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Background/objectives: There is an increasing public health concern regarding high salt intake, which is generally between 9 and 12 g per day, and much higher than the 5 g recommended by World Health Organization. Several relevant sectors of the food industry are engaged in salt reduction, but it is a challenge to reduce salt in products without compromising on taste, shelf-life or expense for consumers. The objective was to develop globally applicable salt reduction criteria as guidance for product reformulation., Subjects/methods: Two sets of product group-specific sodium criteria were developed to reduce salt levels in foods to help consumers reduce their intake towards an interim intake goal of 6 g/day, and—on the longer term—5 g/day. Data modelling using survey data from the United States, United Kingdom and Netherlands was performed to assess the potential impact on population salt intake of cross-industry food product reformulation towards these criteria., Results: Modelling with 6 and 5 g/day criteria resulted in estimated reductions in population salt intake of 25 and 30% for the three countries, respectively, the latter representing an absolute decrease in the median salt intake of 1.8-2.2 g/day., Conclusions: The sodium criteria described in this paper can serve as guidance for salt reduction in foods. However, to enable achieving an intake of 5 g/day, salt reduction should not be limited to product reformulation. A multi-stakeholder approach is needed to make consumers aware of the need to reduce their salt intake. Nevertheless, dietary impact modelling shows that product reformulation by food industry has the potential to contribute substantially to salt-intake reduction.

Background/objective: To assess the quality of weight-loss counseling provided by Dutch primary care practice nurses (PNs) to overweight and obese patients including both PNs' compliance with the Five A's Model for behavioral counseling in primary care, and the use of different communication styles. In addition, relationships between PN/patient characteristics (including Five A's) and communication styles will be examined., Subjects/methods: In this observational study, 100 videotaped real-life consultations, collected in 2010/2011, were viewed using an observational checklist. Selection of consultations was based on PNs' registration of patient's complaint. The quality of weight-loss counseling was assessed by the Five A's Model (sequence of evidence-based practice behaviors that are effective for helping patients to change health behaviors) and by PNs' communication styles. Moreover, several PN and patient characteristics were registered. Descriptive statistics and logistic regression analysis were conducted with significance set at P<0.05., Results: PNs most frequently arranged follow-up, assessed the risk and current behavior and advised. However, they rarely assisted in addressing barriers and securing support. For weight or physical activity, most PNs used a motivational communication style. In discussions of nutrition, they mostly used an informational communication style. Moreover, PNs used a combination of communication styles. PN characteristics, including their behavior concerning the Five A's, were stronger related to communication styles than patient characteristics., Conclusions: PNs reasonably complied with the Five A's Model. The quality of PNs' weight-loss counseling might be increased by routinely providing assistance in addressing barriers and securing support, and routinely reaching agreement with collaboratively set goals.

Consumers and patients are unsure of whom to trust for nutritional advice. Although medical doctors are seen as experts in nutrition and their advice is regularly followed, data are lacking on the amount of nutrition education in European medical school curricula. In line with US research, we distributed a survey on required and/or optional nutrition contact hours to medical education directors of all accredited medical schools (N=217) in Western European Union countries (N=14). In total, respondents from 32 medical schools (14.7%) from 10 countries indicated that nutrition education, in some form, was required in 68.8% of schools where, on average, 23.68 h of required nutrition education was provided. The results from this small-scale survey are comparable to a 2010 US study; conversely, European educators were satisfied with the amount of nutrition education. We substantiate the increasing concern over the inadequate amounts of nutrition education provided to medical students in Europe.

Background/objectives: To examine whether dietary interventions promote intakes of fruit, vegetable, fish and lower salt intake were effective in preventing cognitive decline in older people. Dietary factors have been associated with cognitive function in older people., Subjects/methods: A total of 429 non-demented subjects in 14 old age hostels, with an average age of 83 years, were randomly assigned by hostel to have either regular group dietary counselling and menu changes or advice on hostel menu only. Food and salt intakes were estimated at regular intervals by 24-h recall or food record and fasting urinary sodium, respectively. The primary outcome was cognitive decline as defined by an increase in clinical dementia rating scale score. Secondary clinical outcomes were mini mental state examination, category fluency test, body weight, blood pressures and health-related quality of life., Results: At baseline, the intervention group had more men and lower fish intake. When compared with control group, the intervention group had significantly less decline in intakes of fruit and fish. At month 33%, 22.2% and 27.2% of intervention and control group subjects had cognitive decline, respectively (Unadjusted P=0.285, χ² test). There were no significant group changes in secondary clinical outcomes. On subgroup analysis, fewer cognitively normal subjects in intervention group had cognitive decline at month 24 (adjusted P=0.065)., Conclusions: Dietary interventions in older people were effective in maintaining fruit and fish intake, but this did not lead to a significant reduction in cognitive decline.

Background/objectives: To describe the diet quality of a national sample of Australian women with a recent history of gestational diabetes mellitus (GDM) and determine factors associated with adherence to national dietary recommendations., Subjects/methods: A postpartum lifestyle survey with 1499 Australian women diagnosed with GDM ≤3 years previously. Diet quality was measured using the Australian recommended food score (ARFS) and weighted by demographic and diabetes management characteristics. Multinominal logistic regression analysis was used to determine the association between diet quality and demographic characteristics, health seeking behaviours and diabetes-related risk factors., Results: Mean (±s.d.) ARFS was 30.9±8.1 from a possible maximum score of 74. Subscale component scores demonstrated that the nuts/legumes, grains and fruits were the most poorly scored. Factors associated with being in the highest compared with the lowest ARFS quintile included age (odds ratio (OR) 5-year increase=1.40; 95% (confidence interval) CI:1.16-1.68), tertiary education (OR=2.19; 95% CI:1.52-3.17), speaking only English (OR=1.92; 95% CI:1.19-3.08), being sufficiently physically active (OR=2.11; 95% CI:1.46-3.05), returning for postpartum blood glucose testing (OR=1.75; 95% CI:1.23-2.50) and receiving risk reduction advice from a health professional (OR=1.80; 95% CI:1.24-2.60)., Conclusions: Despite an increased risk of type 2 diabetes, women in this study had an overall poor diet quality as measured by the ARFS. Women with GDM should be targeted for interventions aimed at achieving a postpartum diet consistent with the guidelines for chronic disease prevention. Encouraging women to return for follow-up and providing risk reduction advice may be positive initial steps to improve diet quality, but additional strategies need to be identified.

Background/objectives: Living in socioeconomically disadvantaged neighbourhoods is associated with increased risk of a poor diet; however, the mechanisms underlying associations are not well understood. This study investigated whether selected healthy and unhealthy dietary behaviours are patterned by neighbourhood-socioeconomic disadvantage, and if so, whether features of the neighbourhood-nutrition environment explain these associations., Subjects/methods: A survey was completed by 1399 women from 45 neighbourhoods of varying levels of socioeconomic disadvantage in Melbourne, Australia. Survey data on fruit, vegetable and fast-food consumption were linked with data on food store locations (supermarket, greengrocer and fast-food store density and proximity) and within-store factors (in-store data on price and availability for supermarkets and greengrocers) obtained through objective audits. Multilevel regression analyses were used to examine associations of neighbourhood disadvantage with fruit, vegetable and fast-food consumption, and to test whether nutrition environment factors mediated these associations., Results: After controlling for individual-level demographic and socioeconomic factors, neighbourhood disadvantage was associated with less vegetable consumption and more fast-food consumption, but not with fruit consumption. Some nutrition environmental factors were associated with both neighbourhood disadvantage and with diet. Nutrition environmental features did not mediate neighbourhood-disadvantage variations in vegetable or fast-food consumption., Conclusions: Although we found poorer diets among women living in disadvantaged neighbourhoods in Melbourne, the differences were not attributable to less supportive nutrition environments in these neighbourhoods.

This report describes the European Nutrition Leadership Programme (ENLP), an annual one week seminar aimed at nutrition scientists starting out on their careers as future leaders in the field of nutrition. It marks the 15th anniversary of the programme which is designed to teach leadership, communication, team building and networking skills. The seminar is currently organised by the University of Wageningen with support from the food industry and a network of European universities. It is held each spring in Luxembourg and has generated an active alumni network of several hundred nutrition scientists since it first began in 1994. www.enlp.eu.com

Objectives: To analyze demographic, health-related behaviors, eating habit and knowledge associated with vegetable intake., Methods: Secondary analyses using the dataset from the National Health and Nutrition Survey 2003. Food intake data measured by the food-weighing method in one-day and a questionnaire assessed the dietary intake and health-related behaviors, eating habit and knowledge. This study was made in Japan. The data of 1742 men and 2519 nonpregnant/nonlactating women, aged 20-69 years, energy intake between percentiles 1 and 99 were included. Vegetable intake was analyzed according to the Japanese vegetable recommendation (>or=350 g/day) after age adjustment., Results: Average of VI was 307 g/day in men and 297 g/day in women. Only 35% of men and 31% of women met the recommended amount of vegetable intake. Japanese from city areas, aged 60-69 years, had the highest vegetable intake and subjects from metropolitan areas had the lowest vegetable intake. Depending on the age groups, risks for low vegetable intake in Japanese were found in subjects with skipping meals, alcohol intake and history of smoking., Conclusions: To increase vegetable intake, it is necessary to provide more nutritional education and lifestyle-related diseases education.

Background: Socio-economic factors may affect diet quality, perhaps differentially across gender and ethnicity. The mechanism of this association is still largely unknown., Objectives: We examined the independent effects of socio-economic status (SES), perceived barrier of food price (PBFP) and perceived benefit of diet quality (PBDQ) on diet quality indicators and indices (DQI(j,k)), across gender and ethnicity. Additionally, we estimated the mediation proportion of the effect of SES on DQI(j,k) through PBFP and PBDQ., Methods: Data from two cross-sectional surveys, the Continuing Survey of Food Intakes by Individuals (CSFII) and Diet and Health Knowledge Survey (DHKS) 1994-96 were used. Our sample consisted of 4356 US adults aged 20-65 years. With principal components analysis, SES (an index) was measured using household income per capita and education, and PBDQ was measured using an 11-item scale. PBFP was defined as the ratio of importance of food price score relative to nutrition. DQI(j,k) were assessed by a set of indicators and two indices including the Healthy Eating Index., Results: The associations between SES, PBFP, PBDQ and DQI(j,k) varied significantly across gender and ethnic groups. PBFP acted as a mediator in the association between SES and selected DQI(j) indicators, namely energy, fat intake, sodium and simple sugar consumption (mediation proportion >10%), but not PBDQ., Conclusions: SES, PBFP and PBDQ all affect dietary intake, and vary by ethnicity and gender. Positive effect of SES on DQI(j,k) may be mediated by PBFP but not PBDQ which is an independent protective factor. Nutrition education is important to promote healthy eating.

Objective: (1) To develop nutrition education for professionals in dementia wards. (2) To evaluate the effects of education and determine the outcome of the education on the nutrition of aged residents., Design: Educational intervention with before and after measurements. Both the learning outcomes of the professionals and the effect on the aged residents were assessed., Setting: Nursing home residents in dementia wards and professionals., Subjects and Methods: Twenty-eight professionals completed half-structured feedback questionnaires that were analysed quantitatively and qualitatively. Assessments of 21 residents' energy and nutrient intake and 19 residents' nutritional status with the MNA before and after the education., Results: The learning process included six half-day training sessions. The professionals learned to use and interpret the MNA and detailed food diaries. Keeping the food diaries and analysing them in multi-professional teams was experienced as the main source for learning insights. After calculating the diets and discussing with others, professionals felt easier about responding to the nutritional problems of the residents. After 1 year, the residents' mean energy intake had increased 21% from 1230 to 1487 kcal. Before the education none but after 1 year 16% had a good nutritional status according to the MNA., Conclusions: We used the constructive learning theory to educate professionals. Keeping and analysing food diaries and reflecting on nutritional issues in small group discussions were effective training methods for professionals. The education had positive effects on the nutrition of the residents in dementia wards.

Objective: To examine the long-term effects of the 'Cretan Health and Nutrition Education Program' on blood pressure., Subjects: A representative population of 176 pupils (85 from the intervention schools and 91 from the control schools)., Design: Blood pressure, dietary, anthropometrical and physical activity data were obtained at baseline (academic year 1992-1993) and at follow-up examination (academic year 2001-2002)., Results: The findings of the current study revealed that the increase over the 10-year period in systolic (SBP) and diastolic blood pressure (DBP) was higher in the control group (CG) than in the intervention group (IG) (P=0.003 and P<0.001 respectively). Regarding dietary indices, the IG were found to have a significantly higher intake of potassium (P=0.018) and magnesium (P=0.011) compared to the CG. Furthermore, the decrease in body mass index (BMI) z-score observed in the IG was found to differentiate significantly from the increase observed in the CG (P=0.042). On the contrary, the increase in leisure time, moderate to vigorous physical activities (MVPA) observed in the IG, was found to differentiate significantly from the decrease observed in the CG (P=0.032). Intervention's effect on SBP was mediated by changes in MVPA (beta=-0.20, P=0.030) and BMI (beta=0.19, P=0.048). Similarly, intervention's effect on DBP was mediated by changes in MVPA (beta=-0.18, P=0.048), BMI (beta=0.26, P=0.007) and magnesium intake (beta=-0.20, P=0.048)., Conclusion: The findings of the current study are encouraging, indicating favorable changes in blood pressure, micronutrients intake, BMI and physical activity over the 10 years of follow-up and 4 years after program's cessation, thus providing some support for the effectiveness of school-based health education programs in successfully tackling certain chronic disease risk factors early in life.

Objective: To investigate whether individual counselling on diet and physical activity during pregnancy can have positive effects on diet and leisure time physical activity (LTPA) and prevent excessive gestational weight gain., Design: A controlled trial., Setting: Six maternity clinics in primary health care in Finland. The clinics were selected into three intervention and three control clinics., Subjects: Of the 132 pregnant primiparas, recruited by 15 public health nurses (PHN), 105 completed the study., Interventions: The intervention included individual counselling on diet and LTPA during five routine visits to a PHN until 37 weeks' gestation; the controls received the standard maternity care., Results: The counselling did not affect the proportion of primiparas exceeding the weight gain recommendations or total LTPA when adjusted for confounders. The adjusted proportion of high-fibre bread of the total weekly amount of bread decreased more in the control group than in the intervention group (difference 11.8%-units, 95% confidence interval (CI) 0.6-23.1, P=0.04). The adjusted intake of vegetables, fruit and berries increased by 0.8 portions/day (95% CI 0.3-1.4, P=0.004) and dietary fibre by 3.6 g/day (95% CI 1.0-6.1, P=0.007) more in the intervention group than in the control group. There were no high birth weight babies (>or=4000 g) in the intervention group, but eight (15%) of them in the control group (P=0.006)., Conclusions: The counselling helped pregnant women to maintain the proportion of high-fibre bread and to increase vegetable, fruit and fibre intakes, but was unable to prevent excessive gestational weight gain.

Objective: The aim of this study was to examine consumers' readiness to change to a plant-based diet., Design: Mail survey that included questions on readiness to change, eating habits and perceived benefits and barriers to the consumption of a plant-based diet., Setting: Victoria, Australia., Subjects: A total of 415 randomly selected adults., Results: In terms of their readiness to eat a plant-based diet, the majority (58%) of participants were in the precontemplation stage of change, while 14% were in contemplation/preparation, and 28% in action/maintenance. Those in the action/maintenance stage ate more fruit, vegetables, nuts, seeds, whole-meal bread, and cooked cereals than those in earlier stages. There were statistically significant differences in age and vegetarian status between the stages of change, but not for other demographic variables. There were strong differences across the stages of change with regard to perceived benefits and barriers to plant-based diets. For example, those in action/maintenance scored highest for benefit factors associated with well-being, weight, health, convenience and finances, whereas those in the precontemplation stage did not recognise such benefits., Conclusions: These findings can be utilised to help provide appropriate nutrition education and advertising, targeted at specific stages of change. For example, education about how it is possible to obtain iron and protein from a plant-based diet and on the benefits of change, in addition to tips on how to make a gradual, easy transition to a plant-based diet, could help progress precontemplators to later stages., Sponsorship: Australian Research Council.

The current study examines the long-term effects of a school-based 'Health and Nutrition Education programme' on body mass index (BMI) changes and the prevalence of overweight. The intervention group consisted of all pupils registered in the first grade of two counties of the island of Crete in 1992, while all pupils registered in a third county formed the control group. For evaluation purposes, a representative sample was examined at baseline (1992) following the 6-y intervention (1998) and 4 y after the programme's cessation (2002). The data presented here are based on pupils with full anthropometrical data in all three examination periods (284 intervention group pupils and 257 control group pupils). Former intervention group pupils had lower average BMI (by 0.7 kg/m2, s.e. 0.28, P = 0.019) at the 10-y follow-up compared to the control group subjects, while no differences were detected in the prevalence of obesity between the two groups. The findings of the current study indicate that the beneficial effects of the programme on pupils' BMI continue, to an extent, 4 years after its cessation. However, the lack of significant differences in the prevalence of overweight between the two groups indicates that the effects of the intervention may not be equally distributed in the population, with greater effects in certain subgroups and less or none in others.

Objective: To determine whether General Practitioners (GPs) consider or provide nutrition counselling for hypertension, diabetes, lipid disorders, ischaemic heart disease (IHD), overweight or obesity, and whether GPs include assessment of the patient's usual diet, assessment of the patient's readiness to change their diet, provision and discussion of nutrition leaflets when counselling., Design: A self-completed questionnaire., Setting: New South Wales, Australia., Subjects: A total of 399 GPs were surveyed using a division mailing list., Methods: Questionnaires were distributed in May 2004 with two reminders provided at four-weekly intervals., Results: Of the 399 GPs, 28 no longer practiced at the address while nine were on extended leave. Of the remaining 362, 50% responded, 5% declining to participate, while 163 (45%) completed the questionnaire. GPs were less likely to strongly agree to consider nutrition for hypertension (37%), IHD (61%) and overweight (68%), than diabetes (86%), lipid disorders (82%) and obesity (83%). They were also less likely to strongly agree to provide nutrition for hypertension (22%), IHD (46%) and overweight (45%), than diabetes (79%), lipid disorders (71%) and obesity (68%). In total, 97% of GPs provided some nutrition counselling, with 66% 'often' assessing the patients diet and 59% 'often' assessing the patient's readiness to change their diet. In total, 45% were unaware of stage of change behaviour theory. A total of 85% used nutrition leaflets and 59% 'often' discussed these with their patients., Conclusions: Determining what are the barriers to nutrition counselling for hypertension, IHD and overweight is urgently needed. Educating GPs on stage of change behaviour theory could increase the efficacy of the counselling provided.

Objective: To assess the nutrition communication styles of Dutch family doctors and in particular to assess its psychosocial and sociodemographic correlates., Design: A cross-sectional study in which a representative sample of 600 Dutch family doctors completed a questionnaire., Setting: The survey was conducted in October and November 2004 in the Netherlands., Subjects: A total of 267 family doctors completed the questionnaire (response rate 45%)., Methods: Principal component factor analyses with varimax rotation were performed to construct factors. Cronbach's alpha was used as an index of reliability. Our hypothetical model for nutrition communication style was tested using multiple regression analysis, combining the forward and backward procedures under the condition of the same results., Results: Many family doctors felt at ease with a motivational nutrition communication style. The main predictor for motivational nutrition communication style was task perception of prevention (26%). Some individual and environmental correlates had an additional influence (explained variance 49%). Other styles showed explained variances up to 57%. The motivational style was the best predictor for actual nutrition communication behaviour (35%), while the confrontational style was the best predictor for actual nutrition communication behaviour towards overweight (34%)., Conclusions: In contemporary busy practice, family doctors seem to rely on their predominant nutrition communication style to deal with standard situations efficiently: for the majority, this proved to be the motivational nutrition communication style. Moreover, family doctors used a combination of styles. This study suggests that family doctors behave like chameleons, by adapting their style to the specific circumstances, like context, time and patient. If family doctors communicate about nutrition in general, they select any of the five nutrition communication styles. If they communicate about overweight, they pick either the confrontational or motivational style.

The potential effectiveness of personalized nutrition communication through the Internet is promising in terms of addressing personal relevance, flexibility, interactive options and amount of people that can be reached. However, little research on the contribution to behaviour change has been done. The MyFood program at Wageningen University aims at providing insight into strategies to implement personalized nutrition communication through interactive tools. In this article we present the framework for research on social acceptance of personalized nutrition communication through interactive computer technology as part of the MyFood program.

Every year 7000 people die from obesity and another 13,000 people die by wrong diets in The Netherlands. Part of this problem can be solved when the communication between general practitioners (GPs) and patients about nutrition and diets improves. There are four activities that can contribute greatly to the communication between GPs and their patients. (1) GPs can ask nonjudgemental questions that help to understand their patients' perspective on the illness, its causes and possible treatments. (2) GPs can listen carefully to their patients' replies and try to pick up clues to their understanding as well as their ability to adhere to a recommended treatment. (3) GPs can work with patients and family members to set realistic and achievable goals for behavioural change. (4) GPs can involve their patients in active problem solving. The role that practitioners play in changing patients' behaviour to healthy lifestyles is more similar to a coach. They should be along the sideline, empowering patients, helping them develop their own healthy lifestyles. When GPs apply these principles in daily practice, they will find out that they can effectively influence the nutrition patterns of their patients.

Lifestyle modifications, including dietary and physical activity, are treatments for many chronic health conditions. Therefore, there is continued interest in improving the quantity and quality of nutrition information provided to the patient by the physician. This paper reviews the evidence to support motivational interviewing and other similar strategies for nutrition communications. Limited but positive data were found.

The Arbor Clinical Nutrition Updates (ACNU) is a weekly electronic nutrition journal for health professionals. Each issue summarises several recent clinical research papers appearing in the general medical and nutrition literature and which deal with a common nutrition topic. A commentary is added on how this research fits in with previous work, and what it all means for the practising clinician. ACNU is the world's most widely read electronic nutrition publication, with over 100,000 largely health-professional readers in 186 countries. It is published in nine languages and distributed by email without charge in both plain text and Acrobat formats. ACNU utilises a number of the Internet's unique characteristics to facilitate broad reach, currency and active reader feedback. This, together with its brevity and summarising format, helps to maintain its relevance to the nutrition education needs of health professionals, particularly those in clinical practice, and to overcome the factors most commonly reported by health professionals as obstacles to their greater adoption of evidence-based medicine. ACNU is intended to be a collaboration with the primary research journals to extend the reach of new nutrition research findings to a wider community of researchers, academics and clinicians than each journal might otherwise reach individually. As such, ACNU utilises the Internet to promote the goals of open-access publishing and evidence-based medicine.

Objective: To review the possibilities of using the Internet and especially the World Wide Web (WWW) in nutrition education., Results: A healthy existence is partly dependent on dietary behaviours. One way to promote health-promoting dietary habits is nutrition education. In the last decades several potentially important new channels for health communication and nutrition education have emerged, with the Internet and its WWW as the most striking example. The introduction and growth of the WWW has enabled swift and inexpensive distribution of nutrition education expertise and materials. Furthermore, the WWW has also been used for tailoring nutrition education to the personal characteristics of the user. Only few studies have investigated the effects of generic web-based nutrition education, while web-based computer-tailored nutrition education has been studied in randomised controlled trials, with promising but mixed results. Two important challenges for web-based nutrition education interventions are to realise sufficient exposure and to ensure sufficient source reliability and credibility., Conclusions: Next to the great opportunities, there are many challenges for web-based nutrition education. Some evidence for effects of web-based computer-tailored nutrition education has been reported, but more research is needed to obtain evidence for the effectiveness in real-life situations.

This paper was based on collaborative research efforts from Wageningen University and the University Medical Centre St Radboud in The Netherlands and describes the rationale for web-based nutrition counselling applications in general practice as well as some of the frequently used models and theories (predominantly the Stages of Change Model). General practitioners can play an important role in cardiovascular risk reduction by giving nutrition counselling to patients at elevated cardiovascular risk. Unfortunately, general practitioners perceive barriers that may limit their nutrition counselling practices. Some of these barriers may be overcome using computer and Internet technologies. Computerized reminders for preventive services, and websites with reliable high-quality information may prove to be valuable additions to usual care. Cooperation with dietitians may also lead to improvements in nutrition counselling in general practice. For example, general practitioners could use their unique position to create awareness and motivation among patients. They could subsequently refer motivated patients to dietitians for detailed personal dietary advice.

Community-based interventions have increasingly received attention since researchers and public health professionals have come to acknowledge the importance of an environment that makes the healthy choice the easy choice. All stakeholders including the target community are involved to achieve changes in legislation, in people's social and physical context, and in individual characteristics that support healthy diets and other lifestyles. Some early large-scale community-based heart health interventions showed promising results. The Stanford Five City Project, for example, showed net improvements in knowledge of coronary heart disease risk factors of approximately 12%. Net declines in smoking prevalence (14%), cholesterol (2%), and systolic (3%) and diastolic (5%) blood pressure were also observed. Most later studies did not replicate these findings and it was therefore suggested that community-based interventions, which require substantial commitment and resources, may be less effective than approaches targeting high-risk groups. We present the rationale and theories for community-based interventions, and then elaborate on the methodological challenges in the design and the outcome and process evaluation of community-based interventions. We provide an overview of some of the evidence on the effectiveness of community-based heart health interventions and conclude with the perspectives for community-based interventions in future research and practice.

Background: Research has shown that especially pregnant women, and also women with a wish for a child, have increased nutrition awareness. Seeking nutrition information seemed to be an important determinant for nutrition awareness. However, little research has been carried out about nutrition-related information-seeking behaviours before and during pregnancy., Objective: This study aimed to explore nutrition-related information sources, nutrition information-seeking behaviours and motives for seeking nutrition information before and throughout the course of pregnancy., Design: Data were collected by means of retrospective in-depth face-to-face interviews of 1 h with five groups of 12 women: women with a child wish, women in their first, second and third trimester of the first pregnancy and women in their first trimester of the second pregnancy. Women were mainly selected via midwifery practices. The interviews took place at conference rooms or at the respondent's home. Qualitative data were analysed with the software program NUD(*)IST (QSR, Melbourne). This was based on the research objectives and relevant text segments of transcripts., Results: Women with a child wish generally sought little nutrition information because they were not pregnant yet. Information sources were the Internet (anonymous) and the social environment (models). In relation to the manifestation of nutrition-related information-seeking behaviours during first-time pregnancies, three groups of women could be distinguished: (1) women who feel like a mother from the moment they know that they are pregnant, (2) women who feel like a mother later in pregnancy and (3) women who do not feel like a mother yet. Each group had its own specific information-seeking behaviour. Important information sources of the first group were the Internet (anonymous and up to date), books (extended) and midwives (expert) during the first trimester; the 9-month calendar (fun and tips), friends (experienced) in the second trimester; and friends (information on breastfeeding) in the third trimester. Information sources of the second group of women were mainly brochures provided by the midwife and the midwife herself. The third group of women mainly relied on their own common sense. Second-time pregnant women mainly relied on their experience, the midwife and books for specific questions., Conclusions: Pregnant women perceive pregnancy-specific nutrition information as important because it is one of the few things that they can apply in their daily lives to protect the health of the fetus. Nutrition-related information-seeking behaviours mainly were pregnancy specific in character, rather than directed to general nutrition information.

Objective: To improve the management of obese adults (18-75 y) in primary care., Design: Cohort study., Settings: UK primary care., Subjects: Obese patients (body mass index > or =30 kg/m(2)) or BMI> or =28 kg/m(2) with obesity-related comorbidities in 80 general practices., Intervention: The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation., Main Outcome Measures: Proportion of practices trained and recruiting patients, and weight change at 12 months., Results: By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months., Conclusion: The Counterweight programme provides a promising model to improve the management of obesity in primary care.

Objective: We investigated the nutritional, cognitive and functional status in residents of two service-flat (SF) complexes and the effects of a nutrition education programme for care staff., Design: Controlled nonrandomised study., Setting: Two SF complexes, that is community-assisted accommodation., Subjects: Of 115 eligible SF residents, 80 subjects participated (age 83+/-7 y, 70% women)., Intervention: The nutritional status was assessed using body mass index (BMI, kg/m(2)), subjective global assessment (SGA), serum concentrations of albumin, insulin-like growth factor-I (IGF-I) and vitamin B(12). Cognitive and functional status were evaluated using the Mini Mental State Examination (MMSE, 0-30 points, <24 points indicates impaired cognition) and the Katz activities of daily living (ADL) index, respectively. Two assessments were made with a 5-month interval. At the start, a 12-h education programme was given to the staff at one of the SF complexes., Results: At baseline, the means of BMI and the biochemical nutritional indices were normal, whereas one-third had BMI <22 kg/m(2) and one-fourth had lost > or =10% of previous weight. According to SGA, 30% demonstrated possible or serious malnutrition. The median MMSE was 23 points (19.5-26.5, 25-75th percentile). Nearly 70% were ADL-independent. At the 5-month follow-up there were no differences in the nutritional and cognitive status of the residents. The nutritional knowledge of the staff improved slightly (P<0.05) at both SF complexes (NS between groups)., Conclusions: Around one-third of SF residents appeared to be at nutritional risk. Five months after a 12-h staff nutrition education programme, no objective changes were seen in the nutritional status of the SF residents.

Objective: To investigate the short- and medium-term (ie, at 1-y follow-up) effects of a hospital-based body weight reduction (BWR) program lasting 3 weeks in severely obese individuals., Design: Longitudinal, clinical intervention study entailing energy-restricted diet, tailored aerobic-strength exercise, psychological counselling and nutritional education during a 3-week period followed by 49 weeks of indirect supervision at home., Subjects: In all, 45 women and 19 men aged 30.2 +/- 7.2 y (mean +/- s.d.) with severe obesity (BMI: 41.3 +/- 4.3 kg/m(2)), classified as weight losers (final < initial weight) and regainers (final> or =initial weight)., Interventions: Body composition, physical performance and cardiovascular risk factors before and after the BWR program and at follow-up., Results: The large majority of the experimental subjects obtained a clinical success after the 1-y period, and the rate was higher in females (n = 37/45, ie, 82.2%) than in males (n = 11/19, ie, 57.9%). At follow-up, weight losers had higher percent fat-free mass, muscle strength, HDL-cholesterol and self-reported physical activity level and lower total cholesterol and glucose levels than weight regainers (P < 0.05-0.01). Males displayed significantly larger fat-free mass losses than females at post-BWR and at follow-up. CONCLUSIONS A 3-week hospital-based integrated BWR program resulted in a high rate of clinical success in severely obese individuals at 1-y follow-up (particularly in females), that was associated with increased levels of self-reported physical activity and improved muscle strength and lipid profile. Further research is needed to establish the long-term effects (ie, at 2-5 y) associated to this treatment.

Objective: For more effective nutrition communication, it is crucial to identify sources from which consumers seek information. Our purpose was to assess perceived relevance and information needs regarding food topics, and preferred information sources by means of quantitative consumer research., Design: Based on qualitative studies, a quantitative questionnaire was developed and administered in face-to-face interviews., Subjects: The study population consisted of Dutch adults aged 18-80 y. A stratified sample of 923 adults was taken from the GfK ScriptPanel; 603 respondents completed the questionnaire., Results: Despite high perceived relevance of food topics regarding dietary guidelines (55-78%), most respondents indicated that they did not want more information about these topics (71-74%). Furthermore, our study revealed information needs regarding safety- and health-related food topics (up to 77% in some subgroups). Differences in perceived relevance and information needs were found in subgroups based on gender, age, perceived weight and socioeconomic status. Education offices of the food sector and the family doctor were mentioned for most food topics, who ranked among the highest regarding perceived reliability, perceived expertise, clearness and accessibility., Conclusions: With respect to five food topics (losing weight, sports and nutrition, lowering cholesterol, carbohydrates and food composition), interested subgroups should receive tailored information. For other groups and food topics, a population-wide strategy should suffice, utilising the preferred information source. If people who are not yet interested become interested through a life event, information on demand can be put into action., Sponsorship: Dutch Dairy Association., (Copyright 2004 Nature Publishing Group)

Objective: New findings, that relate poor foetal growth to long-term outcomes, highlight the need to understand more about the nature of women's diets before and during pregnancy. This study examines the influence of sociodemographic and anthropometric factors on the quality of the diets of young women in the UK., Design: Diet was assessed by an interviewer-administered food frequency questionnaire. A single diet score was calculated for each woman using the first component defined by principal components analysis., Setting: Southampton, UK., Subjects: A total of 6125 non pregnant women aged 20-34 y., Results: The diets of women with low diet scores were characterised by low intakes of fruit and vegetables, wholemeal bread, rice and pasta, yogurt, and breakfast cereals, but high intakes of chips and roast potatoes, sugar, white bread, red, and processed meat and full-fat dairy products. Educational attainment was the most important factor related to the diet score. In all, 55% (95% CI 50-59%) of women with no educational qualifications had scores in the lowest quarter of the distribution, compared with only 3% (95% CI 2-4%) of those who had a degree. Smoking, watching television, lack of strenuous exercise, and living with children were also associated with lower diet scores. After taking these factors into account, no other factor including social class, the deprivation score of the neighbourhood, or receipt of benefits added more than 1% to the variance in the diet score., Conclusions: Poor achievement at school defines a substantial group of women in the UK who may be vulnerable. Many of these women have poor diets that are not simply a result of the level of deprivation in their neighbourhood, or of living at a level of poverty that entitles them to benefits. We suggest that it is a priority to identify and to address the barriers that prevent these women from improving the quality of their diets., Sponsorship: The study was funded by the Dunhill Medical Trust, the University of Southampton and the Medical Research Council.

Objective: To evaluate a nutrition education intervention using a radio programme in the Canary Islands., Design: Pre-post quasiexperimental epidemiological study., Setting: Free living population in the Canary Islands, Spain., Subjects: A sample of 1753 individuals out of 6846 volunteers participating in the educational programme., Interventions: A 6-week radio programme consisting of 12 didactic units with supplementary print support material and four optional attendance-based healthy cooking seminars., Results: At 2 months postintervention, an increased consumption of pulses, salads, fruits and juices, cereals and fish, and a decreased consumption of meat, sausages, pastries, French fries, bread and eggs were observed.

Health promotion from the early stages in life by fostering healthy eating practices and regular physical activity has the potential for a major impact on health and well-being during childhood and later stages in life.School-based nutrition education should consider the needs and interests of students, teachers and the school. Educational strategies include efforts to increase health awareness, communication and skill building. Previous literature reviews identified educational strategies directly relevant to a behavioural focus and theory-driven strategies among the elements conducive to successful programmes. Other features that contribute to gain effectiveness are the provision of adequate time and intensity for the intervention, involvement of families, particularly for younger children, and incorporation of self-assessment and feedback in interventions for older children. School meals provide a valuable opportunity for nutrition education. The emphasis on environmental and behavioural factors in successful school-based physical activity and nutrition interventions highlights the importance of involving parents and other community members.

Objective: To see whether mortality among men with angina can be reduced by dietary advice., Design: A randomized controlled factorial trial., Setting: Male patients of general practitioners in south Wales., Subjects: A total of 3114 men under 70 y of age with angina., Interventions: Subjects were randomly allocated to four groups: (1) advised to eat two portions of oily fish each week, or to take three fish oil capsules daily; (2) advised to eat more fruit, vegetables and oats; (3) given both the above types of advice; and (4) given no specific dietary advice. Mortality was ascertained after 3-9 y., Results: Compliance was better with the fish advice than with the fruit advice. All-cause mortality was not reduced by either form of advice, and no other effects were attributable to fruit advice. Risk of cardiac death was higher among subjects advised to take oily fish than among those not so advised; the adjusted hazard ratio was 1.26 (95% confidence interval 1.00, 1.58; P=0.047), and even greater for sudden cardiac death (1.54; 95% CI 1.06, 2.23; P=0.025). The excess risk was largely located among the subgroup given fish oil capsules. There was no evidence that it was due to interactions with medication., Conclusions: Advice to eat more fruit was poorly complied with and had no detectable effect on mortality. Men advised to eat oily fish, and particularly those supplied with fish oil capsules, had a higher risk of cardiac death. This result is unexplained; it may arise from risk compensation or some other effect on patients' or doctors' behaviour.

Objective: To examine the effects of socioeconomic status (SES) on the obesity knowledge of adolescents in six Latin American cities., Design: Data were collected using an anonymous, self-administered questionnaire consisting of demographic questions and a 25-item multiple-choice obesity knowledge test. Test items were clustered under five topics: the fat and calorie content of foods and beverages; weight loss methods; energy expenditure; food preparation methods; and the relationship between obesity and health., Subjects: A total of 1272 ninth grade students from higher and lower SES families were recruited at schools in Buenos Aires, Argentina (n=195); Guatemala City, Guatemala (n=212); Havana, Cuba (n=213); Lima, Peru (n=218); Panama City, Panama (n=195); and Santiago, Chile (n=239)., Results: Mean test scores reflected a low level of obesity knowledge among adolescents from higher and lower SES groups in all six cities. Nevertheless, a trend for higher scores emerged in favor of adolescents from wealthier families. This income effect persisted after controlling for gender and weight status. The weakest knowledge areas among youth from the higher SES groups were food preparation methods and the relationship between obesity and health while those for adolescents from the lower SES groups were the fat and calorie content of foods and beverages and the relationship between obesity and health. Classroom instruction about obesity was generally more available to students from the higher SES groups. The majority of adolescents from both SES groups were interested in learning more about weight loss methods, energy expenditure, and the fat and calorie content of foods and beverages. The topic of least interest was the relationship between obesity and health., Conclusion: These preliminary findings suggest a need for more obesity education programs for adolescents, especially for those living in poverty.

Objective: To promote weight loss in Samoan church communities through an exercise program and nutrition education., Methods: A quasi-experimental design was used to assess weight change, over 1 y, in cohorts of people aged 20-77 y from three non-randomised Samoan church communities (two intervention, n=365 and one control, n=106) in Auckland, New Zealand. The intervention churches received aerobics sessions and nutrition education about dietary fat., Results: Baseline body mass index for the intervention and control churches was (mean+/-s.e.) 34.8+/-0.4 and 34.3+/-0.9 kg/m(2), respectively. The intervention churches lost an average of 0.4+/-0.3 kg compared to a 1.3+/-0.6 kg weight gain in the control church (P=0.039, adjusted for confounders). The number of people who were vigorously active increased by 10% in the intervention churches compared to a 5% decline in the control church (P=0.007). Nutrition education had little apparent impact on knowledge or behaviour., Conclusion: Samoan communities in New Zealand are very obese and have high rates of annual weight gain. A community-based intervention program arrested this weight gain in the short term.

Objective: Obesity prevention is necessary to address the steady rise in the prevalence of obesity. Although all experts agree that obesity prevention has high priority there is almost no research in this area. The effectiveness of different intervention strategies is not well documented. There is also no structured framework for obesity prevention., Design: Based on (i) our current and limited knowledge and (ii) the idea that prevention of childhood obesity is an effective treatment of adult obesity, the Kiel Obesity Prevention Study (KOPS) was started in 1996. Concept, intervention strategies and first results of KOPS are reported in this paper. KOPS is an ongoing 8 y follow-up study. We first enrolled a large scale cohort of 5 to 7-y-old children, providing sufficient baseline data. KOPS allows further analyses of the role of individual risk factors as well as of long-term effectiveness of different intervention strategies., Results: From 1996 to 1999 a representative group of 2440 5 to 7-y-old children was recruited (ie 30.2% of the total population of 5 to 7-y-old children examined by the school physicians) and a full data set was obtained from 1640 children. Of the children, 340 (20.7%) were considered as overweight and obese, 1108 children (67.6%) were normal weight, and underweight was found in 192 children (11.7%). Of the normal-weight children, 31% or 346 (21.1% of the total population) were considered to have a risk of becoming obese. Cross-sectional data provided evidence that (i) there is an inverse social gradient in childhood overweight as well as health-related behaviours and (ii) parental fatness had a strong influence on childhood overweight. We observed considerable changes in health-related behaviours within 1 y after combined "school-" and "family-based" interventions. Interventions aimed to improve health-related behaviours had significant effects on the age-dependent increases in median triceps skinfolds of the whole group (from 10.9 to 11.3 mm in "intervention schools" vs from 10.7 to 13.0 mm in "control schools", P<0.01) as well as in percentage fat mass of overweight children (increase by 3.6 vs 0.4% per year without and with intervention, respectively; P<0.05)., Conclusion: First results of KOPS are promising. Besides health promotion, a better school education and social support seem to be promising strategies for future interventions.

Objective: We describe the design and baseline data of the Prevention Education Program (PEP), a home-based and family oriented intervention program, aimed to assess and improve cardiovascular risk factors in school children and their families during an intervention period of 10 y., Design and Methods: At study entry all participants were randomized either to an intervention group (screening and intervention program) or to a control group (risk screening, general advice). Cardiovascular risk factors (hypertension, elevated lipids, smoking, obesity) as well as dietary behaviour are evaluated yearly using structured interview, physical examination, laboratory analysis, and seven-day dietary protocol., Results: During the years 1993-1998, 3547 adults (age 36.2+/-7 y) and 3495 children (age 6.5+/-2 y) were recruited. Adults show a high prevalence of risk factors: hypertension 21%; active smoking 39%, elevated LDL-cholesterol 19%; and obesity 42%. Children exhibit these risk factors in comparable frequency: hypertension 20%; passive smoking 44%; elevated LDL-cholesterol 17%; and obesity 19%. The analysis of the dietary protocols (1926 adults, 1569 children) shows that both generations adhere to a diet exceeding the recommended fat intake (adults 38% of total energy, children 38%), while carbohydrate intake (adults 43% of total energy intake, children 50%) is reduced compared to NCEP-(step I)-guidelines., Conclusion: The finding, that children show a prevalence of risk factors which is comparable to that found in adults, supports the need for an early beginning of intervention. Since both generations adhere to an unhealthy diet which contributes to cardiovascular risk, dietary intervention may be a promising method in primary prevention of cardiovascular risk.

Objective: The goal of the present study was to identify covariates and predictors of post-treatment weight reduction. To clarify the impact of the individual factors, we compared "winners" (losing more than 2 BMI-points in the follow-up period) with "losers" (gaining more than 2 BMI-points in the same time)., Design: In a questionnaire based study, we evaluated the psychological impact on eating behavior, general psychopathology and depressive symptoms at three points in time: three months prior to admission (T0), at the beginning (T1) and at the end of in-patient treatment (T2) as well as 6, 12, and 18 months after treatment (T3-T5)., Subjects: One hundred and thirty eight obese patients (BMI<30 kg/m(2)) were recruited to the study. All patients participated in a multimodal in-patient treatment program over a period of 10 weeks. Treatment elements were cognitive behavioral therapy, movement therapy, and nutritional counseling. The aim of treatment was to regulate food intake, to minimize dysfunctional emotional influences on eating behavior, to enhance physical exercise and to treat comorbid psychiatric disorders. Twenty nine patients (13%) of the initial sample dropped out or were excluded during the treatment and post-treatment period., Results: During in-patient treatment eating behavior improved and body weight decreased considerably in all patients. The weight reduction continued slightly in the follow-up period. Moreover, general psychopathology, depressive symptoms and eating behavior improved and remained stable during follow-up. These benefits were closely related to weight reduction. Neither eating behavior, nor eating related cognition nor psychopathology measured at T0 and T1 predicted long term success at T5. "Winners" as compared to "losers" at follow-up showed less psychopathology, less depressive symptoms and a less disturbed eating behavior. Already at discharge (T2), winners were less prone to eating triggered by external stimuli and reported fewer feelings of hunger. These differences predicted post-treatment weight reduction (T3-T5)., Conclusion: Reported feelings of hunger and the tendency to disinhibited eating behavior measured at discharge were able to predict post-treatment weight reduction in our sample. Patients suffering from a feeling of hunger during in-patient treatment were less likely to show further weight reduction in the follow-up period. Similarly, reduction of "disinhibition" during treatment is a precondition for post-treatment weight loss.

Objectives: Evaluation of the impact of a coronary heart disease prevention program on calcium, magnesium, phosphorus and vitamin D dietary intake in respect of recommended daily allowances in a large Italian rural population., Design: Retrospective analysis of the Brisighella Study dietary data. The Brisighella Study started in 1972 as a longitudinal study on atherosclerosis risk factors., Setting: Brisighella, a rural North Italian village., Subjects: The Brisighella population's dietary habits were monitored from 1980 every 4 h through a dietary record sheet. 1,350 constantly tested subjects were subdivided according to NHI Consensus Conference on Calcium RDA., Intervention: In 1986, the studied subjects were invited to reduce their consumption of animal fats and cholesterol through a Nutrition Educational Program (NEP)., Results: Before NEP, calcium intake was low in each sex and age category: 20-40% of the populatioin had a daily intake < 550 mg. In 1988, among the 1350 subjects who constantly completed the questionnaire (M = 651, F = 699), the mean calcium intake significantly rose in all age categories: M = 1,003 (25-65 y) and 877 ( > 65) mg/24h (P < 0.001 vs 1984); F = 923 (25-50), 860 (51-65) and 767 (> 65)mg/24h (P < 0.05). In 1992, 3y after the NEP conclusion, calcium intake dropped in each sex and age category. The NEP influenced vitamin D, phosphorus and magnesium intakes less., Conclusions: A collective NEP aimed at lowering saturated fats and cholesterol intakes, improves the calcium intake; in order to maintain their efficacy on nutritional habit changes, these programs must become an ongoing item.

The aim of this review is to show how hunger, satiety and appetite can be seen as a central research subject for the social sciences, both as the locus where food consumption is bodily regulated and as the nexus where biology, social praxis and cultural meanings meet and are negotiated by the individual. The number of people developing overweight and obesity is increasing, as is the prevalence of eating disorders and weight preoccupation. These tendencies can be considered as expressions of a polarization of eating habits in modern societies, where lack of control or exaggerated control over eating are still more common phenomena. At the same time the tendencies may be seen as the result of a more general ambivalence in relation to food, which influences the experiences of hunger, satiety and appetite and their regulating effect on food consumption.

Clinical nutrition is concerned with the diagnosis and treatment of diseases that affect the intake, absorption, and metabolism of dietary constituents and with the promotion of health through the prevention of diet related diseases. Adult diseases of clinical nutrition encompass the most common causes of mortality in the developed world and include obesity with its co-morbidities of hypertension, diabetes, dyslipidemias, increased risks of cardiovascular disease, some cancers, and pulmonary failure; intestinal disorders related to inadequate nutrient absorption; eating disorders; and malnutrition associated with chronic illness and surgical trauma. Scientific advances on the relationship of dietary substances to the cellular mechanisms of disease occur with regularity and frequency. Yet, despite the prevalence of nutritional disorders in clinical medicine and increasing scientific evidence on the significance of dietary modification to disease prevention, present day practitioners of medicine are typically untrained in the relationship of diet to health and disease. In the absence of reliable medical advice on nutrition, patients increasingly turn to herbal dietary supplements, costly diet schemes for weight reduction, and other unproved and potentially harmful remedies. Standardization of curricula for nutrition education of medical students and trainees and the provision of knowledgeable clinical nutrition specialist educators and role models in medical institutions is increasingly relevant to the cost-effective integration of nutritional concepts into medical practice.