Nutrition Research Highlights 6|2012

Keeping consumers and stakeholders up to date

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This newsletter is published by the Nutrition & Health Group of the JRC’s Institute for Health and Consumer Protection. Regularly surveying the top nutrition and medical journals, we select the most recent news on nutrition research, relevant to current societal debates or policies. These are then summarized as “News” items or presented as a “View”, comprising an analysis and expert opinion. Enjoy your reading!


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    Coeliac Disease: Alternative wheat instead of wheat alternatives

    Fields of wheatCoeliac disease* is a chronic and immune-mediated intestinal disease, mostly accompanied with maldigestion and malabsorption of nutrients, caused by intolerance to gluten, a protein fraction of wheat, rye and barley. Adherence to a strict gluten-free diet is the only treatment for coeliac disease (1); it requires avoiding foodstuffs based on or containing wheat, rye, barley and their crossbreds as well as oats for some individuals (oats do not contain gluten themselves but are often contaminated with wheat, rye or barely during harvesting, transport, storage and processing). The disease, often under-diagnosed (2), is more common than once though and affects around 1% of the European population with large but unexplained variations between countries (0.3% in Germany to 2.4% in Finland) (3). A gluten-free dietary regime is often costly, difficult to maintain and risks being imbalanced. Eating out, for example is particularly difficult for coeliac people (2). An additional burden in adhering to a strict dietary regime includes exposure to the presence of "hidden" gluten in processed foods that are not gluten based such as processed meat, potato-based processed foods (e.g., French fries, chips), sauces, soups etc. This risk is greatly reduced in the EU since ingredient listing of gluten containing cereals or labelling of the presence of gluten is mandatory since the end of 2005 (4). The food industry has developed a range of products specifically targeted at coeliac people either by removal of gluten from or by replacing gluten containing grains, but low levels of gluten can still be present in those foods. Hence, since January 2012 a Commission Regulation (5) sets clear rules for gluten thresholds and associated labelling: 'gluten-free' means less than 20 mg/kg and 'very low gluten' less than 100 mg/kg gluten in the final food product.

    Wheat is arguable the world's most important cereal crop, partly also due to the particular food technological properties of the main wheat protein gluten, which is also the reason for the wide range of wheat based products as well as the widespread use of wheat flour or gluten in processed foods. Interestingly, quite some research is devoted to finding alternative wheat species and cultivars for consumption by coeliac people, which may seem peculiar since the presence of gluten in wheat is both reason to the success of wheat and the cause of coeliac disease (6). Only very few of the existing wheat species and their cultivars are cultivated by modern societies, and those have been selected specifically for their high yields and protein contents. There are however ancient wheat species, rarely cultivated, that also contain gluten but that appear to be little or non-toxic, suggesting them as alternatives to a strict gluten-free diet (6). The reason for the tolerance of coeliac patients to these species seems to be slight differences in the part of the protein that causes the immune response. As the exact mechanisms in coeliac disease are still not fully understood solid research and clinical tests need to be performed before suggesting alternative wheat cultivars for coeliac people (7). However, should in the future alternatives be identified that offer more food variety to coeliac people, legislators and health professionals will face another challenge: how to communicate that gluten from one wheat source needs to be avoided and gluten from another wheat source needs not? Nevertheless, hope still remains that one day people with coeliac disease will not be restricted to gluten-free products but may freely enjoy traditional foods containing non-toxic gluten, based on alternative wheat varieties. (JW)

     *Coeliac disease can be asymptomatic ("silent") while overt disease symptoms include stomach pain, gas, and bloating, diarrhoea, weight loss, anaemia, oedema, bone or joint pain (1).

    1. Orphanet J of Rare Dis (2006) 1:3

    2. Br Med Bull (2008) 88: 157–170

    3. Ann Med (2010) 42: 587-595

    4. Directives 2000/13/EC and 2003/89/EC

    5. Commission Regulation (EC) No 41/2009

    6. Am J Clin Nutr (2012) 96:1247–1248

    7. Am J Clin Nutr (2012) 96:1339–1345

    Image: Fields of wheat (Wikimedia commons)


    School lessons on fruits and vegetables

    School Fruit SchemeFruits and vegetables are colourful and tasty and are essential components of a healthy diet. Nutritional recommendations suggest having 400g or more of fruits and vegetables per day (1). However, despite their good looks and beneficial properties, the average consumption of fruits and vegetables in the EU27 is quite below this recommendation (2). As part of an effort to promote fruit and vegetable consumption, the European Commission started in 2009 a programme that co-finances the provision of fruits and vegetables to school children in the EU (EU School Fruit Scheme) (3).  The scheme has now been evaluated for the first time (4) and the results are promising; the programme has reached more than 54 000 schools and the number of schools benefiting from it grew significantly from the 1st to the 2nd year. Of course there is room for improvement; for example the evaluation of the scheme reports that in the majority of the member states fruits and vegetables are supplied only once or twice per week, "which can be considered as not sufficient to reach the goals of the programme". Nevertheless, and although it is too early to comment on the long term impacts of the scheme, the EU Member States qualitative evaluation indicates that in the short-term, the School Fruit Scheme has a positive impact in the consumption of fruit and vegetables by children. A more general evaluation of school-based interventions to improve fruit and vegetable intake just published by researchers from Leeds University (5) confirms the potential of these kind of schemes. The researchers conclude that despite lack of strong data, school-based interventions do appear to improve fruit intake (albeit not vegetable intake). Single-component interventions (that rely only on distribution of fruits and vegetables, like the School Fruit Scheme) are less effective than multi-component interventions, (where other tools are used to motivate and engage children and families), however they are easier to implement.

    Back to the EU School Fruit Scheme, its evaluation also pinpointed potential success factors at the school level that are important for increasing consumption of the fruits and vegetables offered. These are for example, offering a wide range of products frequently (min 3x /week) and continuously. We hope these lessons are taken – not only by the pupils eating their fruit and vegetables but importantly by those that can make successful school based schemes happen too! (SC) 

    Mediterranean diet componentsWe have previously discussed the health benefits of the Mediterranean diet on cardiovascular disease and the metabolic syndrome in general. The traditional Mediterranean diet, originating in South European countries, is characterised by high consumption of fruit and vegetables, whole grain and monounsaturated fatty acids from olive oil as well as moderate consumption of fish, poultry and alcohol and low consumption of red meat. Despite its proven benefits the Mediterranean diet in South Europe is being shifted towards the so-called "Western" diet model of high animal protein, high saturated fat and sugar consumption (1). Indeed, a recent article (2) reports that even in its place of birth, the European South, the Mediterranean Diet is not followed by everyone. Bonaccio et al. examined the dietary patterns and risk factors for cardiovascular disease in more than 13.000 citizens in the region of Molise in South Italy and found that it was mostly in households of higher income that there was an adherence to a Mediterranean Diet pattern. Not surprisingly, obesity prevalence was lowest in this group (20%) when compared to the lowest income group, where the percentage of obesity was 36%.Higher education was also associated with a greater adherence to Mediterranean Diet eating patterns.

    While this recent Italian study clearly focuses on a single region of South Italy and extrapolating its results to the rest of the European Mediterranean countries should be done carefully, other studies have also indicated that higher-quality diets are, in general, consumed by the more affluent and educated people (3). The study of Bonaccio et al. suggests that the cost of the Mediterranean diet is one of the factors explaining why people are drifting away from it, and report on various other studies that support this assumption. The authors also argue however, that the economic cost of the Mediterranean diet could be outweighed by the long term health benefits and savings in healthcare that it brings. Of course, consumers do not always behave rationally to maximise their long term benefits...

    To conclude, although the benefits of adhering to a Mediterranean -like diet are clear, this is of limited value on a public health level if this beneficial dietary pattern is not affordable or accessible to all, in particular to the lower socioeconomic groups. Therefore, research priorities must be directed to not only investigate the health aspects of particular diets but also to what social and economical policy interventions are needed to make healthy options available to all. (PM)


      Image: Italian olive oil and Greek vegetable market (Wikimedia commons)



      Sin taxes

      Sin taxesThe latest report of the International Food Information Council Foundation’s 2012 Food & Health Survey (1) indicated that Americans find doing their own taxes simpler than improving diet and health. How about ‘using taxes to improve diet and health’ then? Will it be easier or simpler? 

      "It is believed that taxing foods products on the basis of their nutrient profile could affect price and consumption"

      The question is of particular relevance, given the extended coverage which type of ‘sin’ taxes i.e. taxes on sugar-sweetened beverages, fast food, chocolate etc. have received over the last years, as part of a public health regulatory approach utilising the power of taxation (2). The reasoning behind this type of food taxes is that, as price is one of the most important determinants of food choice, taxing food products on the basis of their nutrient profile (e.g. sugar or fat content) could affect price and consumption. Thus, increasing the price of high fat, salt and sugar foods could lead to a decrease in their consumption at a population level. It is important however to note that the notion of high price - low consumption might not be directly proportionate, and might be dependant on price elasticity* (4, 5). At a European level, a number of EU Member States have already applied or have voiced intentions of applying fiscal measures to food. But the issue is not a simple one; in fact, while some member states did go on to apply such measures, others postponed them and others even introduced taxes to later recall them (3).

      "In Europe, a number of countries have already applied or have voiced intentions of applying fiscal measures to food e.g. taxing sugar or fat"

      In the past year, Hungary has introduced a 'junk food tax' (packaged products with high sugar, salt or caffeine levels.) plus higher tariffs on soft drinks and alcohol with profits been reinvested into health care costs, France introduced a tax on all beverages with added sugar or with artificial sweeteners and Finland restored taxes on sweets and increased taxes on soft drinks (3, 6). Over the last couple of years, a number of other European countries have announced plans to introduce fiscal measures on foods high in fat, sugar and salt; for instance, the Irish Health Minister announced that it is considering a sugar tax on sugar-sweetened drinks. Both the Italian (August 2012) and the Romanian (2010) governments were also looking into a tax on soft drinks and foods high on fats, salt, sugars and additives but their plans were however postponed or did not go through (6). More recently, the UK Prime Minister raised considerations for a fat tax. The latest news comes from France and Russia, where a French Senator made suggestions of France imposing a 300% increase in the tax on palm oil imports, and Russian authorities considering imposing additional tax on 'unhealthy' meat producers and taxes to all fast-food products respectively (6, 7).  

      "Current evidence is not indubitable but does suggest a shift in the consumption towards the desired direction"

      What of the world's first so-called 'fat tax' however? Just over a year ago we reported and discussed on the Danish tax on food products containing more than 2.3% saturated fat with the intention of decreasing consumption levels by 4%. A few weeks ago however, the Danish authorities announced that they are scrapping the fat tax on the basis of it having adverse effects in the economy, inflating food charges and leading Danish consumers to travel across the borders to Germany to buy the same foods without the tax (6).

      "Some call for a two-way fiscal measures i.e. making the healthier option more affordable while making the unhealthy more expensive combined with health promotion measures"

      Interestingly, a recent analysis by Mytton et al. (5) examined the effectiveness of these sort of taxes based on various sources of evidence and research designs and concluded that health-related food taxes can indeed improve health; Similarly, Thow et al. (8) concluded that larger taxes were associated with more significant changes in food consumption, body weight and disease. Thus, we can see that even though current evidence, is not indubitable, it does suggest a shift in the consumption towards the desired direction. We should however be careful the interpretation of the results till more studies and evidence of empirical evaluation of existing taxes is available (5, 8). In fact, others studies are calling for governments to implement appropriate evaluations (9, 10) before claiming that fiscal measures are successful. The acceptability, support and views from the various stakeholders on this type of fiscal measures have to be also considered as they can affect policy implementation and sustainability (11). At the end of the day, taxing foods is a process involving public health, policy makers, the food industry and the consumer. The feeling in the air is that many of the stakeholders 'still need to be convinced of their viability and acceptability when compared with other measures' (12).