DIET, NUTRITION AND THE PREVENTION OF CHRONIC DISEASES

This report contains the collective views of an international group of experts and does not necessarily represent the decisions
or the stated policy of the World Health Organization or of the Food and Agriculture Organization of the United Nations
WHO Technical Report Series
916
DIET, NUTRITION AND
THE PREVENTION OF
CHRONIC DISEASES
Report of a
Joint WHO/FAO Expert Consultation
World Health Organization
Geneva 2003

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WHO Library Cataloguing-in-Publication Data
Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of
Chronic Diseases (2002 : Geneva, Switzerland)
Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert
consultation, Geneva, 28 January -- 1 February 2002.
(WHO technical report series ; 916)
1.Chronic disease -- epidemiology 2.Diet -- standards
3.Feeding behavior 4.Energy metabolism 5.Motor activity
6.Cost of illness I.Title II.Series.
ISBN 92 4 120916 X
(NLM classification: QU 145)
ISSN 0512-3054
q World Health Organization 2003
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This publication contains the collective views of an international group of experts and does not
necessarily represent the decisions or the stated policy of the World Health Organization or of the Food
and Agriculture Organization of the United Nations.
Typeset and printed in Switzerland

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Contents
1. Introduction
1
Reference
3
2. Background
4
2.1 The global burden of chronic diseases
4
2.2 The double burden of diseases in the developing world
8
2.3 An integrated approach to diet-related and nutrition-related diseases
9
References
10
3. Global and regional food consumption patterns and trends
13
3.1 Introduction
13
3.2 Developments in the availability of dietary energy
14
3.3 Availability and changes in consumption of dietary fat
17
3.4 Availability and changes in consumption of animal products
20
3.5 Availability and consumption of fish
22
3.6 Availability and consumption of fruits and vegetables
23
3.7 Future trends in demand, food availability and consumption
25
3.8 Conclusions
27
References
29
4. Diet, nutrition and chronic diseases in context
30
4.1 Introduction
30
4.2 Diet, nutrition and the prevention of chronic diseases
through the life course
31
4.2.1 Fetal development and the maternal environment
31
4.2.2 Infancy
32
4.2.3 Childhood and adolescence
34
4.2.4 Adulthood
38
4.2.5 Ageing and older people
39
4.3 Interactions between early and later factors throughout the life course
40
4.3.1 Clustering of risk factors
41
4.3.2 Intergenerational effects
41
4.4 Gene--nutrient interactions and genetic susceptibility
41
4.5 Intervening throughout life
42
References
46
5. Population nutrient intake goals for preventing diet-related chronic diseases
54
5.1 Overall goals
54
5.1.1 Background
54
5.1.2 Strength of evidence
54
5.1.3 A summary of population nutrient intake goals
55
References
59
iii

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5.2 Recommendations for preventing excess weight gain and obesity
61
5.2.1 Background
61
5.2.2 Trends
61
5.2.3 Diet, physical activity and excess weight gain and obesity
61
5.2.4 Strength of evidence
62
5.2.5 General strategies for obesity prevention
67
5.2.6 Disease-specific recommendations
68
References
70
5.3 Recommendations for preventing diabetes
72
5.3.1 Background
72
5.3.2 Trends
72
5.3.3 Diet, physical activity and diabetes
73
5.3.4 Strength of evidence
73
5.3.5 Disease-specific recommendations
77
References
78
5.4 Recommendations for preventing cardiovascular diseases
81
5.4.1 Background
81
5.4.2 Trends
81
5.4.3 Diet, physical activity and cardiovascular disease
81
5.4.4 Strength of evidence
81
5.4.5 Disease-specific recommendations
87
References
91
5.5 Recommendations for preventing cancer
95
5.5.1 Background
95
5.5.2 Trends
95
5.5.3 Diet, physical activity and cancer
95
5.5.4 Strength of evidence
95
5.5.5 Disease-specific recommendations
101
References
101
5.6 Recommendations for preventing dental diseases
105
5.6.1 Background
105
5.6.2 Trends
105
5.6.3 Diet and dental disease
107
5.6.4 Strength of evidence
116
5.6.5 Disease-specific recommendations
119
References
119
5.7 Recommendations for preventing osteoporosis
129
5.7.1 Background
129
5.7.2 Trends
129
5.7.3 Diet, physical activity and osteoporosis
129
5.7.4 Strength of evidence
130
5.7.5 Disease-specific recommendations
131
References
132
6. Strategic directions and recommendations for policy and research
134
6.1 Introduction
134
iv

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6.2 Policy principles for the promotion of healthy diets
and physical activity
135
6.3 Prerequisites for effective strategies
136
6.3.1 Leadership for effective action
136
6.3.2 Effective communication
137
6.3.3 Functioning alliances and partnerships
138
6.3.4 Enabling environments
138
6.4 Strategic actions for promoting healthy diets and physical activity
142
6.4.1 Surveillance of people’s diets, physical activity
and related disease burden
142
6.4.2 Enabling people to make informed choices
and take effective action
142
6.4.3 Making the best use of standards and legislation
142
6.4.4 Ensuring that ‘‘healthy diet’’ components are available to all
143
6.4.5 Achieving success through intersectoral initiatives
143
6.4.6 Making the best use of health services and the
professionals who provide them
143
6.5 Call to action
143
Reference
144
Acknowledgements
144
Annex
Summary of the strength of evidence for obesity, type 2 diabetes,
cardiovascular disease (CVD), cancer, dental disease and osteoporosis
148
v

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Joint WHO/FAO Expert Consultation on Diet, Nutrition
and the Prevention of Chronic Diseases
Geneva, 28 January--1 February 2002
Members
Dr E.K. Amine, Dean, High Institute of Public Health, Alexandria University,
Alexandria, Egypt
Dr N.H. Baba, Chairperson, Department of Nutrition and Food Sciences, American
University of Beirut, Beirut, Lebanon
Dr M. Belhadj, Professor of Internal Medicine and Diabetologia, Centre Hospitalier
Universitaire, Oran, Algeria
Dr M. Deurenberg-Yap, Director, Research and Information Management, Health
Promotion Board, Singapore (Co-Rapporteur)
Dr A. Djazayery, Professor of Nutrition, Department of Nutrition and Biochemistry,
School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic
Republic of Iran
Dr T. Forrester, Director, Tropical Medicine Research Institute, The University of the
West Indies, Kingston, Jamaica
Dr D.A. Galuska, Division of Nutrition and Physical Activity, National Center for
Chronic Disease, Prevention and Health Promotion, Centers for Disease Control
and Prevention, Atlanta, GA, USA
Dr S. Herman, Senior Researcher, Nutrition Research and Development Centre,
Ministry of Health, Bogor, Indonesia
Professor W.P.T. James, Chairman, International Obesity Task Force, London,
England
Dr J.R. M’Buyamba Kabangu, Hypertension Unit, Department of Internal Medicine,
University of Kinshasa Hospital, Kinshasa, Democratic Republic of the Congo
Professor M.B. Katan, Division of Human Nutrition and Epidemiology, Wageningen
University, Wageningen, Netherlands
Dr T.J. Key, Cancer Research UK, Epidemiology Unit, University of Oxford, The
Radcliffe Infirmary, Oxford, England
Professor S. Kumanyika, Center for Clinical Epidemiology and Biostatistics, School of
Medicine, University of Pennsylvania, Philadelphia, PA, USA (Vice-Chairperson)
Professor J. Mann, Department of Human Nutrition, University of Otago, Dunedin,
New Zealand
Dr P.J. Moynihan, School of Dental Sciences, University of Newcastle-upon-Tyne,
Newcastle-upon-Tyne, England
Dr A.O. Musaiger, Director, Environmental and Biological Programme, Bahrain
Centre for Studies and Research, Manama, Bahrain
Dr G.W. Olwit, Kampala, Uganda
Dr J. Petkeviciene, Institute for Biomedical Research, Kaunas Medical University,
Kaunas, Lithuania
vi

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Dr A. Prentice, Director, Human Nutrition Research, Medical Research Council,
Cambridge, England
Professor K.S. Reddy, Department of Cardiology, Cardiothoracic Centre, All India
Institute of Medical Science, New Delhi, India
Dr A. Schatzkin, Nutritional Epidemiology Branch, National Cancer Institute, National
Institute of Health, Rockville, MD, USA
Professor J.C. Seidell, National Institute of Public Health and the Environment,
Bilthoven, Netherlands (Co-Rapporteur)
Dr A.P. Simopoulos, President, The Center for Genetics, Nutrition and Health,
Washington, DC, USA
Professor S. Srianujata, Director, Institute of Nutrition, Mahidol University, Nakhon
Pathom, Thailand
Dr N. Steyn, Chronic Diseases of Lifestyle, Medical Research Council, Tygerberg,
South Africa
Professor B. Swinburn, School of Health Sciences, Deakin University, Melbourne,
Victoria, Australia
Dr R. Uauy, Institute of Nutrition and Food Technology, University of Chile, Santiago,
Chile; and Department of Epidemiology and Population Health, London School of
Hygiene and Tropical Medicine, London, England (Chairperson)
Dr M. Wahlqvist, Director, Asia Pacific Health and Nutrition Centre, Monash Asia
Institute, Monash University, Melbourne, Victoria, Australia
Professor Wu Zhao-Su, Institute of Heart, Lung and Blood Vessel Diseases, Beijing,
China
Dr N. Yoshiike, Division of Health and Nutrition Monitoring, National Institute of Health
and Nutrition, Tokyo, Japan
Representatives of other organizations*
United Nations Administrative Committee on Coordination/Subcommittee on Nutrition
(ACC/SCN),
Dr S. Rabenek, Technical Secretary, ACC/SCN, Geneva, Switzerland
Secretariat{
Dr K. Bagchi, Regional Adviser, Nutrition, Food Security and Safety, WHO Regional
Office for the Eastern Mediterranean, Cairo, Egypt
Dr T. Cavalli-Sforza, Regional Adviser, Nutrition, WHO Regional Office for the Western
Pacific, Manila, Philippines
*
Unable to attend: International Atomic Energy Agency, Vienna, Austria; Secretariat of the Pacific
Community, Noumea, New Caledonia; United Nations Children’s Fund, New York, NY, USA; United
Nations University, Tokyo, Japan; World Bank, Washington, DC, USA.
{
Unable to attend: Dr H. Delgado, Director, Institute of Nutrition of Central America and Panama,
Guatemala City, Guatemala; Dr F.J. Henry, Director, Caribbean Food and Nutrition Institute, The
University of the West Indies, Kingston, Jamaica.
vii

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Dr G.A. Clugston, Director, Department of Nutrition for Health and Development,
Sustainable Development and Healthy Environments, WHO, Geneva, Switzerland
Dr I. Darnton-Hill, Department of Noncommunicable Disease Prevention and Health
Promotion, Noncommunicable Diseases and Mental Health, WHO, Geneva,
Switzerland
Professor A. Ferro-Luzzi, National Institute for Food and Nutrition Research, Rome,
Italy (Temporary Adviser)
Dr J. Leowski, Regional Adviser, Noncommunicable Diseases, WHO Regional Office
for South-East Asia, New Delhi, India
Dr C. Nishida, Department of Nutrition for Health and Development, Sustainable
Development and Healthy Environments, WHO, Geneva, Switzerland (Secretary)
Dr D. Nyamwaya, Medical Officer, Health Promotion, WHO Regional Office for Africa,
Harare, Zimbabwe
Dr A. Ouedraogo, Regional Officer, Nutrition, WHO Regional Office for Africa, Harare,
Zimbabwe
Dr P. Pietinen, Department of Noncommunicable Disease Prevention and Health
Promotion, Noncommunicable Diseases and Mental Health, WHO, Geneva,
Switzerland
Dr P. Puska, Director, Department of Noncommunicable Disease Prevention and
Health Promotion, Noncommunicable Diseases and Mental Health, WHO,
Geneva, Switzerland
Dr E. Riboli, International Agency for Research on Cancer, Lyon, France
Dr A. Robertson, Regional Adviser, Nutrition and Food Security Programme, WHO
Regional Office for Europe, Copenhagen, Denmark
Dr P. Shetty, Chief, Nutrition Planning, Assessment and Evaluation Service, Food and
Nutrition Division, FAO, Rome, Italy
Dr R. Weisell, Nutrition Planning, Assessment and Evaluation Service, Food and
Nutrition Division, FAO, Rome, Italy
Dr D. Yach, Executive Director, Noncommunicable Diseases and Mental Health,
WHO, Geneva, Switzerland
viii

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Abbreviations
The following abbreviations are used in this report:
ACC
United Nations Administrative Committee on Coordination
AIDS
acquired immunodeficiency syndrome
BMI
body mass index
CARMEN
Carbohydrate Ratio Management in European National diets
CHD
coronary heart disease
CVD
cardiovascular disease
DALY
disability-adjusted life year
DASH
dietary approaches to stop hypertension
DEXA
dual-energy X-ray absorptiometry
DHA
docosahexaenoic acid
dmf
decayed, missing, filled primary (teeth)
DMF
decayed, missing, filled permanent (teeth)
dmft
decayed, missing, filled primary teeth
DMFT
decayed, missing, filled permanent teeth
DONALD
Dortmund Nutritional and Anthropometric Longitudinally
Designed Study
ECC
early childhood caries
EPA
eicosapentaenoic acid
EPIC
European Prospective Investigation into Cancer and Nutrition
ERGOB
European Research Group for Oral Biology
FAOSTAT
Food and Agricultural Organization of the United Nations
Statistical Databases
FER
fat to energy ratio
GDP
gross domestic product
GISSI
Gruppo Italiano por lo Studio della Sopravvivenza nell’Infarto
Miocardico
GNP
gross national product
HBP
high blood pressure
HDL
high-density lipoprotein
HFI
hereditary fructose intolerance
HIV
human immunodeficiency virus
HOPE
Heart Outcomes Prevention Evaluation
IARC
International Agency for Research on Cancer
IDDM
insulin-dependent diabetes mellitus
IGT
impaired glucose tolerance
IHD
ischaemic heart disease
ix

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IUGR
intrauterine growth retardation
LDL
low-density lipoprotein
MGRS
multicentre growth reference study (i.e. the WHO MGRS study)
mRNA
messenger ribonucleic acid
MSG
monosodium glutamate
MUFA
monounsaturated fatty acid
NCD
noncommunicable disease
NGO
nongovernmental organization
NIDDM
non-insulin-dependent diabetes mellitus
NSP
non-starch polysaccharides
PUFA
polyunsaturated fatty acid
RCT
randomized controlled trial
SCN
ACC Subcommittee on Nutrition1
SFA
saturated fatty acid
T1DM
type 1 diabetes
T2DM
type 2 diabetes
VLDL
very low-density lipoprotein
WCRF
World Cancer Research Fund
WHR
waist:hip circumference ratio or waist:hip ratio
1
In April 2002 the name of the Subcommittee on Nutrition was changed to the United Nations System
Standing Committee on Nutrition.
x

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