Efforts targeting the main nutritional problems

Chapter 2 listed a number of major diet-related health problems, the resolution of which could result in substantial health gain. This section describes the Dutch govern-ment’s efforts with regard to these specific nutritional problems.

Overweight

Until a few years ago, overweight was not treated as a priority. It was in the 1998 poli-cy document Nederland: Goed Gevoed? (‘The Netherlands: well fed?’) that it became The interim measurements reveal that, after two

years, there was a slight improvement in terms of the determinants of behaviour (with the exception of fruit consumption) which could lead to a posi-tive change in consumption patterns. However, the main barrier to actual behavioural change – misconceptions – remained in place (Maessen, 2001). The target group agrees that their diet is not sufficiently healthy, but blames this on

envi-ronmental factors and does not accept personal responsibility. Accordingly, the campaign did not bring about any positive behavioural change. In fact, the consumption of fruit and vegetables actually fell. Awareness among the target groups was at a reasonably high level, and knowledge with regard to good nutrition was slightly improved.

Textbox 3.4: ‘Good nutrition: what’s stopping you? (1997 to 2001), intended to increase the consumption of complex carbohydrates, dietary fibre and antioxidants.

one of the objectives of nutrition policy (see textbox 3.1). In late 2002, a response to the Health Council’s advisory report on the National Food Consumption Surveys set out the measures that had since been taken to counter overweight. The Health Coun-cil was asked to produce recommendations with regard to obesity, a knowledge cen-tre was founded to provide information and to help prevent overweight, and the Nutrition Centre was asked to devise and implement a public campaign. The subse-quent policy document Langer gezond leven (‘Living longer in good health’) (2003) raised overweight to the status of ‘spearhead’. The approach is still under develop-ment, with the government attempting to form a broad coalition of interested parties.

In May 2003, a start-up conference was held, to which 25 relevant social organizations were invited. Themes and action points were established during the conference. One of the main intentions is for the government to make agreements with both the sup-pliers of food products and organizers of physical activities, whereby ‘the healthy choice can be made the easy choice’.

Fat intake

Reduction of fat intake was cited as an objective in the First Progress Report further to the 1983 policy document. The Let op Vet (‘Watch the Fat’) campaign was instigated with this aim in mind. Subsequent Nutrition Centre campaigns (Goed gevoed, wat let je and Maak je niet dik) also adopted reduction of fat intake and the improvement of the fatty acid composition of the diet as important aims. The government has opted to fol-low a two-pronged approach. On the one hand, the consumer is encouraged to eat less fat and to increase the proportion of the ‘better’ fats within the total amount con-sumed. On the other, manufacturers are encouraged to modify their products. In the 2003 policy document (‘Living longer in good health’) the government encourages the food industry to develop products with a reduced fat content and improved fatty acid composition. Further to this, the Nutrition Centre compiled a project plan in 2003, entitled ‘Hidden fats’. Its intention is to increase knowledge of the hidden fat content of foods, in collaboration with manufacturers themselves.

Fruit and vegetable consumption

For several years, one of the government’s main dietary objectives has been to increase the consumption of fruit and vegetables. The Nutrition Centre’s second pub-lic campaign was intended to achieve this aim, but appears to have been unsuccessful.

The consumption of fruit and vegetables has been falling for several years. A number of other national initiatives have been launched to encourage consumers to eat more fruit and vegetables. They include:

• a specially designed logo and label for fruit and vegetables, which producers can apply to their products to provide additional consumer information

• the project in which schoolchildren are given a free portion of fruit or vegetables twice weekly (see section 3.3)

• the campaign Lekker in je vel met groente en fruit (‘Feel good with fruit and vegeta-bles’), launched in 2003 to tie in with the trend for ‘wellness’ diets. The campaign seeks to encourage the consumption of fruit and vegetables among young adults by emphasizing the short-term positive effects (helping to maintain both a healthy

weight and adequate resistance). The campaign is run by AGF Promotie Nederland (Central marketing and communication bureau for the Dutch produce sector)

The following may be added with regard to the two nutritional problems linked to a certain life phase.

The elderly

It was the 1998 policy document which designated the elderly as a separate target group, acknowledging the risk of undernutrition. An action programme was announced, primarily intended to enhance the expertise of care-givers in the health sector. The intention was to conduct a study of the nutritional status of elderly persons and of means by which this could be improved. The market introduction of foods with high nutritional value would also be encouraged. The subsequent 2003 policy docu-ment does not devote any attention to the nutritional status of the elderly. Apparent-ly, their situation is no longer regarded as problematic.

Breastfeeding

It has long been acknowledged that the proportion of Dutch newborn babies being breastfed is too low. The government has stated the objective of increasing the per-centage, and has taken certain measures in this respect. For example, the Warenwet-regeling Zuigelingenvoeding (Commodities Decree on Baby Food Preparations) includes a ban on the advertising of mother-milk substitutes by the industry. The World Health Organization’s International Code of Conduct also restricts the marketing of such preparations. The Dutch Food and Consumer Product Safety Authority operates an active and repressive enforcement strategy. In the late 1990s, the Nutrition Centre produced guidelines for baby foods, included in a Health Care Inspectorate bulletin on nutrition for children under four, intended for the use of health sector staff. Sticht-ing Zorg voor BorstvoedSticht-ing (the BreastfeedSticht-ing Promotion Foundation), which is funded by ZonMw, participates in the worldwide Baby Friendly Hospital Initiative, under the auspices of the WHO and Unicef. Part of the initiative entails certification of hospitals with an active breastfeeding policy.

The 2003 policy document points to a rising trend, but states that the percentage of breastfed babies remains too low. The objective of having at least 25% of children breastfed for the first six months of life was set. Accordingly, the Nutrition Centre was asked by the Ministry of Health to devise an action plan to encourage breastfeeding.

The plan includes a five-year campaign Borstvoeding verdient tijd (‘Breastfeeding deserves time’) which was commenced in 2003. It draws attention to the benefits of breastfeeding from various perspectives: the mother, the child, the environment, health care and policy.

In summary, we may state that the Ministry of Health has devoted both ongoing and incidental attention to the dietary problems listed, and established policy objectives accordingly. Priority has been given to fat intake and to the consumption of fruit and vegetables, while breastfeeding has also enjoyed ongoing attention. However, the

efforts to date have not (yet) had the desired effect. The 2003 policy document (‘Living longer in good health’) announced activities relating to four of the five issues: under-nutrition among the elderly was no longer included. Given the extent of this problem, it does seem advisable to devote attention to undernutrition among the elderly once again. It is too early to make any statement regarding the extent to which the new ini-tiatives will be able to alleviate the problems they address.

3.6 Summary and conclusions

As long ago as the 1980s, the Dutch government acknowledged that the dietary pat-tern has a strong influence on public health, and set itself the task of promoting healthy (or healthier) choices on the part of consumers. At the time, the priority was the role of fatty acids in the development of coronary heart diseases. It was decided to invest in periodic research into food consumption, but no structural budget was set.

‘Guidelines for Good Nutrition’ were also established. The general objective (the encouragement of the healthy choice) has since been elaborated to form quantitative targets for the general population and, since the mid-1990s, there has been a con-scious effort to inform specific target groups.

The measures implemented by the government over the past twenty years have tar-geted both consumers and food producers. Agreements with the industry have had a positive effect. A greater range of products with lower saturated fat content has served to reduce consumption of these fats, although not to the degree considered desirable under the ‘Guidelines for Good Nutrition’. The government realizes that the consumer must be allowed a reasonable freedom of choice with regard to the range of foods, whereby its own role is to create the preconditions, provide information and encourage the healthy choice. It wishes to ‘seduce’ the consumer into making the healthy choice, and is increasingly doing so in collaboration with other parties. The fact that it is the consumer who bears final responsibility for making the healthy choice is subject to ever greater emphasis.

Government policy continues to address the diet-related areas in which substantial health gains are possible, as listed in chapter 2, to a greater or lesser extent. However, it is only since the publication of the 2003 policy document ‘Living longer in good health’ that a specific policy on overweight has been in place. Investments are now being made in research and knowledge development (albeit on a limited scale) and a national campaign has been launched. Since the late 1990s, several measures have been implemented and initiatives begun to encourage the consumption of fruit and vegetables, and that of products containing high levels of dietary fibre. Nevertheless, there has been a reduction in the consumption of such products. An initiative which can reverse this trend must now be sought. The promotion of breastfeeding has formed part of nutrition policy for many years, but it was not until 2003 that a quanti-tative target was set and a public campaign begun. Finally, undernutrition among the extremely elderly and those in residential care was subject to specific attention in the

1998 policy document but is not acknowledged as a problem in the later (2003) docu-ment.

It is not possible to state whether the government’s interventions to promote a healthy diet have been successful based on an analysis of the policy documents alone.

However, some conclusions may be drawn, and indicators for future policy may be identified based on epidemiological trends and the experience gained in preventive interventions to date.

The problem of overweight has only recently been placed on the agenda. It is a signi-ficant problem which deserves to be given high priority in public health policy. Success will depend on the concerted efforts of many actors, comparable to the efforts intend-ed to rintend-educe smoking and excessive alcohol consumption. However, the government’s role with regard to overweight is somewhat more difficult than that in these other areas of public health, since overweight is an individual problem and does not direct-ly affect the health of others. As stated in section 3.4, an integrated approach targeting both producers (supply) and consumers (behaviour) seems to be the most promising.

The food industry can do much to help by improving the composition of products, by developing and promoting products with a low energy-density but high nutritional value, by modifying portion sizes, and by reducing the amount of advertising for

‘between meals’ snacks and drinks. At the same time, consumer awareness of the problem should be increased, with clear and unequivocal messages enabling and

‘seducing’ the public to make the healthy choices. It is important that this message is directed at specific target groups in their relevant settings.

A similar approach is appropriate with regard to promoting the consumption of fruit and vegetables. The campaign Goede voeding, wat let je? (‘Good nutrition: what’s stop-ping you?’) did not have the desired effect. Apart from information and education, various initiatives are required to make fruit and vegetables the easier, more attrac-tive choice. It remains unclear whether initiaattrac-tives such as that in which free fruit and vegetables are provided to schoolchildren will serve to increase consumption on a permanent basis.

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