. This reduces to a net cost of $27 million to $41 million after taking into account the savings to the health budget from a less obese population. For the PBS listing of weight loss pills, the estimated annual gross cost to the budget is $292 million. This reduces to a net cost of $87 million to $206 million after taking into account the savings to the health budget from a less obese population. This implies that weight reduction programs deliver far better value for the budget dollar than weight loss pills. The budget cost of the rebate for weight reduction programs per enrolment is far less than the budget cost of the PBS benefit for weight loss pills per treatment. Weight reduction programs offer a net social benefit of $1.5 per $1 of net budget cost of the rebate. Weight loss pills offer a net social benefit of between minus $1 and plus $0.6 per $1 of net budget cost of the PBS listing. The key comparative results for the two programs are summarised in Charts 3 for the low case and Chart 4 for the high case. These are broad estimates only. More precise estimates would require a detailed analysis.

This review is premised on the importance of reducing both underweight prevalence of children, as the key policy variable for hunger reduction, but also reducing "hidden hunger" - the micronutrient deficiencies that rob life, health, ability and productivity. The role of nutrition in development is discussed, balancing the importance of broad infrastructure policies and nutrition-relevant actions in health services and in community development. Convergent approaches to eliminating micronutrient deficiencies include supplementation, fortification and biofortification. Relatve costs drive a reordering of the mix. Next, community-based health and nutrition programs in South Asia and Sub Saharan Africa could be the focus of a global strategy to reduce underweight prevalence among under-fives, and resource needs are discussed. An approximation of resources needed to met the first Millennium Development Goal (halving global hunger), with side benefits to MDG # 4 on child mortality) is offered. The author draws upon his recent paper on costs and benefits of hunger alleviation prepared for the United Nations Hunger Task Force.

Worldwide degradation of arable land, freshwater depletion and the loss of biodiversity are three of several ongoing 'global environmental changes' that endanger the biosphere's human utility - including food supplies, an essential, 'utility'. The degradation of local and regional food-producing environmental assets is a familiar story historically. Today, however, pressures and stresses on food production are becoming global in scale, reflecting (in addition to the above three) a range of large-scale human-induced environmental changes, such as global climate change and environmental nitrification. Human-induced biodiversity loss reflects land-use changes, other aspects of the over-exploitation of productive terrestrial and marine ecosystems, climate change, and the trans-boundary migration of pollutants and exotic species. Indeed, biodiversity loss has, for long, been an inevitable trade-off against the increased capacity to produce food for larger human populations - as occurs in agrarian societies when forests are replaced by crops. More recently, trade, technology, knowledge dissemination, and the worldwide transformation of ecosystems have further boosted food supplies for the increasing human population. (That this abundance often fails to improve health, for example by fuelling obesity, is another story.) Recent time-series data show an unusual, continuing, decline in per capita yields of grain, globally, since 1996. Detrimental environmental changes may be a contributory explanation, but causal attribution is complex. The links between environmental changes, food production, nutrient status and human health are similarly complex, and difficult to demonstrate epidemiologically. These environmental (particularly ecosystem) changes mostly affect the health of populations via complex, indirect pathways, and these impacts are modulated by local social-economic conditions.

In spite of the natural endowment in Africa, the problems of hunger and under nutrition still remain the bane of human development. Problems related to nutrition are critical constraints to economic growth and these have been exacerbated with HIV/AIDS epidemics, leading to an increase in the number of orphans in Africa. Poverty and hunger are intertwined and these undoubtedly impinge on child survival. Finding solutions to nutritional dilemmas in Africa needs to go beyond non-nutritional divides and it should be realized that improving nutrition in developing countries is both a humanitarian and an economic imperative. Sustained poverty reduction will require economic growth centered on labour-intensive, employment creating policies and technologies in the atmosphere of political stability. However, economic growth can be a slow process by which to reduce poverty, and there is no guarantee that growth alone will adequately improve the incomes of the poorest in society. Therefore, it becomes necessary to institute strategies, which would not only focus on economic growth indices but also include programmes that will better the living conditions of the people, with special consideration for children. African countries need to identify with the Millennium Development Goals (MDGs) if sincere nutritional care is to be provided for the people to improve their well-being and production capacity. Therefore, it is appropriate for national governments and their development partners to initiate different "better life programmes" (BLPs) to facilitate and ensure that citizens have access to the tools that will allow them meet their food and nutrition requirements. Thus, the interventions, in addition to their intrinsic value in reducing child inadequate nutrition, are likely to provide important gains in terms of reducing current poverty and increasing future productivity.

The effective management of the health and fiscal implications of an ageing society requires a proactive rather than reactive response to meeting the needs of older persons, particularly in regional communities. The strong ties between the food industry and regional economies suggest that the food industry is strategically well placed to be a key influence in the development of proactive strategies to managing ageing societies. By offering employment to older persons and maintaining infrastructure in regional centres, the food industry can play a key role in strengthening regional areas as not only vibrant economies, but also as desirable, low cost and healthy places for independent older persons to live and participate meaningfully in the wider society.

The joint food standards regulator for Australia and New Zealand is currently working on a proposal to allow nutrition, health and related claims to appear on the labelling of foods. This paper describes the policy within which this proposal is being developed and sets out the degree of substantiation that must be met before such a claim can be permitted.

Many diseases including obesity, cardiovascular disease, diabetes (Type 2), intestinal inflammation and allergies can arise from imbalances of microflora in the gastrointestinal tract. Such imbalances can be addressed by dietary strategies including nutritional supplementation with probiotics and prebiotics such as high fibre diets and complex carbohydrates. With the advent of new diagnostic molecular technologies that can both characterise and enumerate complex cultivable and non-culturable microbial populations, it becomes feasible to profile changes in bacteria composition following nutraceutical intervention. Over time, the assembly of data relating to the analysis of changes in microbial populations of the gut, in relation to diet in health and disease, will form the basis of formulating nutritional regimes designed to promote intestinal health.

With regard to anti-inflammatory effects of diet away from the gut, altering the balance of dietary poly-unsaturated fatty acids (PUFA) in favour of n-3 PUFA provides the best documented examples of effective dietary intervention. PUFA are essential macronutrients of which there are two non-interchangeable classes, n-6 and n-3. These fatty acids are metabolized to mediators that regulate cardiovascular homeostasis and inflammation. n-6 rich diets tend to be pro-inflammatory and, by comparison diets rich in n-3 PUFA are anti-inflammatory. The difference is explained by the action of n-3 PUFA as competitive inhibitors of enzymes that metabolize n-6 fats and by the lesser biological activities of most n-3 mediators, compared with their n-6 counterparts. Fish oils are a particularly rich source of desirable long chain n-3 PUFA. Fish oil has been used with benefit in the treatment of inflammatory diseases of joints and other organs and tissues. Our long-term studies in rheumatoid arthritis (RA) show that this approach, in conjunction with pharmacotherapy, can be sustained in the long term (>5 years). A potential collateral benefit is reduced risk for adverse cardiovascular events, which are increased in RA. Lack of knowledge amongst physicians of relevant biochemistry, evidence of efficacy, dose response relationships, latency in effect, availability of affordable preparations and tactics for discussing issues efficiently with patients appears to be a barrier to broader clinical use.

Socio-economic development and progressive urbanization has been accompanied by an increase in the rates of cardiovascular disease (CVD) in developing countries. The cause of this increase is multifactorial. It is very likely that changes in lifestyle (particularly diet and physical activity) play an important role. The evidence that some ethnic groups may be at particular risk when exposed to an urban environment suggests that genetic factors may also be involved. This situation is exemplified by the experience of Chinese, Malays and Asian Indians in Singapore, where Asian Indians have three times the rates of myocardial infarction compared to Chinese despite exposure to a similar environment. However, genetic factors do not seem to explain the differences between ethnic groups either. Rather, it appears that a complex interplay of environmental and genetic factors give rise to these ethnic differences. Some genetic variants appear to identify subgroups of the population that are maladapted to an urban lifestyle. For example, a high fat diet is associated with higher serum triglyceride and lower HDL-cholesterol concentrations (a more atherogenic phenotype) in those with the TT genotype at position -514 of the LIPC locus while those with the CC or CT genotypes have lower serum triglyceride and higher HDL-cholesterol concentration (a less atherogenic phenotype) under the same dietary conditions. These types of findings may provide the basis for personalized lifestyle modification therapy that will optimize the benefits of such therapy for the individual concerned..