Dietary guidelines for adults in Greece
MINISTRY OF HEALTH AND WELFARE
Supreme Scientific Health Council
The need to establish food-based dietary guidelines for the Greek population.
Several countries have formulated their own national food-based dietary guidelines (FBNG) (World Health Organisation, 1998). The United States FBNG (US Department of Agriculture - US Department of Health and Human Services, 1995), depicted in the form of a food pyramid, have been widely publicized and can be accessed through the internet (http://www.pueblo.gsa.gov/cic_text/food/dietgd/ dietgd.html). A Harvard-led group, with substantial input from Greek scientists, has also developed an alternative pyramid based on the principles of the traditional Mediterranean diet (Willett et al, 1995). Within Europe, several countries have developed their own FBNG. A report to the European Parliament (Trichopoulou A, ed., 1997) pointed out that the traditional Mediterranean diet has several advantages over other traditional healthy dietary patterns. The development of FBNG for Europe is currently the objective of a large European Union funded project. In Greece, the Ministry of Health has issued a poster depicting a Greek version of the Harvard developed Mediterranean diet pyramid, acknowledging the importance of this pattern for the health of the Greek population (Greek Ministry of Health, Division of Health Education, Mediterranean Diet Pyramid poster. Source: National Nutrition Center). Moreover, the Hellenic Supreme Scientific Health Council has recently called for the development of a document summarizing FBNG for the Greek population, taking into account evidence from studies in this population. The reasons dictating the development of FBNG specifically for the Greek population are the following:
- In the late '60s, Greece enjoyed low mortality rates from coronary heart disease and several forms of cancer, conditions that appear to have strong nutritional etiological components. Increasing mortality from these diseases over the last three decades has followed the westernization of the dietary patterns of a large segment of the Greek population. This can be considered as evidence that the model diet for the Greek population closely approximates the traditional Greek diet in the late '50s.
- A series of case-control studies, undertaken in Greece during the last two decades, have provided evidence that several forms of cancer, coronary heart disease and other chronic diseases (Manousos et al, 1985; Trichopoulos et al, 1985; Katsouyanni et al, 1991; Trichopoulou et al, 1995a; Tzonou et al, 1999; Lagiou et al, 1999) have powerful inverse relations with critical components of the traditional Greek diet. These findings were compatible with those previously or subsequently reported from other major studies.
- There has been a successful attempt to operationalize the critical components of the traditional Greek diet and translate them into a uni-dimensional score (Trichopoulou et al, 1995b). This score has been found to predict total mortality in the Greek (Trichopoulou et al, 1995c), as well as in other populations (Osler and Schroll, 1997; Kouris-Blazos et al, 1999). Essentially, these data confirm, at the proper individual level, the ecological evidence generated by the classical Keys study (Keys, 1980; Keys et al, 1986).
- Several studies in Greece have pointed out critical dietary changes (Trichopoulou and Eftathiadis, 1989; Kafatos et al, 1993; Trichopoulou et al, 1993; Kafatos et al, 1997; Roma-Giannikou et al, 1997) in the Greek population. These changes could be targeted for reversal. Moreover, changes in nutrition-related parameters, such as obesity and blood lipids, have been identified and could represent important intermediate objectives in any strategy for nutritional changes.
- There is a wealth of information from the Food and Agriculture Organization (FAO) food balance sheets, household budget surveys (Trichopoulou, 1992a), surveys of healthy individuals (Kafatos et al, 1993), case-control studies (Trichopoulos et al, 1991) and the large prospective European study EPIC (Gnardellis et al, 1998) concerning the contemporary Greek diet and its variation across socioeconomic strata. This information facilitates the establishment of critical categories targeted for preservation or change.
- The Greek population, like other Mediterranean populations, is unusual in its accessibility to olive oil, a food which is both important in itself and also facilitates the adoption of a versatile dietary pattern rich in fresh vegetables, as well as cooked vegetables, pulses and even cereals.
- The existence of food composition tables for Greek foods and recipes (Trichopoulou, 1992b) allows the translation of dietary intakes into nutritional intakes.
- The proximity of the traditional Greek diet to an optimal diet resolves the conflict between two schools of thought, the one arguing that guidelines should focus on optimal consumption and the other stating that guidelines should target realistic changes.
- Dietary guidelines for the Greek population should be as simple as possible. Experience with tobacco smoking indicates that Greeks are highly resistant to health messages. People should not be given the excuse that guidelines are, or appear to be, too sophisticated to allow general adherence to. Even simple guidelines, as those of the Unites States, require more attention than the average healthy Greek is ready to dedicate to the scientific rationale for dietary guidelines.
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