House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

APPENDIX 5

Memorandum by the British Heart Foundation (OB 12)

The British Heart Foundation (BHF) is delighted that the Health Select Committee has chosen the topic of Obesity in the UK for an inquiry as it is a growing public health problem which currently has no reduction targets in England, Wales, Scotland and Northern Ireland.

The aim of the British Heart Foundation is to play a leading role in the fight against heart disease so that it is no longer a major cause of disability and premature death. The BHF does this by: funding research into the causes, prevention, diagnosis and treatment of heart disease; providing support and information to heart patients and their families through the British Heart Foundation nurses, rehabilitation programmes and support groups; educating the public and health professionals about heart disease, its prevention and treatment; promoting training in emergency life support skills for the public and health professionals and providing vital life-saving equipment to hospitals and other health providers.

Coronary Heart Disease (CHD) causes over 120,000 deaths a year in the UK: approximately one in four deaths in men and one in six deaths in women and is the most common cause of premature death in the UK.

Overweight/obesity is one of the main modifiable risk factors for CHD as the conditions are associated with health problems such as high blood pressure, high cholesterol and Type 2 diabetes, all of which contribute to an increased risk of heart disease.

It is estimated that about 5% of CHD deaths in men and 6% of CHD deaths in women are due to obesity[1] And that 2% of deaths from CHD in the UK could be avoided if the old Health of the Nation targets for the prevalence of obesity (6% for men and 8% for women) were to be achieved.

While the number of deaths from CHD has dropped dramatically in the UK in recent years, the BHF is concerned that rising levels of obesity could lead to an increased number of CHD deaths once again. Tackling the problem of obesity will need a combination of strategies—inproved diet, higher levels of physical activity and greater awareness of risk factors. The BHF believes that many parts of government have a role to play in cutting obesity levels in the UK; and that the Government must take an active role in tackling growing levels of obesity, improving joined-up working between government departments and tackling the problem at local level.

The supporting evidence attached in the following memorandum is taken from the British Heart Foundation Statistics Database on Coronary Heart Disease 2003 and sets ut the current statistical information on obesity looking at age and sex differences, temporal trends, socio-economic differences, ethnic differences and international differences. The memorandum also looks at the evidence on physical activity and diet, both of which are linked to obesity.

The BHF is currently funding a number of research and educational projects on obesity, physical activity and healthy eating to help tackle the growing prevalence of obesity.

We would welcome the opportunity to give oral evidence to the Select Committee on the health implications of obesity and the importance of joined up strategy across government to promote physical activity and healthy eating as part of an obesity strategy.

April 2003

Annex

THE FOLLOWING SUPPORTING EVIDENCE IS TAKEN FROM THE BRITISH HEART FOUNDATION STATISTICS DATABASE ON CORONARY HEART DISEASE 2003

OVERWEIGHT AND OBESITY

1. Overweight and obesity increase the risk of Coronary Heart Disease (CHD). It is estimated that about 5% of deaths from CHD in men and that 6% of such deaths in women are due to obesity (a Body Mass Index (BMI) of greater than 30 kg/m3) and that 2% of deaths from CHD in the UK could be avoided if the old Health of the Nation targets for the prevalence of obesity (6% for men and 8% for women) were to be achieved[2].

2. Recent research from the World Health Organization suggests that the cardiovascular burden due to raised BMI may be greater than previously suggested. The World Health Report 2002 estimates that over 7% of all disease burden in developed countries is caused by raised blood pressure, and that between 25-49% of CHD in developed countries is due to levels of BMI in excess of the theoretical minimum (21 kg/m3)[3].

3. The adverse effect of excess weight is more pronounced when the fat is concentrated mainly in the abdomen. This is known as central obesity and can be identified by a high waist to hip ratio[4].

Overall prevalence

4. In England about 45% of men and 34% of women are overweight (a BMI of 25-30 kg/m3), and an additional 20% of men and 19% of women are obese (a BMI of more than 30 kg/m3) (Table 1.1). Central obesity (a waist-hip ratio of 0.95 and over in men and 0.85 and over in women) is also common among adults in England. Around 28% of men and 20% of women have central obesity (Table 1.2).

Age and sex differences

5. Overweight and obesity increase with age. About 27% of men and 31% of women aged 16-24 are overweight or obese but 79% of men and 71% of women aged 55-64 are overweight or obese (Table 1.1). The prevalence of central obesity also increases with age, especially in men. About 7% of both men and women aged 16-34 have central obesity but 46% of men and 23% of women aged 55 and over have central obesity (Table 1.2).

6. The prevalence of obesity increases with age throughout childhood (Table 1.3). In 1996, around 13% of eight year olds and 17% of 15 year olds in England were obese[5].

Temporal trends

7. Overweight and obesity are increasing. The percentage of adults who are obese has roughly doubled since the mid 1980's (Table 1.4 and Fig 1.4). This increase in obesity is particularly marked in men, among whom rates have tripled since the mid 1980's, with men now as likely to be obese as women.

8. The high levels of overweight and obesity among children are likely to exacerbate the trend towards overweight and obesity in the adult population since compared to thin children, obese children have a high risk of becoming overweight adults[6].

Socio-economic differences

9. Obesity is more common in adults employed in manual occupations, particularly women. A quarter of women working in unskilled manual occupations have a BMI of more than 30 kg/m2 compared to one in seven of those employed in a professional role. Both men and women working in unskilled manual occupations are over four times as likely as those in professional employment to be classified as morbidly obese (a BMI over 40) (Table 1.5).

10. In both men and women, the prevalence of central obesity is higher in people from manual social classes (IIIM, IV and V) than from non-manual classes (I, II and IIINM). However, as in general obesity, the social class patterning of central obesity is most evident in women, where the prevalence of central obesity gradually increases from 18% in social class I to 27% in social class V (Table 1.6).

Ethnic differences

11. Levels of general and central obesity vary with ethnicity in both men and women in England.

12. Compared with the general population, levels of obesity are much lower in Pakistani, Indian, Chinese, and, most markedly, Bangladeshi men, who are three times less likely to be obese than men in the general population (Table and Fig 1.7). Despite low levels of general obesity, Pakistani, Indian and Bangladeshi men, have relatively high levels of raised waist to hip ratio, with 41% of Indian men classified as centrally obese compared to 28% of men in the general population. Black Caribbean and Chinese men are less likely to have a raised waist hip ratio (Table 1.8).

13. Among women, obesity prevalence is high for Black Caribbean and Pakistani women and low for Bangladeshi and Chinese women (Table and Fig 1.7). However, all female minority ethnic groups have levels of central obesity well above that of the general female population, with Black Caribbean and Pakistani women two times, and Bangladeshi women over three times, as likely to have a raised waist to hip ratio as women in general (Table 1.8).

International differences

14. Data from national surveys of overweight and obesity collected by Professor Boyd Swinburn and his colleagues at Deakin University, Victoria, Australia show that the prevalence rates for overweight and obesity in the UK are some of the highest in the world. For example the prevalence of obesity is the eighth highest for men (out of 40 countries) and the eleventh highest for women (out of 41 countries) (Table 1.9 and Figure 1.9a).

15. While levels of overweight and obesity are increasing in all countries—both developed and developing—the rate of recent increase in the UK is particularly high (Table 1.9b).

Public health targets

16. There are no overweight and obesity targets for England, Wales, Scotland or Northern Ireland.

Table 1.1

BODY MASS INDEX BY SEX AND AGE, 2001, ENGLAND

Body mass index (kg/m2)	All ages	16-24	25-34	35-44	45-54	55-64	65-74	75 and over
	%	%	%	%	%	%	%	%
MEN
20 or less	4	16	5	2	1	2	2	4
Over 20-25	28	48	35	27	22	21	22	27
ver 25-30	47	27	44	48	51	51	52	52
Over 30-40	20	9	15	22	25	26	24	18
Over 40	1	0	1	1	1	0	0	0
All over 30 (obese)	21	10	16	23	26	27	24	18
Base	6,267	757	1,051	1,220	1,112	958	766	403
WOMEN
20 or less	6	17	9	4	4	3	3	6
Over 20-25	38	49	46	43	33	29	26	32
Over 25-30	33	22	26	31	36	38	41	41
Over 30-40	21	11	17	19	24	28	28	19
Over 40	3	1	2	3	4	3	2	1
All over 30 (obese)	24	12	19	22	28	31	30	20
Base	7,414	856	1,221	1,513	1,331	1,038	871	584
Notes: Adults aged 16 and over.
Source: Health Survey for England 2001 (2003). www.doh.gov/stats/tables/trendtab06.xls

Table 1.2

PREVALENCE OF A RAISED WAIST-HIP RATIO (WHR) BY SEX AND AGE, 1998, ENGLAND

	All ages	16-34	35-54	55 and over
	%	%	%	%
Men	28	7	27	46
Base	7,193	2,213	2,594	2,386
Women	20	7	17	34
Base	8,715	2,636	3,057	3,022
Notes: Raised waist-hip ratio for men is defined as 0.95 and over and for women is 0.85 and over.
Source: Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

Table 1.3

PREVALENCE OF OB ESITY AND OVERWEIGHT IN CHILDREN BY SEX AND AGE, 1996, ENGLAND

	Age (years)
	6	7	8	9	10	11	12	13	14	15
BOYS
% overweight	22	26	24	25.2	23	25.4	27.8	25.2	30.1	32.9
% obese	12	9	12	13	9.6	13.9	11.9	12.2	14	16.4
Base	154	144	136	131	135	122	126	131	136	140
GIRLS
% overweight	22	18	21	19	23.9	23.9	28.3	28	29.2	28.8
% obese	9	12	13	9.5	11.1	11.1	18.3	15.9	13.3	17.3
Base	144	136	159	116	117	134	120	132	113	104
BOTH
% overweight	22	22	22	22.3	23.4	24.6	28	26.6	29.7	31.1
% obese	10	10	13	11.3	10.3	12.5	15	14.,1	14.6	16.8
Base	298	280	295	247	252	256	246	263	249	244

Notes: Health Survey for England 1996 data. Children were defined as overweight if their BMI was above the 85th centile of the 1990 Body Mass Index reference curves for the UK, and obese if obove the 95th centile.

Source: Reilly J, Dorosty A (1999) Epidemic of obesity in UK children. Lancet; 354:1874-75.

Table 1.4

BODY MASS INDEX BY SEX, 1986/87-2001, ENGLAND

	1986-87	1991-92	1993	1994	1995	1996	1997	1998	1999	2000	2001
Body mass index(kg/	%	%	%	%	%	%	%	%	%	%	%
MEN
20 or less	6	6	5	5	5	5	4	3.9	5.18	5	4
Over 20-25	49	41	39	39	38	36	35	35.3	34.08	31	30
Over 25-30	38	40	43	43	43	43	43	43.9	42.42	43	45
More than 30	7	13	13	13	15	16	17	16.9	18.32	21	21
Bases	n/a	n/a	5,998	5,597	5,471	5,731	3,078	5,422	2,626	2,650	5,098
WOMEN
20 or less	11	9	8	8	7	7	7	5	7.66	7	6
Over 20-25	53	50	47	47	46	44	43	41	41.28	42	40
Over 25-30	24	26	30	29	30	31	30	33	31	32	31
More than 30	12	15	16	16	17	17	19	22	19.97	20	23
Bases	n/a	n/a	6,389	6,147	6,180	6,401	3,424	6,201	3,004	2,955	5,959

Notes: Adults 16-64 years.

Sources: From 1993, Health Survey for England. See Department of Health website: http://www.doh. gov.uk/stats/tables/trendtab06.xls Earlier figures, Central Health Monitoring Unit, Department of Health, personal communication.

Figure 1.4

Table 1.5

PREVALENCE OF MORBID OB ESITY, OB ESITY AND OVERWEIGHT BY SEX AND SOCIAL CLASS, 1998 ENGLAND

	I	II	IIIN	IIIM	IV	V
Body mass index (kg)	%	%	%	%	%	%
Men
25-30 (overwight)	46	47	43	44	44	40
Over 30 (obese)	12	16	16	20	16	18
Over 40 (morbid obesity)	0	1	0	1	1	2
Bases	461	2,031	662	2,072	938	301
Women
25-30 (overwight)	30	33	31	32	32	32
Over 30 (obese)	14	18	18	24	25	28
Over 40 (morbid obesity)	1	2	1	2	3	3
Bases	471	2,231	1,193	1,983	1,201	429

Notes: Age-standardised percentages. For method of age-standardisation see source. Adults aged 16 and above with a valid height and weight measurement.

Source: Joint Health Surveys unit (1999) health Survey for England 1998. The Stationery Office: London.

Table 1.5

PREVALENCE OF A RAISED WAIST-HIP RATIO BY SEX AND SOCIAL CLASS, 1998, ENGLAND

	Social class of head of household
	I	II	IIIN	IIIM	IV	V
	%	%	%	%	%	%
MEN	20	24	23	31	28	29
Base	418	1,896	601	1,926	863	273
WOMEN	18	18	18	22	24	27
Base	432	2,062	1,098	1,836	1,117	390

Notes: Adults aged 16 and over. Raised waist-hip ratio for men is 0.95 and over and for women is 0.85 and over; age-standardised percentages; see source for method of age-standardisation.

Source: Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

Table 1.6

PREVALENCE OF OBESITY BY SEX AND ETHNIC GROUP, 1999, ENGLAND

	General population	Black Caribbean	Indian	Pakistani	Bangladeshi	Chinese	Irish
	%	%	%	%	%	%	%
MEN	19	19	12	14	6	7	20
Base	3,204	466	527	556	409	284	481
WOMEN	21	33	21	34	13	4	22
Base	3,699	618	572	550	408	339	631

Notes: Adults aged 16 and over. Obesity: a BMI of over 30; age-standardised percentages; see source for method of age-standardisation.

Source: Joint Health Surveys Unit (2001) Health Survey for England. The Health of Minority Ethnic Groups 1999. The Stationery Office: London.

Figure 1.7

Table 1.8

PREVALENCE OF A RAISED WAIST-HIP RATIO BY SEX AND ETHNIC GROUP, 1999, ENGLAND

	General Population	Black Caribbean	Indian	Pakistani	Bangladeshi	Chinese	Irish
	%	%	%	%	%	%	%
MEN	28	17	41	42	37	21	32
Base	6,095	363	467	387	273	196	408
WOMEN	20	42	34	56	72	36	27
Base	7,135	513	461	403	288	249	540

Notes: Adults aged 16 and over.

A raised waist-hip ratio for men is 0.95 and over and for women is 0.85 and over; age-standardised percentages; see source for method of age-standardisation.

Source: Joint Health Surveys Unit (2001) Health Survey for England. The Health of Minority Ethnic Groups 1999. The Stationery Office: London.

Table 1.9

BODY MASS INDEX BY SEX, 1960—1999, ALL AVAILABLE COUNTRIES

		BMI—Men				BMI—Women

Country	Year	Base	Age	Mean	25	30	Mean	25	30	Notes
			(y)	(kg/m2)	(%)	(%)	(kg/m2)	(%)	(%)
Australia	1980	5,603	25-64	25.3	49.9	9.3	23.7	28.2	8.0	6 main cities
	1983	7,615	25-64	25.3	49.1	9.1	24.1	32.5	10.5	6 main cities
	1989	6,097	25-64	25.7	55.6	11.5	24.7	38.3	13.2	6 main cities
	1995	10,652	19+	26.7	64.5	17.9	26.0	49.2	16.7
Austria	1991	NR	20+	25.0		8.3	24.1		9.0	8 regions
Belgium	1979-84	11,302	25-74	25.9	58.6	12.1	26.0	53.6	18.4
Brazil	1974-75	95,062	20+	22.3		2.4	22.8		7.0	NE and SE regions
	1989	15,585	20+	23.3		4.7	24.3		12.0	NE and SE regions
	1996-97	10,680	20+	24.3	42.5	6.9	24.6	51.3	12.5	NE and SE regions
Canada	1981	10,911	20-69	25.3	47.9	9.4	23.8	40.6	12.1
	1985	9,241	20-69	24.6	37.4	6.1	23.1	36.7	8.1
	1988	1,269	19-69	23.2		9.0	24.8		9.2
	1986-90	17,858	18-74	26.0	56.0	15.0	25.0	38.0	15.0
	1994	12,318	20-64	26.1		13.5	24.8		15.7
	1996	NR	20-64	26.2	59.2	13.3	24.5	37.2	11.8
	1998-89	NR	15+	25.9	56.0		24.6	38.0
China	1989	3,981	20-45	20.4	6.4	0.3	20.9	11.7	0.9	8 provinces (same people
	1991	3,981	22-47	21.4	8.9	0.4	21.9	13.1	0.9	in 1989 and 1991)
	1992	54,006	20+	21.4	11.9		21.7	17.0
	1993	4,920	20-45	20.9	9.0	0.7	20.9	12.0	0.7
Cuba	1982	30,063	20-59	23.7	31.5		24.7	39.4		Parents from children's survey
Denmark	1994	4,668	16+	24.9	44.2	8.2	23.3	28.0	7.0
Egypt	1993	5,812	15+				28.5	71.9	35.1
Finland	1966-72	17,294	15+	24.6		8.3	25.3		17.4
	1978-80	4,225	15-64	24.7	42.0		24.3	36.0
	1982	9,111	25-64	26.3	61.0	15.4	25.8	50.0	16.6	3 regions
	1985-87	4,125	15-64	24.8	43.0		24.3	36.0
	1987	6,025	25-64	26.7	65.4	17.5	26.2	52.3	20.3	3 regions
	1988-90	3,850	15-64	25.0	45.0		24.5	38.0
	1992	4,618	25-64	26.8	64.9	19.9	26.1	51.9	20.0	3 regions
	1994-96	3,575	15-64	25.4	50.0		25.1	43.0
	1997	4,329	25-64	27.1	67.4	20.1	26.2	52.4	19.2	3 regions
	1999	3,371	15-64	25.4	50.0		25.0	42.0
France	1980-81	13,942	20+	24.6	39.4	6.4	23.2	26.8	6.3
	1988	1,941	16-50	23.5			22.1			1,272 men, 669 women
	1991-92	15,106	20+	24.7	40.8	6.5	23.3	27.5	7.0
Germany	1984-85	4,790	25-69	26.5		15.1	25.8		16.5
	1987-88	5,335	25-69	26.5		14.7	25.8		17.2
	1990-91	5,311	25-69	26.8		17.2	26.2		19.3
	1992	7,410	25-69	26.8			26.3
	1998	7,124	18-79	26.9			26.3
Ghana	1987-89	9,215	20-65	20.8	5.3	0.6	22.1	18.1	6.1	Uncertain sampling methods
Greece	1993-99	14,281	30-82	27.9			28.0			Baseline of cohort study
Hong Kong	1995-96	2,875	25-74	24.3	38.0	5.0	24.0	34.0	7.0
Hungary	1986-88	16,113	18+	26.0	57.2	16.5	27.3	61.7	19.6
India	1974-79	39143	18+	18.6	2.3	0.2	18.8	3.4	0.5	Mainly rural areas
	1988-90	21,361	18+	18.9	2.7	0.2	19.0	4.1	0.5	Mainly rural areas
	1995-96	177,841	18+	19.8	4.3	0.3	19.4	4.6	0.6	Uncertain sampling methods
Italy	1983	72,284	15+	24.6	41.2	7.1	23.4	28.9	7.6
	1978-87	63,046	20-69	26.3			26.4			9 surveys pooled
	1991	50,692	15+	25.1	46.2	7.0	23.6	30.6	6.1
	1994	13,048	15+	25.1	46.1	6.5	23.7	31.3	6.3
Japan	1976	NR	20+	21.0		0.7	22.0		2.8
	1980	17,858	30-69	22.7			22.8
	1982	NR	20+	21.4		0.9	21.9		2.6
	1983	16,195	30-69	22.9			22.9
	1986	16,822	30-69	22.9			22.8
	1987	NR	20+	22.0		1.3	22.0		2.8
	1989	16,210	30-69	23.0			22.6
	1990-94	52,307	15-84	22.8	22.1	1.8	22.5	20.6	2.6
	1993	NR	20+	22.5		1.8	21.9		2.6
Jordan	1994-96	2,836	25+	27.1		32.7	30.6		59.8	Uncertain sampling methods
Korea	1990	22,354	30+	22.8	22.6		23.4	30.2
	1995	6,480	15+	22.6			21.7
Kuwait	1980	2,067	18+	25.0	45.7	14.9	27.5	57.0	30.3	From randomly
	1993	3,435	18+	27.5	67.5	32.3	29.0	72.9	40.6	selected clinics
Kyrgyzstan	1993	4,053	18-59	23.6	30.6	4.2	24.2	35.0	10.7
Malaysia	1990	4,747	18-64	23.4	28.7	4.7	23.0	26.0	7.9	Mixed ethnic groups
	1996	28,737	20+	22.7	24.1	4.0	23.1	29.0	7.6	Mixed ethnic groups
Mauritius	1987	5,021	25-74	22.8	26.1	3.4	24.2	37.9	10.4	Mixed ethnic groups
	1992	5,111	25-74	24.1	35.7	5.3	25.7	47.7	15.1	Mixed ethnic groups
Mexico	1988	19,022	Adults				22.9	25.0		Uncertain sampling methods
	1995	2,042	Adults	25.4	50.0	11.0	26.9	58.0	23.0
Morocco	1984	NR	20+	22.9		2.3	25.2		14.6
Netherlands	1981	~9,000	20+	23.7		3.9	23.4		6.2
	1982	~9,000	20+	23.6		3.5	23.3		5.9
	1982-84	~9,000	20+	24.3	37.0	3.7	23.5	29.4	6.0
	1984	~9,000	20+	23.7		3.9	23.4		6.2
	1985	~9,000	20+	23.6		3.6	23.3		6.0
	1985-87	~9,000	20+	24.3	38.3	3.8	23.6	30.0	6.3
	1987	~9,000	20+	23.8		4.1	23.4		6.3
	1988	~9,000	20+	24.0		4.6	23.5		6.8
	1987-91	36,266	20-59	24.9		7.4	24.3		9.0	3 municipalities
	1989-91	~9,000	20+	24.5	39.3	5.1	23.8	31.3	7.1
	1993-95	12,905	20-59	25.8		8.0	25.0		10.0	3 municipalities
	1993-95	~9,000	20+	24.7	42.0	5.9	24.0	33.3	7.4
	1995	4,601	20-59	25.5	53.3	10.0	24.8	38.9	10.3	3 municipalities
	1996-98	21,764	20+	24.8	43.5	6.5	24.3	36.5	9.1
Neth Antilles	1993-4	2,248	18+	26.0		18.7	28.3		36.2	Curacao
New Caledonia	1992-94	6,503	30-59	27.1			28.6	70.4		Mixed ethnic groups
New Zealand	1989	3,204	15+	25.3	53.0	10.0	24.7	40.0	13.0	Mixed ethnic groups
	1997	4,636	15+	26.2	55.1	14.7	26.1	49.3	19.2	Mixed ethnic groups
Norway	1994	3,144	16-79	24.6	42.0	5.0	23.4	26.0	5.0
Pakistan	1995	1,404	25+	22.1			23.9	35.9		1 urban, 1 rural area
Philippines	1993	9,585	20+	21.5	12.7	1.7	21.5	15.2	3.4
Samoa	1978	1,484	25-74	27.1		27.5	29.1	74.8	48.5	3 regions
	1991	1,729	25-74	30.5		46.8	33.2		66.1	3 regions
Saudi Arabia	1990-3	10,165	20+	25.6	50.9	17.8	26.9	56.0	26.6
Seychelles	1987	1,078	25-64	23.9		4.2	26.2		20.9	Mahe, mixed ethnic groups
	1994	806	35-64	24.5			28.0			Mahe, mixed ethnic groups
Singapore	1982-85	2,143	18-69	22.5	17.4		23.1	30.4		Mixed ethnic groups
	1992	3,568	18-69	23.0	27.5		22.6	24.9		Mixed ethnic groups
South Africa	1979	7,187	15-64	26.0	56.6	14.7	25.8		18.0	Whites, SW Cape
	1998	13,827	15+	23.4	28.5	9.1	26.5	54.9	29.4
Spain	1989-94	5,388	25-60	25.6		11.5	25.3		15.2	4 regions
Sweden	1980-1	14,474	16-84	24.2	35.7	4.7	23.4	27.6	5.4
	1988-89	12,387	16-84	24.4	38.2	5.2	23.4	27.9	5.6
	1996-97	11,417	16-84	25.0	45.9	6.8	24.0	33.6	7.2
Switzerland	1992-3	15,288	15+	24.5	39.2	6.1	22.4	21.8	4.7
	1997	79,311	15+	24.7	42.1	6.7	23.3	28.0	6.9
Togo	1986	4,443	Adults	22.0	14.6	2.6	23.0	22.8	3.5	Urban
Tunisia	1976-81	5,613	20+	23.2			25.2			1 urban, 1 rural region
	1990	NR	Adults	22.8	22.4	2.4	24.9	41.0	8.3
Turkey	1990	3,689	20+	25.1		9.0	26.3		21.7
United Kingdom	1980	8,434	20-64	24.8	43.0	8.0	24.0	34.0	9.0
	1986	2,319	16-64	24.9	45.0	8.0	24.6	36.0	12.0
	1988	1,747	16-50	23.8			23.2			Men oversampled
	1991	NR	16-64	25.7		12.7	25.3		15.0
	1993	15,284	16+	25.9	57.6	13.2	25.7	48.6	16.4
	1994	14,679	16+	26.0	58.1	13.8	25.8	48.7	17.3
	1995	14,436	16+	26.1	59.3	15.3	25.9	50.4	17.5
	1996	15,061	16+	26.3	61.0	16.4	26.0	52.0	18.4
	1997	7,939	16+	26.5	62.2	17.0	26.2	52.5	19.7
	1998	14,330	16+	26.5	62.8	17.3	26.4	53.3	21.2
United States	1960-62	~7,800	20-74	25.2	48.2	10.4	24.6	38.6	15.0	NHES I
	1971-74	~28,000	20-74	25.6	52.9	11.8	24.7	39.8	16.2	NHANES I
	1976-80	20,325	20-74	25.5	51.4	12.3	25.1	40.8	16.5	NHANES II
	1982-87	14,407	25-74	25.6			27.8
	1988	1,892	16-50	24.9			24.1
	1987-91	114,954	25-74	26.0			26.9
	1988-94	~40,000	20-74	26.3	59.4	20.0	26.1	49.8	24.9	NHANES III
Uruguay	1998	900	18+	26.0	57.0	17.0	25.9	49.0	19.0	Montevideo
Vietnam	1981-85	12,800	18+	19.1			19.1			10 rural areas
	1987-89	12,442	18+	19.3			19.2			Urban, rural

Notes: For references to the original studies from which these data are extracted contact the authors of this supplement or Professor Boyd Swinburn (swinburn@deakin.edu.au)

Source: Extracted from a draft World Health Organisation report on the impact of rapid transitions on the increasing public health problem of obesity prepared by Swinburn, B et al.

CONTRIBUTORY FACTORS TO OBESITY

Diet

17. Unhealthy diets are a cause of CHD. It is estimated that up to 30% of deaths from CHD are due to unhealthy diets[7].

18. The dietary changes which would help to reduce rates of CHD in the UK population have been identified by various expert bodies, including the Government's Committee on the Medical Aspects of Food and Nutrition Policy (COMA)[8]. COMA recommends a reduction in fat intake, particularly saturated fat intake, a reduction in salt intake and an increase in carbohydrate intake. The committee also recommends that the consumption of fruit and vegetables be increased by 50% to about 400g per day, which is equivalent to at least five daily portions (Table 2.1).

19. Recent research from the World Health Organization highlights the specific importance of low fruit and vegetable consumption as a cause of CHD. The World Health Report 2002 estimates that just under 4% of all disease burden in developed countries is caused by low fruit and vegetable consumption, and that between 25% and 49% of CHD in developed countries is due to fruit and vegetable consumption levels of below 600g/day[9].

Overall levels of consumption

20. Levels of consumption of food and nutrients are difficult to assess. In the UK food consumption patterns have been tracked for over 50 years by the National Food Survey. While this survey is useful for investigating trends over time, it only provides a general idea about individual levels of consumption. It suggests that overall British adults derive around 38% of food energy from total fat, and around 15% from saturated fat—significantly higher than the COMA targets (Table 2.2).

21. The best estimate of fruit and vegetable consumption in adults comes from the 2002 National Diet and Nutrition Survey. On average both men and women consume fewer than three portions of fruit and vegetables a day—2.7 for men and 2.9 for women (Table 2.3). Overall, just 13% of men and 15% of women consume the recommended five or more portions of fruit and vegetables a day. These proportions increase with age: none of the men and just 4% of the women aged 19-24 years surveyed in the National Diet and Nutrition Survey consumed five or more portions of fruit and vegetables, compared with 24% of men and 22% of women aged 50-64 years.

22. The best estimate of overall consumption of salt comes from the National Diet and Nutrition Survey, which utilises 24-hour urine collections to determine salt intake. As yet, only the results of the 1986/87 survey are available, and these suggest that the average daily salt intake for men is 10.4g and for women 7.9g—both significantly higher than the COMA target[10][11].

Temporal trends

23. The percentage of food energy derived from total fat in the British diet is falling only gradually; according to the National Food Survey from 42% in the mid 1970s to just over 38% in 2000. The type of fat eaten has changed more dramatically; the percentage of food energy derived from saturated fat falling from around 20% to about 15% (Fig 2.1a and Table 2.2).

24. The trends in fat consumption can be explained by changes in food consumption patterns. For example, since the 1970s there have been falls in the consumption of many different types of foods with a relatively high total fat and saturated fat content, including whole milk and butter. There have also been increases in the consumption of foods which are relatively low in total fat and/or saturated fat, for example reduced fat milks and spreads with a reduced content of fat or saturated fat (Figs 2.4a and 2.4b).

25. Total fresh fruit consumption has increased around four fold since the early 1940's, but total fresh vegetable consumption has declined (Table 2.4 and Fig 2.4c).

26. Trends in the consumption of salt are harder to assess than for other nutrients. Data from the National Food Survey suggest that the consumption of salt added to cooking and at table has declined considerably over the last half century (Fig 2.3d). However, this does not mean that total salt intake has declined because around 70% of dietary salt in the UK is obtained from manufactured foods, and the reliance on some such foods—particularly convenience foods that are often high in salt—has increased in recent years.

Eating habits in children

27. It is likely that few children consume the recommended daily intake of five portions of fruit and vegetables a day, but the actual number failing to reach the target is difficult to as certain from the two recent Government surveys which have looked at eating habits in children. The Health Survey for England suggests that only 16% of boys aged 2-15 and 19% of girls eat fruit more than once a day, with smaller proportions (12% and 15%) consuming vegetables at the equivalent frequency (Table 2.5). The more recent National Diet and Nutrition Survey for children showed that one in five 4-18 year olds ate no fruit at all during the week of the survey[12].

28. The National Diet and Nutrition Survey for children found that the average proportion of children's food energy derived from fat was 35.4% for boys and 35.9% for girls, and from saturated fat was 14.2% for boys and 14.3% for girls.

29. Fat intake for children may therefore be lower than adults and is only just above the COMA target of 35%. Saturated fat intake is still well above the COMA target of 10% (COMA targets for fat and saturated fat apply to everyone over the age of five years). COMA did not set a target for salt consumption in children.

REGIONAL DIFFERENCES

30. It is often suggested that the diets of people in Scotland and the North of England are less healthy than in the South. When regional differences in total fat and saturated fat consumption are examined no clear pattern emerges (Table 2.6) and in any case differences between regions are small.

31. Data from the National Food Survey suggest there is a strong North-South gradient in both fruit and vegetable consumption with people in Scotland, Northern Ireland and the North of England eating considerably less than in the South. For example, in 2000, people living in South East consumed over 50% more fruit and vegetables than people living in Northern Ireland (Table 2.6). However, data from the National Diet and Nutrition Survey showed no significant regional differences in the number of portions of fruit and vegetables consumed, or the proportion of men and women who consumed five or more portions a day[13] (Table 2.7).

32. Sodium intake varies little between regions (Table 2.6).

SOCIO-ECONOMIC DIFFERENCES

33. There is little difference in the fat and saturated fat intake of income levels groups (Table 2.8) whereas with fresh fruit and vegetables there is a much higher intake in those in households with higher incomes. For example, the volume of leafy salads and fruit juice consumed Is three times as great in the richest 10% of households compared to the poorest (Table 2.8).

34. Data from the National Diet and Nutrition Survey show that men and women living in households in receipt of state benefits consume fewer portions of fruit and vegetables than those in non benefit households. About one third of those in benefit households (35% of men and 30% of women) ate no fruit at all during the week of the survey compared with around one seventh (19% men and 12% women) in non-benefit households[14].

35. Eating habits in children vary considerably with social class. Children of semi and unskilled manual workers are more likely to frequently consume foods which are high in fat (crisps, biscuits, cake etc) more than once a day, and less likely to consume fruit and vegetables more than once a day, than children of the professionals and managers (Table 2.5 and Figs 2.5a and 2.5b).

ETHNIC DIFFERENCES

36. The Health Survey for England 1999 asked questions about the frequency of consumption of a range of foods, (including fruit and vegetables and a number of high fat and high sugar foodstuffs), to assess the eating habits of minority ethnic groups in the UK. Results show considerable variation in eating habits by ethnic group.

37. Bangladeshi men and women were more likely to frequently consume both red meat and fried foods than adults from other ethnic minority groups. In contrast, Indian men and women were the least likely to frequently eat red meat and Indian men were the least likely to frequently eat fried foods (Table 2.9).

38. These differences were reflected in the overall fat score (calculated from the food-frequency questionnaire). The proportions with a high fat score were highest in Bangladeshi (22%) and Irish (21%) and lowest in Indian (11%) men. In women 27% of Bangladeshi women had a high fat score compared with 8% of Indian women[15].

39. Amongst minority ethnic groups, Chinese men and women have the highest levels of fruit and vegetable consumption, with 46% of men and 60% of women consuming fruit, and 53% of men and 69% of women consuming vegetables, six or more times per week. Bangladeshi adults have the lowest levels of fruit consumption with only 15% of men and 16% women consuming fruit six or more times a week. The lowest levels of vegetable consumption are amongst the Pakistani community, with just 7% of men and 11% of women eating vegetables on six or more days a week (Table 2.9).

International differences

40. The proportion of energy available from fat varies across European countries, from 41% in France to 18% in Georgia. The UK figure of 39% corresponds to the EU average, but is still markedly higher than the European average of 32% (Table 2.10 and Fig 2.10).

41. Dietary intake data show that consumption of fruit and vegetables is generally higher in Southern European countries than it is in Northern, Western, Central and Eastern European countries. Consumption of fruit and vegetables in the UK is around half that found in Spain and around 50% higher than that found in Azerbaijan (Table 2.11).

Targets

42. Progress towards the COMA targets for saturated fat and total fat has been disappointing (Fig 2.1a). COMA does not specify by when it considers the 50% increase in fruit and vegetable consumption should be achieved, but the current rate of increase in consumption is exceedingly slow (Fig 2.1b). Salt consumption remains well above the levels recommended by COMA and reinforced by Scientific Advisory Committee on Nutrition Salt Subgroup in 2002[16]. A reduction in the salt content of processed foods and drinks is required if the target is to be met.

Table 2.1

SELECTED DIETARY TARGETS FOR THE UNITED KINGDOM

England 1
Total fat—COMA target	To reduce the average contribution of total fat to dietary energy to about 35%
Saturated fat—COMA target	To reduce the average contribution of saturated fatty acids to dietary energy to no more than about 10%
Fruit and vegetables—COMA target	To increase the consumption of fruit and vegetables by at least 50%
Salt—COMA target	To reduce consumption of salt to 6g per day
Wales 2
Fruit and vegetables	To increase the proportion of adults aged 18-64 who eat green vegetables or salads most days to at least 40% by the year 2002
	To increase the proportion of adults aged 18-64 who eat fresh fruit most days to at least 55% by the year 2002
Scotland 3
Fat	To reduce the average percentage of food energy from total fat to no more than 35% by the year 2005
Saturated fat	To reduce the average percentage of food energy from saturated fatty acids to no more than 11% by the year 2005
Fruit and vegetables	To double the average intake of fruit and vegetables to more than 400g per day by the year 2005
Northern Ireland 4
Fat	To reduce the average contribution of total fat to dietary energy to 35%, by the year 2002
Saturated fat	To reduce the average contribution of saturated fat to dietary energy to 10% or less by the year 2002
Fruit and vegetables	To increase the average consumption of fruit and vegetables to at least five portions of fruit and vegetables each day by the year 2002
1. Department of Health (1994) Nutritional Aspects of Cardiovascular Disease. Report of the Cardiovascular Review Group of the Committee on Medical Aspects of Food Policy. HMSO: London. 2. The Welsh Office Health Department (1997) New Strategic Plans. DGM(97)74, New Strategic Plans: Revision of Targets, Welsh Office Circular. 11 June 1997. The Welsh Office: Cardiff. 3. The Scottish Office (1996) Eating for Health. A Diet Action Plan for Scotland. The Scottish Office: Edinburgh. 4. The Health Promotion Agency for Northern Ireland (1996) Eating and Health. A Food and Nutrition Strategy for Northern Ireland. HPANI: Belfast. Figure 2.1a Figure 2.1b Table 2.2 HOUSEHOLD CONSUMPTION OF ENERGY, FAT, SATURATED FAT, POLYUNSATURATED FAT, AND MONOUNSATURATED FAT, 1975-2000, GREAT BRITAIN Consumption per person per day

Percentage of food energy from fats
	Energy (kcal)
Energy (MJ)	Fat
Saturated fatty acids	Polyun- saturated fatty acids
Monoun- saturated fatty acids
1975	2,290
9.6	42.1
20.3	4.0
15.6
1976	2,280
9.5	41.4
19.8	4.1
15.7
1977	2,260
9.5	41.8
18.9	4.1
15.5
1978	2,260
9.5	42.2
18.8	4.2
15.7
1979	2,250
9.4	42.4
19.1	4.3
15.9
1980	2,230
9.3	42.8
18.9	4.6
16.0
1981	2,210
9.2	42.4
18.6	4.6
15.8
1982	2,180
9.1	42.5
18.3	5.0
16.0
1983	2,140
9.0	42.5
18.7	5.4
15.6
1984	2,060
8.6	42.4
18.3	5.5
15.3
1985	2,020
8.5	42.8
18.1	5.8
15.5
1986	2,070
8.7	42.6
17.7	6.2
15.6
1987	2,040
8.5	42.4
17.4	6.4
15.4
1988	2,000
8.4	41.9
17.2	6.4
15.2
1989	1,940
8.1	41.8
17.1	6.3
15.4
1990	1,872
7.8	41.3
16.6	6.7
15.3
1991	1,840
7.7	41.6
16.5	6.8
15.4
1992	1,860
7.8	41.6
16.3	7.0
15.4
1993	1,830
7.7	41.3
16.1	6.9
15.2
1994	1,790
7.5	40.2
15.6	7.0
14.9
1995	1,780
7.4	39.4
15.6	6.8
14.5
1996	1,850
7.8	39.9
15.4	7.2
14.3
1997	1,790
7.5	39.2
15.2	7.0
13.8
1998	1,740
7.3	38.8
15.2	7.0
13.8
1999	1,690
7.1	38.3
14.9	7.0
13.6
2000	1,750
7.3	38.2
15.0	6.9
13.5

Notes: Percentage of food energy calculated using the formula—(fat (g) x 9)/total energy (kcal) x 100. The figures for 1994-2000 use updated values for the nutritional composition of meat.

Source: Department for Environment, Foor and Rural Affairs (2001) National Foor Survey 2000. The Stationery Office: London, and previous editions.

Notes: Portions include fruit and vegetables consumed in composite dishes such as fruit pies, vegetable lasagne, cauliflour cheese and vegetable samosas.

Data are weighted for non-response.

Source: Office for National Statistics (2002). The National Diet and Nutrition Survey: adults aged 19 to 64 years. Volume 1. Types and quantities of foods consumed. The Stationery Office: London.

Notes: Men and women aged 16 and above.

Source: Department for Environment, Food and Rural Affairs (2001) National Food Survey 2000. The Stationery Office: London, and previous editions.

Figure 2.4a

Figure 2.4b

Figure 2.4c

Figure 2.4d

Table 2.5

Figure 2.5a

Figure 2.5b

Table 2.6

Table 2.7

Table 2.8

Table 2.10

Figure 2.10

Table 2.11

Physical activity

43. People who are physically active have a lower risk of CHD. To produce the maximum benefit the activity needs to be regular and aerobic. Aerobic activity involves using the large muscle groups in the arms, legs and back steadily and rhythmically so that breathing and heart rate are significantly increased.

44. It is estimated that about 36% of deaths from CHD in men and 38% of deaths from CHD in women are due to lack of physical activity and that 9% of deaths from CHD in the UK could be avoided if people who are currently sedentary or have a light level of physical activity increased their level of physical activity to a moderate level[17].

45. More recent research from the World Health Organization suggests these estimates may be too high, but confirm the importance of physical inactivity as a major risk factor for CHD. The World Health Report 2002 estimates that around 3% of all disease burden in developed countries is caused by physical inactivity, and that between 1 and 24% of CHD in developed countries is due to levels of physical activity below 2.5 hours moderate intensity activity per week[18].

46. The Government recommendation on physical activity is that adults should participate in a minimum of 30 minutes of at least moderate intensity activity (such as brisk walking, cycling or climbing the stairs) on five or more days of the week[19][20].

Overall levels of physical activity

47. Physical activity levels are low in the UK: only 37% of men and 25% of women meet the current guidelines suggested by the Government (Table 3.2). In addition, over one third of adults are currently inactive, that is participate in less that one occasion of 30 minutes activity a week (Table 3.2).

Age and sex differences

48. Physical activity declines rapidly with increasing age for both men and women, although for women this decline does not begin until the mid forties (Tables 3.2 and Figs 3.2a and 3.2b). Whereas 58% of men and 33% of women aged 16-24 are physically active for 30 minutes or more at least five days a week, this declines to 17% of men and 12% of women in the 65-74 age group (Table 3.2 and Figs 3.2a and 3.2b).

49. It is recommended that all children and young people aged 5-18 participate in physical activity of at least moderate intensity for one hour a day[21]. In England, 55% of boys aged 2-15 and 39% of girls, are active for at least an hour on five or more days a week (Table 3.3). Participation rates decline with age after around 8-10 years, with the steepest decline in girls. By the age of 15, less than one in five girls reach the recommended level of activity (Table 3.3 and Fig 3.3).

Temporal trends

50. It is generally thought that over the last 20 years, physical activity levels have declined in the UK[22]. Since 1994 the proportion meeting the current recommended level of physical activity has remained stable at 37% in men and increased slightly, from 22% to 25% in women; but the proportion classified as sedentary (less than one occasion of physical activity of 30 minutes a week) has increased from 30% in 1994 to 35% in 1998 in men, and from 35% to 41% in women (Table 3.2).

Regional differences

51. In Scotland, levels of physical activity are similar to those found in England for adults between the ages of 16 to 54. However, among those aged 55-74, adults in Scotland are less likely to meet current recommended levels[23].

Socio-economic differences

52. Socio-economic differences in physical activity are complex. In men, overall activity levels are greater in manual social classes than in non-manual classes: half of those working in unskilled manual employment meet current recommended levels compared to just under a third of those in professional jobs. In women, however, there is no clear pattern according to social class in the proportion meeting the recommended activity level (Table 3.4).

53. The type of activity, however, does vary with social class in men and women, with more work related activity in manual classes (especially in men) and sports activity (especially in women) in non-manual classes[24].

54. Overall activity levels vary by household income in men, being highest among those with midrange household incomes and lowest at both extremes of the income distribution. No pattern is apparent in women (Table 3.5). However, participation in two specific types of physical activity, sports/exercise and walking, increases with income in both men and women[25].

Ethnic differences

55. Compared with the general population, South Asian and Chinese men and women are less likely to participate in physical activity, with the lowest levels found in the Bangladeshi community. Only 18% of Bangladeshi men and 7% of Bangladeshi women meet the current recommended physical activity levels (30 minutes activity on five or more days a week). Black Caribbean men and women are the most likely to be physically active at the recommended level (Table 3.6 and Fig 3.6).

International differences

56. Levels of activity vary across European member states, with levels of activity in the UK falling below the EU average (Table 3.7 and Fig 3.7).

Targets

57. Only Scotland and Northern Ireland have physical activity targets (Table 3.1). Recent data from the Scottish Health Survey suggest good progress towards Scotland's physical activity targets for both men and women (Fig 3.1).

Activity levels relate to the scale developed for the Allied Dunbar National Fitness survey4. Activity level scale is based on the total number of occasions of moderate or vigorous intensity activity, of at least 20 minutes duration, during the previous four weeks:

Level 5 12 or more occasions of vigorous activity;

Level 4 12 or more occasions of a mix of moderate or vigorous activity;

Level 3 12 or more occasions of moderate activity;

Level 2 Five to 11 occasions of at least moderate activity;

Level 1 One to four occasions of at least moderate activity;<etLevel 0<ntNo occasions of moderate or vigorous activity.

1. The Scottish Office (1993) Towards a Healthier Scotland. The Scottish Office: Edinburgh.

2. Northern Ireland Physical Activity Strategy Group (1996) Be Active-Be Healthy: Northern Ireland Physical Activity Strategy 1996-2002. Health Promotion Agency for Northern Ireland: Belfast.

3. Department of Health and Social Services (1996) Health and Wellbeing: Into the Next Millennium. Department of Health and Social Services: Belfast.

4. Allied Dunbar National Fitness Survey (1992) Allied Dunbar National Fitness Survey Main Findings. The Sports Council and the Health Education Authority; London.

Figure 3.3

Table 3.2

Notes: Adults aged 16 and over.

Group 3= 30 minutes or more on at least five days a week;

Group 2= 30 minutes on one to four days a week;

Group 1= lower level of activity.

Source: Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office: London.

Figure 3.2a

Figure 3.2b

Table 3.3

Notes:<ntGroup 3=60 minutes or more on at least 5 days a week;

Group 2=30-59 minutes on at least 5 days a week;

Group 1=lower level of activity.<et

Source:<ntJoint Health Surveys Unit (1998) Health Survey for England: The Health of Young People '95-97. The Stationery Office: London.<et

Figure 3.3

Table 3.4

Notes: Adults aged 16 and over.

Age-standardised percentages. For method of age-standardisation see source.

Group 3= 30 minutes or more physical activity on at least five days a week;

Group 2= 30 minutes or more on one to four days a week;

Group 1= lower level of activity.

Source: Joint Health Surveys Unit (1999) Health Survey for England 1998.

Table 3.5

Notes: Adults aged 16 and over.

Age-standardised percentages. For method of age-standardisation see source.

Group 3= 30 minutes or more physical activity on at least five days a week;

Group 2= 30 minutes or more on one to four days a week;

Group 1= lower level of activity.

Source: Joint Health Surveys Unit (1999) Health Survey for England 1998. The Stationery Office.

Table 3.6

Notes: Adults aged 16 and over.

Age-standardised percentages (standardised risk ratios x percentage in general population). For observed values see source.

Source: Joint Health Surveys Unit (2001) Health Survey for England 1999. The Health of Minority Ethnic Groups. The Stationery Office: London.

Figure 3.6

Table 3.7

Notes: EU average weighted according to population size.

Source: Institute of European Food Studies, Trinity College, Dublin (1999) A Pan-EU Survey on Consumer Attitudes to Physical Activity, Body-weight and Health. IEFS: Dublin.

Figure 3.7

Statistics compile by the British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford. More statistics on Cardiovascular Disease and Coronary Heart Disease in the UK can be seen at www.heartstats.org

Further information on the British Heart Foundation can be found at www.BHF.org.uk or by contacting

Maura Gillespie, Head of Public Affairs 0207 487 7158 or gillespiem@bhf.org.uk

1 British Heart Foundation Heartstats, http://www.heartstats.org/topic.asp?id=345. Obesity is defined as a Body Mass Index (BMI) of 30kg/m2. Back

2 National Heart Forum (2002) Coronary heart disease: Estimating the impact of changes in risk factors. The Stationery Office. Back

3 World Health Organization (2002) The World Health Report 2002. Reducing Risks, Promoting Healthy Life. World Health Organization: Geneva. Back

4 Central obesity is commonly defined as a waist-hip ratio of 0.95 and over in men and 0.85 and over in women. Back

5 The classification of obesity in children and adolescents is more problematic than in adults, with no clear agreement on the best way to define obesity in this age group (World Health Organization (1998) Obesity. Preventing and managing the global epidemic. WHO: Geneva). In Table 1.6, reference growth charts have been used to classify children as overweight (BMI above 85th centile) or obese (BMI above 95th centile). In contrast, classification of obesity in Table 1.2 is based directly on BMI. These differences in definition and measurement make direct comparison of the adult and childhood tables inappropriate. Back

6 Serdula M, Ivery D, Coates R, Freedman D, Williamson D and Byers T (1993) Do obese children become obese adults? A review of the literature. Prev Med; 22:167-177. Back

7 European Heart Network (1998) Food, Nutrition and Cardiovascular Disease in the European Union. EHN: Brussels. Back

8 Department of Health (1994) Nutritional Aspects of Cardiovascular Disease. Report of the Cardiovascular Review Group of the Committee on Medical Aspects of Food Policy. HMSO: London. Back

9 World Health Organization (2002) The World Health Report 2002. Reducing Risks, Promoting Healthy Life. World Health Organization: Geneva. Back

10 Office of Population Censuses and Surveys Social Surveys Division (1990) The Dietary and Nutritional Survey of British Adults. HMSO: London. Back