4. Diet, nutrition and chronic diseases in context

4.1 Introduction

The diets people eat, in all their cultural variety, define to a large extent people’s health, growth and development. Risk behaviours, such as tobacco use and physical inactivity, modify the result for better or worse. All this takes place in a social, cultural, political and economic environment that can aggravate the health of populations unless active measures are taken to make the environment a health-promoting one.

Although this report has taken a disease approach for convenience, the Expert Consultation was mindful in all its discussions that diet, nutrition and physical activity do not take place in a vacuum. Since the publication of the earlier report in 1990 (1), there have been great advances in basic research, considerable expansion of knowledge, and much community and international experience in the prevention and control of chronic diseases. At the same time, the human genome has been mapped and must now enter any discussion of chronic disease.

Concurrently there has been a return to the concept of the basic life course, i.e. of the continuity of human lives from fetus to old age. The influences in the womb work differently from later influences, but clearly have a strong effect on the subsequent manifestation of chronic disease. The known risk factors are now recognized as being amenable to alleviation throughout life, even into old age. The continuity of the life course is seen in the way that both undernutrition and overnutrition (as well as a host of other factors) play a role in the development of chronic disease. The effects of man-made and natural environments (and the interaction between the two) on the development of chronic diseases are increasingly recognized. Such factors are also being recognized as happening further and further “upstream” in the chain of events predisposing humans to chronic disease. All these broadening perceptions not only give a clearer picture of what is happening in the current epidemic of chronic diseases, but also present many opportunities to address them. The identities of those affected are now better recognized: those most disadvantaged in more affluent countries, and - in numerical terms far greater - the populations of the developing and transitional worlds.

There is a continuity in the influences contributing to chronic disease development, and thus also to the opportunities for prevention. These influences include the life course; the microscopic environment of the gene to macroscopic urban and rural environments; the impact of social and political events in one sphere affecting the health and diet of populations far distant; and the way in which already stretched agriculture and oceanic systems will affect the choices available and the recommendations that can be made. For chronic diseases, risks occur at all ages; conversely, all ages are part of the continuum of opportunities for their prevention and control. Both undernutrition and overnutrition are negative influences in terms of disease development, and possibly a combination is even worse; consequently the developing world needs additional targeting. Those with least power need different preventive approaches from the more affluent. Work has to start with the individual risk factors, but, critically, attempts at prevention and health promotion must also take account of the wider social, political and economic environment. Economics, industry, consumer groups and advertising all must be included in the prevention equation.

4.2 Diet, nutrition and the prevention of chronic diseases through the life course

The rapidly increasing burden of chronic diseases is a key determinant of global public health. Already 79% of deaths attributable to chronic diseases are occurring in developing countries, predominantly in middleaged men (2). There is increasing evidence that chronic disease risks begin in fetal life and continue into old age (3-9). Adult chronic disease, therefore, reflects cumulative differential lifetime exposures to damaging physical and social environments.

For these reasons a life-course approach that captures both the cumulative risk and the many opportunities to intervene that this affords, was adopted by the Expert Consultation. While accepting the imperceptible progression from one life stage to the next, five stages were identified for convenience. These are: fetal development and the maternal environment; infancy; childhood and adolescence; adulthood; and ageing and older people.

4.2.1 Fetal development and the maternal environment

The four relevant factors in fetal life are: (i) intrauterine growth retardation (IUGR); (ii) premature delivery of a normal growth for gestational age fetus; (iii) overnutrition in utero; and (iv) intergenerational factors. There is considerable evidence, mostly from developed countries, that IUGR is associated with an increased risk of coronary heart disease, stroke, diabetes and raised blood pressure (9-20). It may rather be the pattern of growth, i.e. restricted fetal growth followed by very rapid postnatal catch-up growth, that is important in the underlying disease pathways. On the other hand, large size at birth (macrosomia) is also associated with an increased risk of diabetes and cardiovascular disease (16, 21). Among the adult population in India, an association was found between impaired glucose tolerance and high ponderal index (i.e. fatness) at birth (22). In Pima Indians, a U-shaped relationship to birth weight was found, whereas no such relationship was found amongst Mexican Americans (21, 23). Higher birth weight has also been related to an increased risk of breast and other cancers (24).

In sum, the evidence suggests that optimal birth weight and length distribution should be considered, not only in terms of immediate morbidity and mortality but also in regard to long-term outcomes such as susceptibility to diet-related chronic disease later in life.

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