require international coordination by WHO. WHO’s babyfriendly hospital initiative to promote breastfeeding will also reduce SIDS and deserves full support.10
*Jacobus P van Wouwe, Remy A HiraSing
Prevention and Care, Netherlands Organisation for Applied Scientiﬁc Research TNO, 2301 CE Leiden, Netherlands (JPvW, RAHS); and Department of Public and Occupational Health, VU Medical Centre, Amsterdam, Netherlands (RAHS) [email protected]
We declare we have no conﬂict of interest. We thank G A de Jonge, Oegstgeest, Netherlands, for the ﬁgure. 1
Blair PS, Sidebotham P, Berry PJ, Evans M,Fleming PJ. Major epidemiological changes in sudden infant death syndrome: a 20-year population based study in the UK. Lancet 2006; 367: 314–19. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 2005; 116: 1245–55.
Jonge GA de, Hoogenboezem J. Epidemiology of 25 years of cot death (sudden infant death syndrome) in the Netherlands: incidence of cot death and prevalence of risk factors in 1980–2004 [in Dutch]. Ned Tijdschr Geneekd 2005; 149: 1273–78. Abramson H. Accidental mechanical suffocation in infants. Pediatrics 1944; 25: 404–13. Gilbert R, Salanti G, Hareden M, See S. Infants sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. Int J Epidemiol 2005; 34: 874–87. Hirasing RA, Zaal MAE van, Meulmeester JF, Verbrugge HP. Child health in the Netherlands: facts and ﬁgures. Leiden: TNO Prevention and Health, 1997. Olds DL, Robinson J, Pettitt L, et al. Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial. Pediatrics 2004; 114: 1560–68. DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 2004; 113: S1007–15. Flodmark CE, Lissau I, Moreno LA, Pietrobelli A, Widhalm K. New insights into the ﬁeld of children and adolescents’ obesity: the European perspective. Int J Obes Relat Metab Disord 2004; 28: 1189–96. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Geneva: WHO, 2001.
Eat your fruit and vegetables
Selected risk factors
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Your parents were smart when they told you to eat all of your vegetables, and encouraged you to eat your fruit, but they probably did not know that eating more fruit and vegetables would lower the risk of stroke.1,2 Results of epidemiological studies of the relation between intakes of nutrients in fruit and vegetables, such as vitamin C or beta-carotene, and risk of stroke have been inconsistent.3,4 However, disease prevention might not be attributable to single nutrients, but to the interaction of nutrient and non-nutritive components in whole foods. Fruit and vegetables are rich in many healthpromoting nutrients and food compounds, including antioxidants such as vitamin C and folate, potassium,
Blood pressure Obesity Tobacco Cholesterol Low fruit/veg intake Physical inactivity Alcohol Urban air pollution Occupational injuries Occupational particulates Lead exposure Illicit drugs Occupational carcinogens 0
Deaths in millions
Figure: Number of deaths worldwide attributable to selected risk factors,13 2000
phytochemicals, dietary ﬁbre, and plant proteins that have been inversely related to high blood pressure and stroke.3–8 It is likely that the combination of nutrients and compounds in foods has greater health beneﬁts than the individual nutrient alone.9 In this week’s Lancet, a meta-analysis by Feng He and colleagues provides strong evidence of an inverse relation between fruit and vegetable intake and risk of stroke.1 Compared with individuals who consumed less than 3 servings of fruit and vegetables per day, those who ate more than 5 daily servings of fruit and vegetables had a 26% lower risk of stroke, while 3–5 servings per day conferred a 9% lower risk. Less than a quarter of adults in the USA eat 5 or more servings of fruit and vegetables per day, and there is therefore a serious need to develop and implement public-health strategies to achieve this dietary goal. In 1991, a national nutrition education campaign, the 5 A Day for Better Health programme, was created. Despite awareness of the “5 A Day” message,10 the proportion of adults in the USA eating 5 or more daily servings of fruit and vegetables, has only risen from 19% to 23% during the last 14 years. On average, American adults eat 3·75 servings (or 1·75–2 cups or 400–455 g) of fruit and vegetables per day,11 considerably less than the 2005 US Dietary Guidelines recommendation of 3·5–5 cups (or 800–1150 g) of fruit and vegetables daily.12 www.thelancet.com Vol 367 January 28, 2006
Low intake of fruit and vegetables is a major modiﬁable risk factor contributing to the burden of ill health (ﬁgure).13 Because increased fruit and vegetable consumption may prevent adulthood diseases including stroke,1 CHD,3,5,6 some cancers,14 and other chronic disease,15 additional efforts are needed to promote healthy eating habits in children and adults. The Commission of the European Communities and the US Food and Nutrition Board at the Institute of Medicine, National Academies of Science released reports at the end of 2005,16,17 which describe the growing problems of obesity and associated chronic disease. The European report calls for concrete suggestions for promoting the health of the population, including, but not limited to, improving the availability and affordability of fruits and vegetables, selfregulation in the food and advertising industry, and nutrition education. The report from the USA targets advertising and marketing campaigns as culprits, and challenges the industry to focus on and promote the health and diets of children and young people today.17 Present advertising practices target young people and promote foods and drinks high in fat and sugar.17,18 Because food habits develop in childhood, we must protect young people from developing chronic disease early in life. Therefore, partnerships must be formed between public-health agencies, state and local government, schools, and the food industry and the media to promote healthy food choices. We, as a society, must provide the structure and means for our children to develop healthy eating habits that promote good health into adulthood. So eat your fruit and vegetables, they are good for your health. Lyn M Steffen University of Minnesota School of Public Health, Division of Epidemiology and Community Health, Minneapolis, Minnesota 55454, USA [email protected]
I declare that I have no conﬂict of interest. 1 2
He FJ, Nowson CA, MacGregor GA. Fruit and vegetable consumption and stroke: a meta-analysis of cohort studies. Lancet 2006; 367: 320–26. Ness AR, Maynard M, Frankel S, et al. Diet in childhood and adult cardiovascular and all cause mortality: the Boyd Orr cohort. Heart 2005; 91: 894–98. Ness AR, Powles JW. Fruit and vegetables, and cardiovascular disease: a review. Int J Epidemiol 1997; 26: 1–13. Leppala JM, Virtamo J, Fogelholm R, et al. Controlled trial of alphatocopherol and beta-carotene supplements on stroke incidence and mortality in male smokers. Arterioscler Thromb Vasc Biol 2000; 20: 230–35. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336: 1117–24. Steffen LM, Kroenke CH, Yu X, et al. Associations of plant foods, dairy products, and meat consumption with ﬁfteen-year incidence of elevated blood pressure in young black and white adults: The CARDIA Study. Am J Clin Nutr 2005; 82: 1169–77. John JH, Ziebland S, Yudkin P, Roe LS, Neil HA, for the Oxford Fruit and Vegetable Study Group. Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised controlled trial. Lancet 2002; 359: 1969–74. Bazzano LA, He J, Ogden LG, et al. Dietary intake of folate and risk of stroke in US men and women: NHANES I epidemiologic follow-up study. National health and nutrition examination survey. Stroke 2002; 33: 1183–88. Jacobs DR, Steffen LM. Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr 2003; 78 (suppl): 508S–13. Foerster SB, Kizer KW, Disogra LK, Bal DG, Krieg BF, Bunch KL. California’s “5 a day-for better health!” campaign: an innovative population-based effort to effect large-scale dietary change. Am J Prev Med 1995; 11: 124–31. Li R, Serdula M, Bland S, Mokdad A, Bowman B, Nelson D. Trends in fruit and vegetable consumption among adults in 16 US states: behavioral risk factor surveillance system, 1990–1996. Am J Public Health 2000; 90: 777–81. US Department of Agriculture, US Department of Health and Human Services. MyPyramid.gov: steps to a healthier you. http://www. mypyramid.gov/ (accessed Nov 20, 2005). WHO. The world health report 2002: reducing risks, promoting health. 2002: http://www.who.int/whr/2002/en/whr02_en.pdf (accessed Nov 12, 2005). Riboli E, Norat T. Epidemiologic evidence of the protective effect of fruit and vegetables on cancer risk. Am J Clin Nutr 2003; 78: 559S–69. New SA, Robins SP, Campbell MK, et al. Dietary inﬂuences on bone mass and bone metabolism: further evidence of a positive link between fruit and vegetable consumption and bone health. Am J Clin Nutr 2000; 71: 142–51. Commission of the European Communities. Green paper: promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic disease. Aug 12, 2005: http://europa. eu.int/comm/health/ph_determinants/life_style/nutrition/documents/ nutrition_gp_en.pdf (accessed Dec 9, 2005). Institute of Medicine, National Academy of Sciences, Food and Nutrition Board. Food marketing to children and youth: threat or opportunity. Dec 6, 2005: http://www.iom.edu/CMS/3788/21939/31330.aspx (accessed Dec 7, 2005). Kotz K, Story M. Food advertisements during children's Saturday morning television programming: are they consistent with dietary recommendations? J Am Diet Assoc 1994; 94: 1296–300.
Seeking equity in maternal health In today’s Lancet, Mahbub Chowdhury and colleagues1 take an interesting perspective in the debate about home-based versus facility-based childbirth by considering issues of equity. Inequity in reproductive health between and within countries is well documented, and www.thelancet.com Vol 367 January 28, 2006
even where indicators improve, disparities between rich and poor are as likely to be increasing as decreasing.2 In addition to improving access, it must also be ensured that services are widely used. Because advantaged groups are known to be more apt at using preventive
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