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Frailty in older adults is an increasing burden for public health, both globally as well as in The Netherlands. To focus on frailty prevention from a public health perspective, a clear understanding of frailty prevalence is needed.

This contributed volume is based on the "European Core Competences Framework for health and social care professionals working with older people" (ECCF), developed and verified in a unique international cooperation between 26 universities and universities of applied sciences in 25 European countries, part of the European Later Life Active Network (ELLAN). In addition to the framework, the book outlines the necessary qualifications and describes the roles of professionals working with older people in health and social services. It explores healthy ageing for older people from different perspectives and describes the seven roles of health and social care professionals (Expert, Communicator, Collaborator, Organizer, Health and Welfare Advocate, Scholar, and Professional), before going on to define 18 related competences and elaborating them in performance indicators. Beyond the ECCF, the book explains the widely used CanMED role model and puts forward theories to support a client centered and integrated approach on health and social care in order to change attitudes toward older clients and offer better care and support. It also provides health and social care professionals, for example nurses, allied health professionals and social workers with new contextual information and cultural awareness. It gives a voice to students by addressing selected perspectives for professional development. The book includes questions for reflective learning helping to make the book a vital practical instrument for use in the educational context throughout Europe. Europe’s ageing populations represent a major challenge for both public health and social care systems. 18% of the population is 65 years old and over, and this proportion will increase in the coming years. As a result, more and more health and social care professionals will work with older people in different settings – at home, in the community, in hospitals or in long-term care settings. Older people, and especially the frail, face a host of interrelated issues, e.g. cognitive restrictions, functional restrictions, psychosocial problems, multimorbidity, polypharmacy and social isolation. These problems call for an integrated approach to health and social care, which this book supplies. It is intended for health and social care professionals, students and educators, for a better understanding of Europe’s ageing society and of the impact on care and services. Furthermore, the ECCF offers educational institutes a unique resource for curriculum development, education, training and assessment.

In de Volksgezondheid Toekomst Verkenning (VTV) wordt voor het beschrijven van het voorkomen van ziekten en aandoeningen onder andere gebruik gemaakt van gegevens van huisartsgeneeskundige registraties. Een probleem voor VTV is dat de registraties in Nederland, om geheel plausibele redenen, van elkaar verschillen in de doelstelling waarvoor zij zijn opgezet. De consequentie daarvan is dat gebruikte classificatiesystemen, codeerregels en rekenwijzen nogal van elkaar kunnen verschillen en dat gemeten morbiditeit niet op voorhand vergelijkbaar is. Daarom is een vergelijkende analyse tussen de vier belangrijkste huisartsenregistraties gemaakt, zodat een beter inzicht in de betekenis van cijfers uit deze huisartsenregistraties verkregen kon worden. Deze analyse bestond uit drie onderdelen. Ten eerste is een algemene beschrijving van de registratiekenmerken van de vier huisartsenregistraties gemaakt, met speciale aandacht voor prevalentie- en incidentiebepalingen ten behoeve van VTV. Een tweede onderdeel betrof het samenstellen van een tabellarisch overzicht van de empirisch aangetroffen prevalenties en incidenties. Een derde onderdeel betrof de inhoudelijke vergelijking van de registraties per ziekte. Voor de meeste ziekten kon meer inzicht verkregen worden in de betekenis van de cijfers en voor sommige ziekten konden de aangetroffen verschillen in prevalentie en incidentie min of meer verklaard worden. Soms bleken verschillen echter onverklaarbaar groot te zijn. Beschreven zijn enkele alternatieve mogelijkheden voor het presenteren van cijfers uit huisartsenregistraties in VTV. Omdat de bestaande situatie voor VTV verre van optimaal is, wordt ten slotte gepleid voor het verkennen van de mogelijkheden om ten behoeve van VTV-2001 en volgende VTV's tot een beter passende oplossing te komen.

Dit definitie-rapport 'Volksgezondheid Toekomst Verkenning-1997' schetst de uitgangspunten en hoofdlijnen voor de in 1997 op te leveren tweede 'Volksgezondheid Toekomst Verkenning'(VTV). Bij de opstelling is primair uitgegaan van de wensen zoals die door de opdrachtgever naar voren zijn gebracht, maar tevens van de evaluatie van de reacties op VTV-1993 en van de visie van het projectteam VTV op gewenste verbeteringen en aanvullingen. De algemene doelstelling en daaraan gekoppelde functies van het project VTV kunnen als volgt worden samengevat: het geven van een overzicht en analyse van de beschikbare gegevens op het terrein van de volksgezondheid, met expliciete weergave van aanwezige lacunes in de informatievoorziening, teneinde het gezondheidsbeleid behulpzaam te zijn bij de evaluatie van lopend beleid en de voorbereiding van nieuw beleid. Hierbinnen zijn voor VTV-1997 drie hoofdlijnen geformuleerd:a Actualisering van het in 1993 gepresenteerde beeld; hierdoor kunnen ontwikkelingen in de tijd worden gevolgd, en hierin komt tevens de continuiteit van het VTV-proces naar voren (thema 1). b Uitbreiding ten opzichte van VTV-1993 met vijf thema's: (thema 2) gezondheidsverschillen en de gezondheidstoestand van specifieke groepen in de Nederlandse bevolking, (thema 3) het wegen van ziektelast naar ernst, onder meer ten behoeve van de berekening van geintegreerde gezondheidsmaten, (thema 4) de effecten van preventie, (thema 5) de effecten van (medische) zorg, en (thema 6) de consequenties van ziekten voor het zorggebruik en de zorgbehoefte. c Versterking van de integratie ten opzichte van VTV-1993 ten aanzien van de toekomstige ontwikkelingen (thema 7). Hiervoor vormt het hierboven aangeduide materiaal de basis. VTV-1997 beoogt een stap verder te zetten in het gebruik van interactieve simulatiemodellen voor het in beeld brengen van de dynamiek in de tijd van verschillende factoren in hun onderlinge samenhang. Hierbij wordt ook onderzocht waar, middels ingrijpen op determinanten, aanknopingspunten liggen om de gezondheidstoestand te verbeteren of te handhaven. Het conceptuele model zoals gepresenteerd in VTV-1993 blijft het kader voor de ordening, maar is uitgebreid en verder gedetailleerd om de nieuwe thema's te kunnen herbergen. Dit definitie-rapport geeft een verdere uitwerking van de hierboven genoemde thema's, waarbij zo concreet mogelijk is omschreven wat de positionering is in het totaalkader, wat de te bereiken eindpunten zijn, en hoe de te volgen aanpak wordt gezien. Door de keuze van de thema's en hun uitwerking tracht VTV-1997 een grotere bruikbaarheid voor de beleidsvoorbereiding en -evaluatie te bereiken ten opzichte van VTV-1993. Ten aanzien van de werkwijze is voorzien dat evenals bij VTV-1993 veel op expertise van onderzoeksgroepen binnen het RIVM en daarbuiten een beroep zal worden gedaan. Ook is een structuur voor een inhoudelijke kwaliteitsbewaking en toetsing voorgesteld. Tenslotte is een tijdpad aangegeven voor het verdere traject van uitvoering van VTV-1997, waarin de inhoudelijke discussie over deze definitie-studie een voorname plaats inneemt.

Preventie is vooral succesvol als de maatregel gestructureerd wordt aangeboden, zoals dat nu gebeurt bij de bevolkingsonderzoeken (naar borstkanker bijvoorbeeld) en het Rijksvaccinatieprogramma. Bij een dergelijk programmatisch aanbod zijn de behandelingen voor zover bekend effectief, de kosten en baten in balans, en wordt een groot deel van de doelgroep bereikt. Een groot deel van preventie in de zorg wordt echter niet programmatisch aangeboden. Dat aanbod is sterk versnipperd: een klein en selectief deel van de doelgroep wordt bereikt en de effectiviteit is vaak nog niet aangetoond. Aangenomen wordt dat de effecten van preventie in de zorg sterk verbeteren bij een programmatisch aanbod. Wel moet dan eerst goed worden onderzocht of de interventie op deze manier echt werkt. Het is daarbij raadzaam om niet alleen het gezondheidseffect van de maatregel te onderzoeken, maar ook de maatschappelijke effecten zoals vermindering van school- of werkverzuim. Dit blijkt uit onderzoek van het RIVM naar preventie in de zorg. Dit themarapport is een onderdeel van de Volksgezondheid Toekomst Verkenning (VTV), waarin het RIVM elke vier jaar over ontwikkelingen van de volksgezondheid rapporteert. Het rapport bestaat uit zes verdiepende studies, waaronder rookpreventie in de zorg rond de zwangerschap, vroege opsporing van psychosociale problematiek in de jeugdgezondheidszorg, en het bevolkingsonderzoek naar baarmoederhalskanker. Op basis hiervan is een integrale analyse uitgevoerd naar effecten, kosten en succesfactoren van preventie in de zorg. Factoren die een programmatische uitvoering van preventie in de zorg succesvol maken zijn onder andere: een structurele vergoeding voor degene die de maatregel aanbiedt (bijvoorbeeld de huisarts) en een kosteloze deelname, zoals bij de griepprik. Ook is een goede infrastructuur van belang, die aansluit bij de dagelijkse routine in de praktijk. Verder is het raadzaam de maatregel vanuit de eerste lijn aan te bieden, met de huisarts als spil. Daarnaast is specifieke aandacht nodig voor moeilijk bereikbare risicogroepen. Deze factoren bevorderen dat meer mensen uit de doelgroep aan de maatregel deelnemen.

Dit rapport beschrijft ontwikkelingen in de kosten van de gezondheidszorg in de huidige vijftien landen van de EU in relatie tot ontwikkelingen in Bruto Binnenlandse Product (BBP), vergrijzing en bevolkingsgroei. Omdat zorgkosten o.a. sterk met de leeftijd stijgen is een aantal leeftijd-kostenfuncties opgesteld. Deze zijn geextrapoleerd in de tijd en toegepast op alle EU-landen, uitgaande van de leeftijd-kostenverdeling, zoals die eerder voor Nederland (1988) bepaald werd gebruik makend van bestaande internationale bevolkingsprognoses. Voor het jaar 2020 wordt de grootste toename van de zorgkosten (per capita) door vergrijzing (1990 = 1.00) voorspeld voor Italie (1,11), Griekenland (1,10), Spanje (1,09), Nederland en Finland (1,08), terwijl een geringere toename gevonden wordt voor Zweden (1,00), het Verenigd Koninkrijk (1,01), Oostenrijk en Belgie (1,05), Denemarken en Luxemburg (1,05). Het gewogen gemiddelde voor de EU stijgt naar verwachting van 1,00 in 1990 tot 1,06 in 2020. Schatting voor absolute kostenstijgingen (inclusief schattingen voor de bevolkingsgroei) geven grotere verschillen te zien. De grootste verwachte toename vindt daarbij plaats in Nederland (1,27), Luxemburg (1,20), Spanje (1,14), Frankrijk (1,14) en Finland (1,13), met lagere toenamen voor het Verenigd Koninkrijk (1,06), Portugal (1,09), Zweden, Italie, Ierland (1,10), Duitsland (1,11) en Oostenrijk (1,12). Retrospectief lijkt het er op dat in de meeste EU-landen, ook in Nederland, de stijging van de zorgkosten per capita redelijk in de pas is gebleven met de stijging van het BBP per capita. Na 2010 zal, zeker voor Nederland, vergrijzing echter relatief belangrijker worden, waardoor per capita de totale zorgkosten sterker kunnen stijgen en er minder ruimte is voor kostenstijgingen door andere oorzaken. Epidemiologische, medisch-technologische en sociaal-culturele veranderingen kunnen de leeftijdsverdeling van de zorgkosten en ook de vergelijkbaarheid ervan tussen landen in de toekomst echter op niet-voorspelbare wijze veranderen.

Deze vetzuren hebben een ongunstige invloed op het lipoproteineprofiel in het bloed. In een tabel is de vetzuursamenstelling van geselecteerde koek en snacks weergegeven. Tegenwoordig bevatten de margarines, bak- en braadvetten aanzienlijk minder verzadigd vet

Scenarios are a way of creating alternative pictures of possible and desirable futures in the field of public health and health care. In preparing scenarios use can be made of models, especially mathematical models. Firstly, a review of the use of mathematical models in disease epidemiology studies by the STG is given. The STG is the Steering committee on Future health scenarios in the Netherlands. Secondly, an introduction in modelling, especially mathematical modelling, is given. The following topics are to be discussed: a system, a model, the cycle of building models, markov models and the validation of models. Thirdly, a review of models currently used in describing demography, disease epidemiology, risk and health care is presented. Finally, the link between mathematical modelling and the methodological aspects of scenarios is to be discussed.

This report describes a conceptual framework, that will be the basis for the integral public health model. The key concepts of integral public health and health care modelling are formulated. This report brings together epidemiological research, clinical research, public health research, mathematics, informatics and modelbuilding.

Aandacht voor het demonstratieproject "Risicoanalyse van genetisch gemodificeerde voedingsmiddelen als basis voor marktintroductie". Verslag van een workshop

Iedereen weet instinctief dat natuur gezond is. Toch heeft de natuur nog geen vanzelfsprekende plek in de gezondheidszorg. In de praktijk ontdekken steeds meer zorginstellingen de baten van groen voor hun clienten. Hoe pakken zij dit aan en wat zijn hun ervaringen? In deze publicatie beschrijven we zes inspirerende voorbeelden waarin de gezondheidszorg gebruik maakt van natuur. Aan het woord komen medewerkers van zorginstellingen en natuurorganisaties, en natuurlijk de clienten zelf. Boeiende verhalen voor iedereen die zelf aan de slag wil met het onderwerp natuur & gezondheid.

Een overzicht van nationale en internationale richtlijnen over de veiligheid van nieuwe voedingsmiddelen. Tevens is ingegaan op knelpunten bij de implementatie van de voorgestelde richtlijnen

In deze notitie staan de zorgkosten van ongezond gedrag centraal, en hierbij ligt de nadruk op roken, overgewicht en lichamelijke activiteit. Er wordt niet alleen naar de huidige zorgkosten gekeken, maar ook naar de invloed van ongezond gedrag op de zorgkosten op lange termijn. De berekeningen in deze notitie zijn uitgevoerd met behulp van het RIVM Chronisch Ziekten Model (CZM).

In deze notitie staan de zorgkosten van ongezond gedrag centraal, en hierbij ligt de nadruk op roken, overgewicht en lichamelijke activiteit. Er wordt niet alleen naar de huidige zorgkosten gekeken, maar ook naar de invloed van ongezond gedrag op de zorgkosten op lange termijn. De berekeningen in deze notitie zijn uitgevoerd met behulp van het RIVM Chronisch Ziekten Model (CZM).

This study had multiple objectives. First, it aimed at examining regional inequality in several welfare variables, such as health and education during the 1998-2004 period, and per capita income over time from 1990 to 2006. The first objective of the study was to gain a better understanding about the magnitude and evolution of regional inequality in health, education and per capita income. In addition, the study paid attention to the levels and trends of between- and within-region differences in these welfare variables separately. The second objective of the study was to explore the relationship between regional income inequality and regional growth during the 1990-2006 period in order to provide knowledge about empirical evidence of the relation between regional income inequality and regional economic growth in Vietnam. The third and final objective of the study was to examine the regional growth patterns in the country for the growth episode stretching from 1990 to 2006. Also in the third objective of the study, the role of space and spatial autocorrelations were considered in order to provide a better understanding about the spatial interaction between regions in Vietnam and its impact on regional economic growth. To attain these objectives, the study employed various methodological methods in order to measure and analyze regional inequality in welfare variables, to explore the empirical relationship between inequality and growth, and to test for growth patterns in the Vietnam economy. The study was subdivided into eight chapters. Besides the introduction provided in chapter one, an overview, conclusions, discussion and recommendations given in chapter eight, the other six chapters, from chapter two to chapter seven, covered all issues relating to characteristics of reform and welfare in Vietnam, the literature, methodological approach and empirical analysis. Economic reforms and changes in welfare in Vietnam were elaborated and discussed in chapter two. The main focus of this chapter was to discuss the macroeconomic situation, as well as the implementation of the economic reforms called doi moi, and its impact on people’s welfare. As discussed in the chapter, before the doi moi, the welfare system in Vietnam functioned quite well. Most Vietnamese people had equal access to most welfare services provided by the government, irrespective of religion, ethnicity or social status. Similar to other communist countries, welfare distribution in Vietnam before the doi moi was relatively equal, although the quality of the welfare system with respect to services offered was still questionable in terms of catching up to the international standard. At the time, most Vietnamese people enjoyed free access to the healthcare system. Pupils and students got free education at all levels. As a result, the free systems culminated in good health records attained throughout the country, high enrolment rates and a high rate of literacy among the Vietnamese people compared with other developing countries with the same or slightly higher level of development. The situation and condition of welfare, such as education and health after the doi moi, were also discussed and compared with the condition of welfare before doi moi to evaluate the impact of high and relatively high rates of economic growth of 6-9% per annum on a changing welfare system, by explanatorily analyzing the welfare system, using Gini coefficients. This showed that regional inequality in the country had generally changed. The methodological issue regarding measuring and analyzing regional welfare inequality was dealt with in chapter three. Apart from discussing the theoretical approach and empirical measurement models, the chapter also provided a short review of the literature on multidimensional regional inequality. From the various approaches to welfare inequality measurement and analysis, the present study chose the multidimensional approach, using Theil’s second index as the inequality measure. The rationale for using Theil’s second index (measure) and the valuable properties of the Theil’s second index were also discussed in this chapter. Theil’s second measure satisfies the property of additive decomposability and is very informative about the status of the distribution of well-being. Additive decomposability property meant that overall inequality could be decomposed into within- and between-region inequality, which would be very meaningful for understanding magnitudes and trends of regional inequality. Theil’s second measure also satisfied several desirable properties as measuring regional income/welfare inequality, such as mean independence, population-size independence, and the Pigou-Dalton principle of transfers. In order to compute Theil’s second measure of inequality, there is a need for estimating a composite index, based on the aggregate function by Maasoumi, in which the indicators’ coefficients and their associated weights are to be estimated. To do so, the chapter also developed the measurement models based on the principal component models (PCA) and partial common principal component models (PCPC), developed and used by Flury. These two types of models were discussed in detail in order to help the readers to comprehend the subsequent empirical parts of the thesis. The measurement and analysis of regional inequality for two welfare variables, namely health and education, were given in chapter four and chapter five, respectively. In chapter four, we proceeded with the measurement and analysis for health facilities and health status, and also examined spillover effects, for example, that health facilities in one region would affect people’s health status in the first-order adjacent province(s). We carried out several tests for spatial dependence among these two subcomponents of health. The results in chapter four revealed that total regional inequality had different patterns for healthcare facilities and health status during the 1998-2004 period. Generally, regional inequality in both the healthcare facilities and health status moderately decreased in Vietnam over the 1998-2004 period. However, there was a sign of increase during this stretch of time, as the results found in chapter four showed a slight increase in inequality in both components of health over the 1998-2002 period, and then it decreased in the next period. Empirical findings in chapter four also proved the importance of spillover effects prevailing in the case of the health component. Healthcare services seemed to be more equally distributed in the case of contiguity than in the case of non-contiguity, as Theil’s second measure in the former was lower than that in the latter. This finding indicated that if we ignored the existence of spillover effects, the regional inequality would be exaggerated. The tests for spatial dependence among health components were also conducted in chapter four for several specifications regarding the relationship between health status and health facilities. The results of the tests confirmed the existence of spatial effects between the two dimensions of health. The test also proved that the spatial error model was an appropriate specification for analysis of the relationship between the composite index with respect to health status and the composite index with respect to health facilities, while the spatial lagged model was a more appropriate specification to analyze the relationship between the composite index with respect to health status and the indicators of health facilities. Following chapter four, the measurement and analysis of multidimensional regional inequality for the education component were carried out in chapter five. However, different from chapter four, contiguity effects were not considered in this chapter, because we argued that due to mandatory education applied in Vietnam, pupils were not allowed to attend school in other regions (provinces) than they were registered to live (even though in practice pupils would seek education in other regions other than the one they lived, but this phenomenon was not common, so we did not have statistics for analysis). Thus, as a result, we did not take spatial dependence into consideration. For regional inequality in education facilities, the research showed that total inequality, its between-region term and within-region components all go into opposite directions between the two periods. However, the change in the within-region inequality was in contrast with the changes in total regional inequality. The between-region component as the total regional inequality and the between-region component in education facilities first decreased during the period 1998-2002 and then increased during the period 2002-2004, while the within-region inequality increased during the 1998-2002 period, then decreased during the 2002-2004 period. As research findings revealed, the distribution of education facilities among the regions in Vietnam was a bit more unequal over time. Meanwhile, the change over time of the within-region component of inequality was very moderate. For regional inequality in enrolments, our findings showed that the pattern of total regional inequality and its decomposed terms were the same as all of them increased in the first period (1998-2002), and declined in the next period (2002-2004). The structural shares of between-region and within-region inequality in the total inequality told us that in all three years under study the between-region term made up a larger part in the total inequality. These implied that the differences in enrolments between regions were more significant to the total inequality than the differences in enrolments within regions. The comparative composite index with respect to education facilities and the composite index with respect to enrolments presented in chapter five revealed that there was a sharp contrast between the two dimensions of education, as the most-favored regions with respect to enrolments were those in the lowland areas with least and medium-favored education facilities. The least-favored regions with respect to the education enrolments were those in the upland areas, which were very high-favored with respect to education facilities in terms of the composite index. Chapter six presented the measurement and analysis of the regional income inequality, and explored the evolution of income disparities, its decomposed terms as well as its relationship with economic growth among regions in Vietnam in the period from 1990 to 2006. The findings confirmed that generally the regional income inequality in the country moderately increased over time. The decomposition of the total inequality revealed that within-region inequality decreased, while between-region increased over time. However, the size of within-region income inequality differed among regions in the country, as within-region Theil’s second inequality measure showed different trends. The empirical exploration of the relationship between regional inequality and regional growth found revealed different patterns of the relationship. The estimates from the panel data regression have found a positive relationship between the rate of economic growth and the initial level of per capita income in all the cases studied. Meanwhile, using the pooled OLS technique, we found negative relationships between growth and inequality for all the cases studied: without both controls and regional dummies, with the controls and no regional dummies, and with both controls and regional dummies. The test for the validity of the method (either the fixed effects or random effects is more appropriate and preferred) revealed that the fixed effects method was appropriate and preferred for the cases: without both the controls and dummies and with controls but no dummies in the growth model, while the random effects technique was more appropriate and more preferred for the case with both the controls, regional and time dummies. Interestingly, estimates by both the fixed effects and random effects methods revealed that there was both a positive and negative relationship between regional growth rate and initial level of per capita income. The empirical results of the relationship between regional inequality and regional growth show that the estimated relationship between inequality and growth changes when using different estimation techniques. However, the estimation using panel data regression, the fixed effects and most cases of random effects methods seem to support the theoretical argument and empirical findings that there is a positive correlation between growth and inequality for developing economies like Vietnam’s, while pooled OLS regression yields the results of a negative relationship between the two variables: inequality and growth. Examination of the growth patterns or tests (absolute β-convergence test and ADF panel IPS t-bar test based on unit root test) for convergence in regional income was conducted in chapter seven. All the tests for convergence were rejected, which meant that regional income in Vietnam did not converge towards one another. Based on an informal exploratory data analysis we may conclude that divergence of regional income took place in Vietnam, given the size of beta and its high statistical significance. Parallel with the test for the per capita GDP convergence, the chapter did also attempt to test for the spatial dependence among provinces, in order to explain the growth pattern of one province in relation with that of others. However, the Moran’s I and both the LM statistics did not support our prior assumption of the spatial dependence among provinces in the growth progress. Lastly, chapter eight provided an overview, the conclusions, discussion and recommendations based on the entire research conducted in this study. The chapter drew several key conclusions. First, regarding the regional inequality in health and education, the key point was that the results from the multidimensional approach to measurement and analysis were satisfactory, because generally, welfare inequality in Vietnam, according to the World Bank reports, increased over time, as inequality in income per capita increased. However, the multidimensional approach found that inequality in education and health decreased over the period studied. Additionally, the chapter concluded that spillover effects were important in the case of measuring and analyzing regional inequality for health, and they should be taken into consideration. For education, analyzing the comparative composite indices with respect to education facilities and education enrolments revealed that in some regions these two indices did not coincide, which meant that regions, which were favored in terms of the composite index with respect to education facilities, were not the ones that were favored in terms of the composite index with respect to enrolments and vice versa. This conclusion would be very useful for policymakers in considering the effective way to invest in improving general education in the country. Chapter eight also described several limitations of the study, regarding the approaches used in the study, the number of indicators used, the sources and duration of the data. However, the limitations were not critical, but if we overcame these setbacks, the results of the study would be more impressive, empirically speaking. In addition, several recommendations for policy were given in chapter eight, regarding policy on health and education, and policy on regional development and sustainable development.

This study had multiple objectives. First, it aimed at examining regional inequality in several welfare variables, such as health and education during the 1998-2004 period, and per capita income over time from 1990 to 2006. The first objective of the study was to gain a better understanding about the magnitude and evolution of regional inequality in health, education and per capita income. In addition, the study paid attention to the levels and trends of between- and within-region differences in these welfare variables separately. The second objective of the study was to explore the relationship between regional income inequality and regional growth during the 1990-2006 period in order to provide knowledge about empirical evidence of the relation between regional income inequality and regional economic growth in Vietnam. The third and final objective of the study was to examine the regional growth patterns in the country for the growth episode stretching from 1990 to 2006. Also in the third objective of the study, the role of space and spatial autocorrelations were considered in order to provide a better understanding about the spatial interaction between regions in Vietnam and its impact on regional economic growth. To attain these objectives, the study employed various methodological methods in order to measure and analyze regional inequality in welfare variables, to explore the empirical relationship between inequality and growth, and to test for growth patterns in the Vietnam economy. The study was subdivided into eight chapters. Besides the introduction provided in chapter one, an overview, conclusions, discussion and recommendations given in chapter eight, the other six chapters, from chapter two to chapter seven, covered all issues relating to characteristics of reform and welfare in Vietnam, the literature, methodological approach and empirical analysis. Economic reforms and changes in welfare in Vietnam were elaborated and discussed in chapter two. The main focus of this chapter was to discuss the macroeconomic situation, as well as the implementation of the economic reforms called doi moi, and its impact on people’s welfare. As discussed in the chapter, before the doi moi, the welfare system in Vietnam functioned quite well. Most Vietnamese people had equal access to most welfare services provided by the government, irrespective of religion, ethnicity or social status. Similar to other communist countries, welfare distribution in Vietnam before the doi moi was relatively equal, although the quality of the welfare system with respect to services offered was still questionable in terms of catching up to the international standard. At the time, most Vietnamese people enjoyed free access to the healthcare system. Pupils and students got free education at all levels. As a result, the free systems culminated in good health records attained throughout the country, high enrolment rates and a high rate of literacy among the Vietnamese people compared with other developing countries with the same or slightly higher level of development. The situation and condition of welfare, such as education and health after the doi moi, were also discussed and compared with the condition of welfare before doi moi to evaluate the impact of high and relatively high rates of economic growth of 6-9% per annum on a changing welfare system, by explanatorily analyzing the welfare system, using Gini coefficients. This showed that regional inequality in the country had generally changed. The methodological issue regarding measuring and analyzing regional welfare inequality was dealt with in chapter three. Apart from discussing the theoretical approach and empirical measurement models, the chapter also provided a short review of the literature on multidimensional regional inequality. From the various approaches to welfare inequality measurement and analysis, the present study chose the multidimensional approach, using Theil’s second index as the inequality measure. The rationale for using Theil’s second index (measure) and the valuable properties of the Theil’s second index were also discussed in this chapter. Theil’s second measure satisfies the property of additive decomposability and is very informative about the status of the distribution of well-being. Additive decomposability property meant that overall inequality could be decomposed into within- and between-region inequality, which would be very meaningful for understanding magnitudes and trends of regional inequality. Theil’s second measure also satisfied several desirable properties as measuring regional income/welfare inequality, such as mean independence, population-size independence, and the Pigou-Dalton principle of transfers. In order to compute Theil’s second measure of inequality, there is a need for estimating a composite index, based on the aggregate function by Maasoumi, in which the indicators’ coefficients and their associated weights are to be estimated. To do so, the chapter also developed the measurement models based on the principal component models (PCA) and partial common principal component models (PCPC), developed and used by Flury. These two types of models were discussed in detail in order to help the readers to comprehend the subsequent empirical parts of the thesis. The measurement and analysis of regional inequality for two welfare variables, namely health and education, were given in chapter four and chapter five, respectively. In chapter four, we proceeded with the measurement and analysis for health facilities and health status, and also examined spillover effects, for example, that health facilities in one region would affect people’s health status in the first-order adjacent province(s). We carried out several tests for spatial dependence among these two subcomponents of health. The results in chapter four revealed that total regional inequality had different patterns for healthcare facilities and health status during the 1998-2004 period. Generally, regional inequality in both the healthcare facilities and health status moderately decreased in Vietnam over the 1998-2004 period. However, there was a sign of increase during this stretch of time, as the results found in chapter four showed a slight increase in inequality in both components of health over the 1998-2002 period, and then it decreased in the next period. Empirical findings in chapter four also proved the importance of spillover effects prevailing in the case of the health component. Healthcare services seemed to be more equally distributed in the case of contiguity than in the case of non-contiguity, as Theil’s second measure in the former was lower than that in the latter. This finding indicated that if we ignored the existence of spillover effects, the regional inequality would be exaggerated. The tests for spatial dependence among health components were also conducted in chapter four for several specifications regarding the relationship between health status and health facilities. The results of the tests confirmed the existence of spatial effects between the two dimensions of health. The test also proved that the spatial error model was an appropriate specification for analysis of the relationship between the composite index with respect to health status and the composite index with respect to health facilities, while the spatial lagged model was a more appropriate specification to analyze the relationship between the composite index with respect to health status and the indicators of health facilities. Following chapter four, the measurement and analysis of multidimensional regional inequality for the education component were carried out in chapter five. However, different from chapter four, contiguity effects were not considered in this chapter, because we argued that due to mandatory education applied in Vietnam, pupils were not allowed to attend school in other regions (provinces) than they were registered to live (even though in practice pupils would seek education in other regions other than the one they lived, but this phenomenon was not common, so we did not have statistics for analysis). Thus, as a result, we did not take spatial dependence into consideration. For regional inequality in education facilities, the research showed that total inequality, its between-region term and within-region components all go into opposite directions between the two periods. However, the change in the within-region inequality was in contrast with the changes in total regional inequality. The between-region component as the total regional inequality and the between-region component in education facilities first decreased during the period 1998-2002 and then increased during the period 2002-2004, while the within-region inequality increased during the 1998-2002 period, then decreased during the 2002-2004 period. As research findings revealed, the distribution of education facilities among the regions in Vietnam was a bit more unequal over time. Meanwhile, the change over time of the within-region component of inequality was very moderate. For regional inequality in enrolments, our findings showed that the pattern of total regional inequality and its decomposed terms were the same as all of them increased in the first period (1998-2002), and declined in the next period (2002-2004). The structural shares of between-region and within-region inequality in the total inequality told us that in all three years under study the between-region term made up a larger part in the total inequality. These implied that the differences in enrolments between regions were more significant to the total inequality than the differences in enrolments within regions. The comparative composite index with respect to education facilities and the composite index with respect to enrolments presented in chapter five revealed that there was a sharp contrast between the two dimensions of education, as the most-favored regions with respect to enrolments were those in the lowland areas with least and medium-favored education facilities. The least-favored regions with respect to the education enrolments were those in the upland areas, which were very high-favored with respect to education facilities in terms of the composite index. Chapter six presented the measurement and analysis of the regional income inequality, and explored the evolution of income disparities, its decomposed terms as well as its relationship with economic growth among regions in Vietnam in the period from 1990 to 2006. The findings confirmed that generally the regional income inequality in the country moderately increased over time. The decomposition of the total inequality revealed that within-region inequality decreased, while between-region increased over time. However, the size of within-region income inequality differed among regions in the country, as within-region Theil’s second inequality measure showed different trends. The empirical exploration of the relationship between regional inequality and regional growth found revealed different patterns of the relationship. The estimates from the panel data regression have found a positive relationship between the rate of economic growth and the initial level of per capita income in all the cases studied. Meanwhile, using the pooled OLS technique, we found negative relationships between growth and inequality for all the cases studied: without both controls and regional dummies, with the controls and no regional dummies, and with both controls and regional dummies. The test for the validity of the method (either the fixed effects or random effects is more appropriate and preferred) revealed that the fixed effects method was appropriate and preferred for the cases: without both the controls and dummies and with controls but no dummies in the growth model, while the random effects technique was more appropriate and more preferred for the case with both the controls, regional and time dummies. Interestingly, estimates by both the fixed effects and random effects methods revealed that there was both a positive and negative relationship between regional growth rate and initial level of per capita income. The empirical results of the relationship between regional inequality and regional growth show that the estimated relationship between inequality and growth changes when using different estimation techniques. However, the estimation using panel data regression, the fixed effects and most cases of random effects methods seem to support the theoretical argument and empirical findings that there is a positive correlation between growth and inequality for developing economies like Vietnam’s, while pooled OLS regression yields the results of a negative relationship between the two variables: inequality and growth. Examination of the growth patterns or tests (absolute β-convergence test and ADF panel IPS t-bar test based on unit root test) for convergence in regional income was conducted in chapter seven. All the tests for convergence were rejected, which meant that regional income in Vietnam did not converge towards one another. Based on an informal exploratory data analysis we may conclude that divergence of regional income took place in Vietnam, given the size of beta and its high statistical significance. Parallel with the test for the per capita GDP convergence, the chapter did also attempt to test for the spatial dependence among provinces, in order to explain the growth pattern of one province in relation with that of others. However, the Moran’s I and both the LM statistics did not support our prior assumption of the spatial dependence among provinces in the growth progress. Lastly, chapter eight provided an overview, the conclusions, discussion and recommendations based on the entire research conducted in this study. The chapter drew several key conclusions. First, regarding the regional inequality in health and education, the key point was that the results from the multidimensional approach to measurement and analysis were satisfactory, because generally, welfare inequality in Vietnam, according to the World Bank reports, increased over time, as inequality in income per capita increased. However, the multidimensional approach found that inequality in education and health decreased over the period studied. Additionally, the chapter concluded that spillover effects were important in the case of measuring and analyzing regional inequality for health, and they should be taken into consideration. For education, analyzing the comparative composite indices with respect to education facilities and education enrolments revealed that in some regions these two indices did not coincide, which meant that regions, which were favored in terms of the composite index with respect to education facilities, were not the ones that were favored in terms of the composite index with respect to enrolments and vice versa. This conclusion would be very useful for policymakers in considering the effective way to invest in improving general education in the country. Chapter eight also described several limitations of the study, regarding the approaches used in the study, the number of indicators used, the sources and duration of the data. However, the limitations were not critical, but if we overcame these setbacks, the results of the study would be more impressive, empirically speaking. In addition, several recommendations for policy were given in chapter eight, regarding policy on health and education, and policy on regional development and sustainable development.

Healthy lifestyles in the prevention of cardiovascular diseases are of utmost importance for people with non insulin-dependent diabetes mellitus, hypertension, and/or dyslipidemia. Because of their continuous contact with almost all segments of the population, general practitioners can play an important role in initiating and encouraging dietary change. Unfortunately, dietary change programs that may be successful on the short term, often do not lead to long-term success. Using the Stages of Change Model to tailor nutrition counselling activities to patients' different levels of awareness and motivation has been shown to increase program effectiveness. Data from our studies, showed that decreases in (saturated) fat intake were larger in patients who received tailored counselling than in patients who received usual care (total fat intake: -5.6 percent of energy versus -2.4 percent of energy). The extent to which patients reduced their (saturated) fat intake after a nutrition counselling program, however, did not depend on how much their levels of awareness and motivation had changed. In research, short questionnaires are used to measure patients' stage of change. In general practice, however, this does not usually happen and general practitioners likely estimate their patients' interest in lifestyle change. Our study showed that general practitioners do not accurately estimate their patients' readiness to reduce their dietary fat intake (Kappa=0.25). To make dietary counselling in general practice more effective, it was therefore suggested that general practitioners should repeatedly ask their patients about their interest in lifestyle change. In our studies, social support was an independent predictor of intention to reduce dietary fat intake. As our systematic review also supported the key role of social support in the long-termmaintenanceof dietary change, increasing levels of perceived social support should be incorporated in dietary change interventions. The role general practitioners can play in increasing social support, however, may be limited because of the non-reciprocal relationship they have with their patients. Internet has also been suggested as a potential tool to help achieve long-term dietary change. Our final study was therefore designed to study the effectiveness of web-based tailored nutrition counselling and social support for patients at elevated risk for cardiovascular diseases. Patients who reported to use the Internet regularly were either given access to an online counselling tool (intervention) or were given usual care (control). The 33% of the patients in the intervention group who used the online tool had larger reductions in systolic blood pressure (-5.3 mmHg versus -0.16) than patients who did not use the tool. No changes in social support were observed. Nutrition counselling based on the Stages of Change Model is a feasible approach in general practice. As patients' levels of awareness and motivation change continuously, general practitioners' repeated attention for lifestyle is necessary. Collaboration with dieticians can help overcome some of the barriers limiting nutrition counselling practices by general practitioners. In the future, Internet can also play an important role.

This thesis derives from a four-year period of anthropological research and practice as a medical doctor among the Huichol indigenous people in the western Sierra Madre of Mexico.The main focus is an analysis of contrasting (and often conflicting) knowledge and belief systems, as represented on the one hand by government health and rural development expertise and practice, and on the other, by the ways in which the Huicholes themselves set about managing questions of sickness and health on the basis of existing cultural understandings and social practice. Linked to this is the study of the organisation of a government intervention programme designed to solve problems relating to malnutrition and to introduce improved health practices. Given the 'expert role' assigned to the anthropologist or doctor employed to work within the programme, a third important strand of the thesis addresses how such a practitioner (the author) comes to terms with the incongruities and conflicting interests and beliefs embedded in the task of helping such rural peoples to improve their life circumstances and health status. As the thesis argues, the reflexivity entailed in the latter becomes a central methodological and experiential strategy for developing close contact with and thus sharing the Huichol people's lifeworlds and health predicaments.The thesis opens with the case of a sick child suffering from what appears to be malnutrition. This helps to open up the discussion of how sickness is defined or diagnosed by the Huicholes as against western medical practice. This situates health problems within a framework that takes account of living conditions, knowledge and beliefs, human agency and government practice. The following chapter presents the arguments and objectives for the government programme, giving close attention to how images of hunger and vulnerability implicit in the outsider view are not shared by the Huichol people. This takes us to the heart of the problem and anticipates the need for a thoroughgoing cultural analysis of local knowledge and beliefs surrounding life events that centre on both propitious situations and misfortune.In the third chapter the parameters and methods used by bio-medical science are examined and shown to be at odds with the ways in which parents conceptualise and explain matters of size, weight, and the normal functioning of the body. In this way the chapter provides a detailed critique of the fundamentals of bio-medical explanation. Several events, biographies and personal dilemmas are analysed to reveal the nature of the underlying beliefs held by Huicholes and are termed 'E/ Costumbre', that is, customary beliefs and orientations to knowledge creation and production.The fourth chapter presents how local healers or doctors (terapeutas locales) go about diagnosis and curing certain illnesses, or, what might be more broadly called, 'disorders'. These local doctors undergo training, which varies in terms of length of time, but in the end results in their being recognised and assuming the joint role of healers and chanters (cantadores) of the mythology and ceremonies of the Huichol. The cultural paradigm that they work with and reproduce serves to emphasize the significance of 'Fl Costumbre' in the ongoing everyday lives of people. Huichol social life is shot through with detailed rules and procedures that govern almost every aspect of life. Indeed as the chapter shows, different social domains (economic, political, religious and familial) are all regulated in this way through specific customs and rituals, under the guidance of Huichol 'priests'.The fifth chapter ties the diagnosis of sickness with the organisation of certain ceremonies and the agricultural cycle. Here we see the healer as a mediator between the earthly or secular Huichol and certain 'entities' that order, regulate, punish, or protect. The demands of the terapeuta's training both in its normative and more esoteric aspects requires being put under microscopic scrutiny by secular authority, though the terapeuta maintains - not without conflict- his 'spiritual' authority, since both share the same explanatory paradigm. Also, like secular authority, the orders of the terapeuta may be obeyed, ignored or delayed, depending upon the personal doubts, pragmatism, routines and hopes of clients.The sixth chapter is a detailed analysis of conversations with the father of one of the children interned at the clinic for malnutrition. The narrative refers, on the one hand, to how El Costumbre is a mark of identity for Huicholes, and on the other hand, to the story of relations with foreigners which have influenced their eating and other habits. Through this we are able to observe the many contacts they have with other groups, the content of this interaction and its repercussions. The chapter recounts how a great number of children develop malnutrition, in a zone where there is increasing competition for land with their mestizo (persons of mixed/ Spanish descent) neighbours. This emphasises that the Huichol people are not an isolated or closed group, nor are they dependent on specific intervention programmes. In fact they have incorporated practices from diverse experiences of outside contact. And the evidence suggests that the different ways of diagnosing and explaining sickness does not necessarily create conflict for them since they are, in part, able to absorb these into their own beliefs and practice.The last chapter provides a chronological synthesis of planned intervention programmes relating to food and health matters among the Huichol. Some of these programmes were oriented to improving education, and others food production and dietary practice. Some led to new habits being taken up, others to the disruption of old practices. A case is used to illustrate the disastrous consequences that such action can have for the livelihoods and culture of an indigenous people.Each chapter of the thesis reveals certain tensions or problematic situations that actors must confront. Sometimes these are solved by returning to the secure terrain of existing customs and habits. On other occasions, they venture a bit further afield to explore other possibilities, and in others, answers are postponed in awaiting new events that are expected to generate a new chain of opportunities. The combination of sarcasm, pragmatism, creativity, doubts, desperation, hopes, fantasies and dreams that lie behind people's decision making is thus made evident in the detailed study of actor-situations. Human agency, always relational, is exercised within the ambiguities and vagueness of social life that allow for the maintenance, destruction and transformation of categories and perceptions. In this way 'real' worlds are made possible and reproduced.

This thesis derives from a four-year period of anthropological research and practice as a medical doctor among the Huichol indigenous people in the western Sierra Madre of Mexico.The main focus is an analysis of contrasting (and often conflicting) knowledge and belief systems, as represented on the one hand by government health and rural development expertise and practice, and on the other, by the ways in which the Huicholes themselves set about managing questions of sickness and health on the basis of existing cultural understandings and social practice. Linked to this is the study of the organisation of a government intervention programme designed to solve problems relating to malnutrition and to introduce improved health practices. Given the 'expert role' assigned to the anthropologist or doctor employed to work within the programme, a third important strand of the thesis addresses how such a practitioner (the author) comes to terms with the incongruities and conflicting interests and beliefs embedded in the task of helping such rural peoples to improve their life circumstances and health status. As the thesis argues, the reflexivity entailed in the latter becomes a central methodological and experiential strategy for developing close contact with and thus sharing the Huichol people's lifeworlds and health predicaments.The thesis opens with the case of a sick child suffering from what appears to be malnutrition. This helps to open up the discussion of how sickness is defined or diagnosed by the Huicholes as against western medical practice. This situates health problems within a framework that takes account of living conditions, knowledge and beliefs, human agency and government practice. The following chapter presents the arguments and objectives for the government programme, giving close attention to how images of hunger and vulnerability implicit in the outsider view are not shared by the Huichol people. This takes us to the heart of the problem and anticipates the need for a thoroughgoing cultural analysis of local knowledge and beliefs surrounding life events that centre on both propitious situations and misfortune.In the third chapter the parameters and methods used by bio-medical science are examined and shown to be at odds with the ways in which parents conceptualise and explain matters of size, weight, and the normal functioning of the body. In this way the chapter provides a detailed critique of the fundamentals of bio-medical explanation. Several events, biographies and personal dilemmas are analysed to reveal the nature of the underlying beliefs held by Huicholes and are termed 'E/ Costumbre', that is, customary beliefs and orientations to knowledge creation and production.The fourth chapter presents how local healers or doctors (terapeutas locales) go about diagnosis and curing certain illnesses, or, what might be more broadly called, 'disorders'. These local doctors undergo training, which varies in terms of length of time, but in the end results in their being recognised and assuming the joint role of healers and chanters (cantadores) of the mythology and ceremonies of the Huichol. The cultural paradigm that they work with and reproduce serves to emphasize the significance of 'Fl Costumbre' in the ongoing everyday lives of people. Huichol social life is shot through with detailed rules and procedures that govern almost every aspect of life. Indeed as the chapter shows, different social domains (economic, political, religious and familial) are all regulated in this way through specific customs and rituals, under the guidance of Huichol 'priests'.The fifth chapter ties the diagnosis of sickness with the organisation of certain ceremonies and the agricultural cycle. Here we see the healer as a mediator between the earthly or secular Huichol and certain 'entities' that order, regulate, punish, or protect. The demands of the terapeuta's training both in its normative and more esoteric aspects requires being put under microscopic scrutiny by secular authority, though the terapeuta maintains - not without conflict- his 'spiritual' authority, since both share the same explanatory paradigm. Also, like secular authority, the orders of the terapeuta may be obeyed, ignored or delayed, depending upon the personal doubts, pragmatism, routines and hopes of clients.The sixth chapter is a detailed analysis of conversations with the father of one of the children interned at the clinic for malnutrition. The narrative refers, on the one hand, to how El Costumbre is a mark of identity for Huicholes, and on the other hand, to the story of relations with foreigners which have influenced their eating and other habits. Through this we are able to observe the many contacts they have with other groups, the content of this interaction and its repercussions. The chapter recounts how a great number of children develop malnutrition, in a zone where there is increasing competition for land with their mestizo (persons of mixed/ Spanish descent) neighbours. This emphasises that the Huichol people are not an isolated or closed group, nor are they dependent on specific intervention programmes. In fact they have incorporated practices from diverse experiences of outside contact. And the evidence suggests that the different ways of diagnosing and explaining sickness does not necessarily create conflict for them since they are, in part, able to absorb these into their own beliefs and practice.The last chapter provides a chronological synthesis of planned intervention programmes relating to food and health matters among the Huichol. Some of these programmes were oriented to improving education, and others food production and dietary practice. Some led to new habits being taken up, others to the disruption of old practices. A case is used to illustrate the disastrous consequences that such action can have for the livelihoods and culture of an indigenous people.Each chapter of the thesis reveals certain tensions or problematic situations that actors must confront. Sometimes these are solved by returning to the secure terrain of existing customs and habits. On other occasions, they venture a bit further afield to explore other possibilities, and in others, answers are postponed in awaiting new events that are expected to generate a new chain of opportunities. The combination of sarcasm, pragmatism, creativity, doubts, desperation, hopes, fantasies and dreams that lie behind people's decision making is thus made evident in the detailed study of actor-situations. Human agency, always relational, is exercised within the ambiguities and vagueness of social life that allow for the maintenance, destruction and transformation of categories and perceptions. In this way 'real' worlds are made possible and reproduced.

Plant pathogenic Fusarium moulds occur world-wide and cereals can become infected during the growing period. Fusarium was detected in 83 % of 69 cereal samples of batches intended for food or feed production and harvested in The Netherlands in 1993. A considerable genotypic and phenotypic variation was observed within two of the most frequently isolated Fusarium species. Mycotoxins can be excreted in the crop by the fungus after the plant becomes infected. A literature review revealed 137 secondary metabolites that could be, produced by Fusarium species which were isolated from food raw materials. Twelve of those secondary metabolites were identified as mycotoxins based on toxicity observed in test animals. Six of those twelve have possibly been involved in human disease outbreaks (T-2 toxin, nivalenol, deoxynivalenol, acetyldeoxynivalenol, fumonisin B1 and zearalenone). Most of the mycotoxins are stable under process conditions used for food production and can be detected in food. Cereals harvested in The Netherlands in 1993 were contaminated with deoxynivalenol (food poisoning and immunotoxic), 3 %, or zearalenone (oestrogen), 1 %. Fumonisin B 1 (carcinogenic, related to human oesophageal cancer) was detected in 98 % of samples of maize from batches imported in The Netherlands and intended for food production. A 28-day toxicity study on the effects of fumonisin B 1 in rats revealed dose-response related apoptosis in the kidney. The lowest observed effect level was at 0.19 mg fumonisin B 1 kg -1rat body weight. The data on fumonisin B 1 toxicity were used to estimate a tolerable daily intake (TDI) of 500 ng fumonisin B 1 kg -1human body weight. The probability of being daily exposed to fumonisin B 1 at a level corresponding to this TDI was 12 % for the people in The Netherlands consuming the average amount of maize, 55 % for people belonging to the group of 'eaters only' and 78 % for people with gluten intolerance. The health of the consumers in The Netherlands might, in the current situation, be challenged by Fusarium mycotoxins present in food. Deoxynivalenol, which has immunotoxic characteristics, can potentially be present in food and feed and might increase human exposure to infectious diseases, especially to those from zoonotic origin.

Deze vetzuren hebben een ongunstige invloed op het lipoproteineprofiel in het bloed. In een tabel is de vetzuursamenstelling van geselecteerde koek en snacks weergegeven. Tegenwoordig bevatten de margarines, bak- en braadvetten aanzienlijk minder verzadigd vet

Plant pathogenic Fusarium moulds occur world-wide and cereals can become infected during the growing period. Fusarium was detected in 83 % of 69 cereal samples of batches intended for food or feed production and harvested in The Netherlands in 1993. A considerable genotypic and phenotypic variation was observed within two of the most frequently isolated Fusarium species. Mycotoxins can be excreted in the crop by the fungus after the plant becomes infected. A literature review revealed 137 secondary metabolites that could be, produced by Fusarium species which were isolated from food raw materials. Twelve of those secondary metabolites were identified as mycotoxins based on toxicity observed in test animals. Six of those twelve have possibly been involved in human disease outbreaks (T-2 toxin, nivalenol, deoxynivalenol, acetyldeoxynivalenol, fumonisin B1 and zearalenone). Most of the mycotoxins are stable under process conditions used for food production and can be detected in food. Cereals harvested in The Netherlands in 1993 were contaminated with deoxynivalenol (food poisoning and immunotoxic), 3 %, or zearalenone (oestrogen), 1 %. Fumonisin B 1 (carcinogenic, related to human oesophageal cancer) was detected in 98 % of samples of maize from batches imported in The Netherlands and intended for food production. A 28-day toxicity study on the effects of fumonisin B 1 in rats revealed dose-response related apoptosis in the kidney. The lowest observed effect level was at 0.19 mg fumonisin B 1 kg -1rat body weight. The data on fumonisin B 1 toxicity were used to estimate a tolerable daily intake (TDI) of 500 ng fumonisin B 1 kg -1human body weight. The probability of being daily exposed to fumonisin B 1 at a level corresponding to this TDI was 12 % for the people in The Netherlands consuming the average amount of maize, 55 % for people belonging to the group of 'eaters only' and 78 % for people with gluten intolerance. The health of the consumers in The Netherlands might, in the current situation, be challenged by Fusarium mycotoxins present in food. Deoxynivalenol, which has immunotoxic characteristics, can potentially be present in food and feed and might increase human exposure to infectious diseases, especially to those from zoonotic origin.

Aandacht voor het demonstratieproject "Risicoanalyse van genetisch gemodificeerde voedingsmiddelen als basis voor marktintroductie". Verslag van een workshop

Een overzicht van nationale en internationale richtlijnen over de veiligheid van nieuwe voedingsmiddelen. Tevens is ingegaan op knelpunten bij de implementatie van de voorgestelde richtlijnen

This study is performed as a part of a study which investigated the health of agrarian women in the EC. It was presented at the seminar "The health of the agrarian women in the EC" in April 1990 in Loenen, The Netherlands.

This study is performed as a part of a study which investigated the health of agrarian women in the EC. It was presented at the seminar "The health of the agrarian women in the EC" in April 1990 in Loenen, The Netherlands.

Enkele van in West-Europa veel voorkomende systemen worden besproken.

Van 6 radio-isotopen zoals koolstof en lood is de bijdrage berekend voor standaardvoedselpakketten in Nederland, Midden-Europa en Groot-Brittannie. De straling van deze isotopen draagt gemiddeld 20-40 procent bij aan de belasting van de mens. Tevens is aangegeven welke isotopen in bepaalde voedingsmiddelen en in (leiding)water een belangrijke afwijking naar boven kunnen geven. Een aantal maatregelen met betrekking tot de voedselkeuze is aangegeven met aandacht voor de kwetsbare groepen zoals jonge kinderen, zieken, zwangeren en bejaarden. De bijdrage van vlees en ei is meestal vrij beperkt

This thesis reports on the association between estimates of the amount and distribution of fat mass with aspects of morbidity in Dutch adults. A literature review on the current insights into these associations is included. The results of several cross-sectional and retrospective cohort studies are presented. The prevalence of severe overweight, defined as a Body Mass Index (BMI=kg/m 2) higher than 30 kg/m 2, is about 6% in women and 4% in men, while about 34% of the men and 24% of the women are moderately overweight (BMI 25-30 kg/m 2). Among overweight persons, especially when severely overweight, the prevalence and incidence of various chronic disorders and use of aspects of medical care was higher than in non-overweight persons. For gout and arteriosclerotic disease, overweight appeared to be a risk factor at lower levels of BMI in men than in women. The incidence was particularly high in men with an initial BMI between 27-30 kg/m 2. The association between BMI and subjective health was more pronounced in women than in men. This was true for certain somatic as well as psychosomatic complaints. Fat distribution, as measured with the waist-hip circumference ratio or waist-thigh circumference ratio, was shown to be related to the prevalence of certain chronic disorders in men and women. These associations were independent of age and BMI. A study in which Computed Tomography scans, taken at the level of the L4 vertebra, were related to anthropometric measurements, revealed that correlations of circumference ratios with the amount of intra-abdominal fat were higher than with subcutaneous abdominal fat.It is concluded that overweight is related to aspects of morbidity but that it may be particularly relevant to include fat distribution measurements in the evaluation of health risks in overweight subjects.

Enkele van in West-Europa veel voorkomende systemen worden besproken.