Working together with multidisciplinary partners

10The discipline of nutrition science is in the midst of a revolutionary change. The Giessen Declaration (2005) repositions nutritional science as follows: “the most relevant and urgent work to be done by professionals working in nutrition science and in food and nutrition policy, is in its three biological, social and environmental dimensions all together” and calls for the design of a broad, integrated approach to nutrition-related problems. The interdependent nature of relations between the diet and lifestyle-related risk factors (Figure 2) reflects the intersectoral nature of food and nutrition problems and involves an ever-widening circle of stakeholders in their causal web (Vandenbroeck et al., 2007; Finegood et al., 2010). The real challenge facing NCD control programmes is to be able to stimulate a multi-sectoral response and to devise nutrition and health promotion programmes for implementation not only by nutrition educators, but also by the various stakeholders.

11It is believed that DE also has a role to play in mobilising the contribution of other sectors to multidisciplinary programmes for achieving shared nutrition objectives on the basis of an understanding of how the potential input of each partner will contribute to the achievement of the shared nutrition goal(s). Relevant ministries and agencies include those for agriculture, food, finance and economy, trade, consumer affairs, development, transport, urban planning, education and research, social welfare, labour, sport, culture, and tourism. The active involvement of civil society is important for fostering public awareness and demand for action and for supporting the implementation of planned activities. Well-formulated food, nutrition and health messages can target various stakeholders and create a synergy between their respective actions, which will address complex and long-acting processes that cannot be managed by single-sector action.

The lead role of health professionals

12The health and nutrition specialist continues to play the leading role in the formulation of the messages conveyed in nutrition communication and education programmes (WHO, 2006). Health and nutrition messages serving the purpose of advocacy directed at the political or decision-making levels in the various sectors must necessarily be backed by economic analyses and arguments that clearly indicate – in health and development terms – the potential gains as well as the negative cost of inaction. It has been observed, however, that the health sector is still hesitating to embrace the other stakeholders concerned in a truly multidisciplinary approach to DE and health promotion. Yet the optimal delivery of the sector’s professional role actually depends on the contribution of other sectors towards improving the underlying determinants of population health, and A.J. McMichael (2009) wonders whether this hesitation on the part of the health sector – which carries primary responsibility for nutrition education – is due to the fact that this interdependence is not fully understood. The success of multidisciplinary approaches depends on action to remedy such deficiencies.

Integrating social health determinants

13The publication of the final report of the WHO Commission on the Social Determinants of Health (CSDH, 2008) drew attention to the impact of those determinants on the health, nutrition and well-being of populations. They have now been added to the list of enabling and supportive environments that enhance a successful outcome for health promotion and dietary education programmes. Extreme poverty, lack of access to clean drinking water and to other basic infrastructure services and hygienic living conditions undermine DE efforts, since their negative impact constitutes a barrier to the application of the knowledge gained from health and nutrition education/promotion measures. Changes in the social and economic environment have been identified as being the cause of risk factors for NCDs becoming widespread (Beaglehole et al., 2011). Diet and physical inactivity, as well as tobacco and harmful alcohol use are risk factors for NCDs, especially in children. Research evidence has shown that a certain level of health and nutrition literacy (Vancheri, 2011), of income, and of household food security is required for families to be able to apply the teachings of the commonly used food pyramid or dietary guidelines and, in particular, to meet the fresh fruit and vegetable requirements (Stewart et al., 2011; Padilla, 2010a). An appropriate social protection system can guarantee equity in access to food and act as conditions enabling poor households to apply the DE messages and advice. The prolonged association of poverty with NCDs poses a developmental risk and can act as a barrier to the attainment of the Millennium Development Goals (MDGs), in particular the health-related Goals, MDGs 1, 4, 5, and 6. (Beaglehole et al., 2011). Under such conditions, DE will need to be backed by poverty alleviation programmes and social protection systems in order to enable poor families to have access to balanced food intake.

Complementarity between dietary education and health promotion

14Research in the fields of health, nutrition and the social and behavioural sciences has accumulated a wealth of details on – inter alia – the way people live, the time spent on food-related activities such as meal patterns, food preferences, when, where and what people eat, how food is prepared, the type and frequency of physical activity, and the impact of different lifestyles on the type and quality of foods consumed. The overlap in the respective health and nutrition objectives of activities for promoting healthy diets and improving health status has led to a mutually beneficial joining of efforts between DE and health promotion activities. This is particularly evident in programmes designed for the prevention and control of NCDs (Sassi and Hurst, 2008). The lifestyle risk factors which are identified in the World Health Organisation’s Action Plan for the Global Strategy for Prevention and Control of Non-communicable Diseases 2008-2013 (WHO, 2009a) and which are the focus of health promotion (and DE) activities in the various strategies for NCD prevention and control include the use of tobacco, harmful alcohol intake, physical inactivity and unhealthy diets.

Chart 3

Past and projected overweight rates in some countries

Past and projected overweight rates in some countries

Chart 4

Past and projected overweight and obesity rates for children in France

Past and projected overweight and obesity rates for children in France

15Given the alarming increase in diet and lifestyle-related NCDs, in particular obesity, over the past few decades (Charts 3 and 4), counselling on physical exercise and management of the body’s energy balance (Kumanyika et al., 2010) has become an essential component of DE and health promotion programmes. Inculcating the physical exercise habit in children at an early age is regarded as an important component of campaigns for the prevention and control of obesity and other NCDs. The same goes for instilling healthy lifestyle habits in young children. The European-funded community-oriented intervention programme studying the “Identification and prevention of dietary and lifestyle-induced health effects in children and infants” (IDEFICS) aims to help develop new pathways for sustainable health-promoting communities. The data generated will produce guidelines for caregivers.

Pregnancy and early childhood

16The period of early childhood (9 months of pregnancy and the first two years of childhood) has been identified as the time when the future health of adults in respect of diet-related chronic non-communicable diseases (NCDs) is determined (Victora et al., 2008). The critical importance of this early formative period in a child’s life is based on scientific evidence that traces the aetiology of several of the diet-related NCDs back to pregnancy and early childhood and to the illnesses, nutritional deficiencies and environmental insults suffered during this period of the human life cycle. A shift has thus resulted in the focus of nutrition education in order to include that critical early period of rapid growth (Chart 2). DE programmes that provide advice and guidance on balanced diets for pregnant women and on the importance of the exclusive breast feeding of newborns for at least 4 months are of paramount importance in NCD prevention and control programmes. In recognition of the above, the international mobilisation for the prevention of hunger and food insecurity has focused support on the first 1,000 days of life.

The school-age child

17It is in programmes targeting this age group that regulatory measures, innovative initiatives, and successful public-private partnerships have been introduced in DE. Innovation included the application of active and participatory education methods and of modern information/communication technology. The rapid and alarming rate of increase in overweight and obesity among school children is monitored by surveillance systems in northern Mediterranean countries (OECD, 2010). Chart 4 gives the projected figures for France. Obesity at an early age is not only a risk factor for chronic health conditions in later life, but is also associated with problems of poor self-esteem and psycho-social difficulties. Preventing obesity in schools builds on the recognition that achieving and maintaining a healthy weight is not just about a “diet” or “programme”. It is part of an on-going apprenticeship in lifestyles and practices that children can adopt at an early age and keep for the rest of their lives. Schools can help children adopt healthy eating habits and physical activity behaviour, which are the keys to preventing obesity. It is their responsibility to include intra-curricular classes for physical education and provide opportunities for sports activities. The participatory approaches and hands-on experiences that were used in some initiatives take DE one step further, turning theory and knowledge into practice.

18The Slow Food Foundation is particularly active in this area, especially in developing countries. Taste education and reviving the “memory of taste” for traditional Mediterranean foods is considered critical for preserving continuity in the eating habits of Mediterranean people. Schools and school-age children across European Union Member States have benefited from a number of regulatory and enabling measures adopted by the European Commission within a strategy for reducing child obesity (Box below). Improving the nutritional quality of school meals, promoting the consumption of fruit and vegetables through the free distribution of fruit in schools, and integrating physical education as an intra-curricular subject are some of the strategies adopted.

Feeding the elderly

19With the increase in life expectancy in Mediterranean countries the elderly form a community that is growing in numbers. On-going European-funded research projects are currently studying how diet can promote the health of the elderly and help prevent the development of age-related disease. One of the tasks that have been assigned is to produce a food pyramid for use in DE for the elderly, which meets the special dietary needs of those over 65 years of age (EUFIC, 2011). Knowledge on how a dietary system can impact on and prevent age-related diseases and functional decline will be valuable for DE as well as for a wide range of stakeholders, from the scientific community and health professionals to policymakers and industry. The integration of new knowledge

20on nutrition and lifestyle into DE for the elderly will help to raise awareness and increase the understanding of the contribution of nutrition to healthy ageing and, in turn, will support the stakeholders in their efforts to improve the health and quality of life of the ageing population (EUFIC, 2011; INPES et al., 2010). DE programmes targeting this age group are expected to guide the consumer in making the right choices from the wide range of food products on the market that claim to be specially suited to the elderly as well as to promote healthy lifestyles and physical exercise.

Public media and information technology

25Although the printed media often convey DE messages and treat DE topics, televised programmes remain the most popular form of media communication to the wider public particularly in the southern Mediterranean countries. Television programmes that disseminate information on traditional Mediterranean foods and sustainable diets and cookery demonstration programmes can reach a much wider audience than health-facility-based DE activities. They are popular and are often the primary communication channel for DE messages. However, television is a double-edged sword in the absence of regulations to control the aggressive advertising campaigns for sweets and junk foods that target children.

26Consumers living in communities with access to the Internet can benefit from the many forms of DE information and counselling services that are available through the World Wide Web, provided they are taught to seek them (Warner et al., 2006; Adams, 2005).

27Several national nutrition programmes have websites that provide all types of information and are often interactive, applying modern education and communication technologies that can even include pre-recorded video footage of live demonstrations. Several examples of DE advice for web-based social media users serve food, health and nutrition objectives. The DE messages are usually coupled with guidance on practical issues such as making out a health-conscious shopping list, composing a healthy menu, deciphering labels on food composition, what foods to avoid for their high salt and sugar content, the types of fat to avoid, and how to manage food allergies; there is even advice on classes of physical exercise and there are tips for physical fitness.

28A good example of a national DE and communication programme is the French National Health and Nutrition Programme 2001-2010 (PNNS). The PNNS is an example of government-sponsored public-private collaboration between research and education institutions, the food industry, healthcare organisations and consumers. The evaluation of the second phase – 2006-2010 – reports the relative success of the “communication” component (Menninger et al., 2010). This positive result could be attributed to the multiplication of communication channels and the diversification of the information campaigns that are decentralised and designed to meet the DE needs of the various segments of the target populations.

Culinary art and gastronomy for propagating DE messages

29The growing popularity among consumers of cooking recipes, cookery classes and demonstrations and the creativity of Mediterranean chefs has added an attractive dimension to DE that is also popular with the public media, whether printed, audiovisual or on digital forms of support as is the case in Turkey [5]. Dissemination of culinary tradition provides DE with the opportunity to document and propagate the country’s food heritage thus serving nutritional objectives as well as preserving memory, protecting biodiversity, and promoting the production and marketing of traditional food products. In the participatory culinary education initiative in Lebanon the chefs are housewives representing different gastronomic regions of the country. The “Tawlet El Tayyeb” weekly culinary demonstrations and tasting sessions (CIHEAM, 2011) use the produce of the regions to demonstrate how to prepare traditional regional Lebanese dishes. The promotion of gastronomic tourism, which also helps to make Mediterranean food systems known and to preserve continuity, is extending to the southern Mediterranean countries and is well underway in Morocco, Tunisia, Turkey and Lebanon. The Chef Association of Egypt is currently engaged in transposing ancient recipes of Egypt’s food heritage and adapting them to the preferences of the 21^st century consumer (Hassan-Wassef, 2011), thus facilitating the trans-generational transmission of a valuable heritage. The contribution of the science of gastronomy to the dissemination of the values of the Mediterranean dietary system has been reinforced by the establishment of the Gastronomic University in Italy [6] (in the Piedmont and Emilia Romagna regions). Furthermore, the participation of Mediterranean countries in local and international food, gastronomy, and catering fairs offers a tasting experience and raises awareness as to the health and nutritional value of their food and helps to create market demand.

A dietary education evolution in progress

33However, DE programmes are not homogeneous; the level and quality of performance varies in both northern and southern Mediterranean countries. The structured and holistic approach to NCD (and obesity) prevention and control is encountered more in the northern countries, where a wide range of partners, and in particular the food industry, are mobilised and involved (Ritsatakis and Makara, 2009). DE in southern Mediterranean countries tends to be more oriented towards controlling individual NCDs and there is less focus on the general preventive and lifestyle aspects of the control programmes (WHO, 2011). Also, NCDs and obesity are not as high on the political agenda as they are in the north despite the fact that some of the highest obesity rates in the region are found in the south, and despite the serious economic implications for developing countries (Global Health Council, 2011; United Nations, 2011).

34The policy and programme implications for DE are examined from the perspective of the current NCDs (and obesity) crisis. Attention is given to policy and programmes that support and enhance the contribution of DE towards promoting the Mediterranean dietary system as the model for a “new food culture” for the 21^st Century. The present point in time is exceptionally opportune for launching action based on the Mediterranean dietary model – a model that can offer practical, affordable, and accessible solutions that are derived from local dietary systems and are culturally acceptable. This would hopefully restore some order to the observed breakdown of meal rhythm and eating habits and the disruption of inherited food systems (Reich and Gwozdz, 2011). As mentioned earlier, the Mediterranean food system has proved to be versatile enough to embrace the various contexts, conditions, imperatives and demands of modernity without losing the essence of its basic features and thus guarantees the ability to adapt to different contexts. The above analysis favours the conclusion reached by Jean-Louis Rastoin and Gérard Ghersi (2010) that tradition and modernity are not enemies and that mutual correction, rather than mere cohabitation, is the solution.

35Several authors have observed that awareness programmes have limited impact and that changing habits is not an easy task (Yach, 2011). If DE programmes are to achieve their expected impact they need to be accompanied by a change in living environments. The effect of any new DE on NCDs will be seriously undermined in the absence of appropriate legal, regulatory and policy measures that serve to reduce obesogenic and other risks (Townshend and Lake, 2009) and to enhance the success of DE programmes.

Basic components of a DE policy

36The following paragraph is derived from various recent capacity and programme evaluation reports (Meninger, 2010; Ritsatakis and Makara, 2009; Alwan et al., 2010; WHO, 2010; IOTF, 2010; OECD, 2010), as well as from the analysis made in preceding sections. It presents the conditions that have been found to contribute to the achievement of DE programme objectives.

37Importance is attached to a forward-looking policy framework which involves all of the relevant sectors with a view to removing any incoherence in legal and policy frameworks that influence healthy environments and which addresses any contradictions that may exist between sectoral policies and DE messages. DE programmes must reflect integrated multi-sectoral policies, strategies and approaches and must be given adequate financial means. The creation of a forum or platform is called for (European Commission, 2007) to allow exchanges between all partners (including consumers) and to act as an overall resource mobilisation and coordination tool facilitating integrated collaborative action. It is crucial that a balance be maintained between the curative and preventive components of NCD programmes and that population-based pathways to healthy living be sustainable. Measures to promote a healthy lifestyle and the practice of regular physical activities are to be regarded as integral components of DE programmes, together with activities aiming to reduce identified risk factors. Elements in DE policy which support the promotion of Mediterranean food systems include the introduction of appropriate measures to preserve biodiversity and the continuity of local eating habits. The latter are reinforced by involving chefs in initiatives to adapt culinary traditions to suit 21^st century consumer preferences. The DE tools used for promoting sustainable consumption patterns must draw on local food resources and the Mediterranean dietary model. The policy is expected to support activities aiming to cultivate the agro-food industry as a strategic partner.

Maintaining the status quo with no change

38In a no-change scenario, the situation regarding poor financing of preventive programmes in NCD (and obesity) programmes continues. Nutrition continues to rank low on the political agenda and remains low (WHO, 2010). The curative health service dimension of the programmes continues to take precedence over the preventive and health-promotion aspects. Several of the dietary educators, especially in the new generations, are not familiar with their own food heritage and food habits, and advice for improving diets does not necessarily draw on local food sources. Only a few dietary educators are aware of the Mediterranean Diet and its value and understand the notion of sustainability and what it means for their work. They may not all be familiar with the contribution of other sectors to the success of DE programmes. Dietary guidelines, tools and communication materials do not reflect local conditions and resources and may not integrate or follow the principles of the Mediterranean model.

39There is no institutionalised forum that brings northern and southern Mediterranean countries together around the subject of a shared Mediterranean dietary system. The limited number of initiatives involving schools or rural communities in southern Mediterranean countries often remain isolated experiences with limited dissemination or impact of their results. There is no platform for fostering regular dialogue with the agro-food industry and other stakeholders, and there are no regulations governing the ultra-processing of food. The leadership role of the health sector is weak and nutrition programmes and their DE components do not adopt an integrated forward-looking vision of the food and nutrition situation and its health implications. Nutrition standards for marketing foods to children – where they exist – are not always heeded. Appropriate supportive measures, whether statutory, regulatory or policy-based, which serve to reduce the identified risks and obesogenic environment are weak or absent, and this considerably undermines the sustainability of the impact of DE programmes. The training of dietary educators is not updated and adapted to the demands of the current situation and remains deficient in components that relate to the shared Mediterranean food heritage and dietary model.

Best-case scenario

40The best-case scenario can be described as a situation where the following is taking place or has been achieved, depending on the context where the measures are being applied. The scenario can include any combination of the factors set out below. In widening the scope of the new nutrition project, George Kent (2006) draws attention to the limited ability of the nutrition profession to adequately cover the added social and environmental dimensions. Adequate coverage of those dimensions is one of the factors assumed to be achieved in a best-case scenario, and will necessarily have to be accompanied by “new” dietary or nutrition education that can meet new demands.

41The existing initiatives and programmes for networking and dialogue between Mediterranean countries around the subject of the sustainable Mediterranean Diet have become inclusive, admitting the membership of all Mediterranean countries. Continuity in the traditional food system is maintained and dietary educators (especially the new generations) are familiar with their food heritage and the nutritional value of local foods and dishes. DE programmes preserve the trans-generational transmission of culinary tradition and the memory of taste for local foods and food products. DE guidelines and DE education programmes draw on and promote the consumption of local products and are based on the Mediterranean dietary model, and DE tools have been revised accordingly. Nutritionists and culinary experts have adapted traditional foods to render them acceptable to the modern consumer. Community-based solutions for promoting DE and a healthy lifestyle are sustainable (IDEFICS, 2011). DE programmes build on the positive experience of communities which have maintained their Mediterranean-style food systems, food habits and way of life over the ages.

42Demand is created for Mediterranean-style eating and living which becomes an accessible and affordable preference for consumers. DE programmes succeed in making Mediterranean-style living and eating a way of life and everyday practice. Appropriate supportive legal and regulatory frameworks and policies have been adopted (Parker et al., 2011) and barriers to healthy living and healthy food choices have been identified and reduced. Fast-food outlets offer foods and menus derived from the local food heritage. A new generation of snacks, convenience foods, and food for the elderly has been derived from local and traditional Mediterranean-style foods and respects the Mediterranean principles of low salt, sugar and fat content. Progress continues to be made by the European and southern Mediterranean food industry in achieving the targeted changes in processed foods (CIAA, 2011). Strategic alliances negotiated with the food industry succeed in curbing the production of unhealthy food. Dietary educators involve agricultural extension workers in achieving the shared goals of the protection of biodiversity, the promotion of local food products and the improvement of household food security (Christoplos, 2010). Feedback from on-going regional debates on sustain - able diets and the health and other attributes of the Mediterranean Diet reach the dietary educator and are integrated into DE programmes. The global survey initiated by FAO (2011b) on the identity and the training requirements of dietary educators has been completed and the opportunity to integrate elements to promote diet sustainability and other characteristics of the Mediterranean model in the new DE training modules is taken and acted upon.