Increased health inequalities are a result of poverty and social inequalities. Examples of how food intake is affected by poverty exist throughout the European Region. The diets of low-income groups are likely to be inadequate. Low-income groups and specific groups such as children, adolescents, pregnant and lactating women, and older people often face problems gaining access to a healthy variety of safe foods. Safe healthy food may not be accessible to those most in need. Yet access to a safe and varied healthy diet is a fundamental human right and policies are needed to address this.

Low birthweight is now known to be associated with increased rates of coronary heart disease and the related disorders stroke, hypertension and non-insulin dependent diabetes. These associations have been extensively replicated in studies in different countries and are not the result of confounding variables. They extend across the normal range of birthweight and depend on lower birthweights in relation to the duration of gestation rather than the effects of premature birth. The associations are thought to be consequences of ‘programming’, whereby a stimulus or insult at a critical, sensitive period of early life has permanent effects on structure, physiology and metabolism. Programming of the fetus may result from adaptations invoked when the materno-placental nutrient supply fails to match the fetal nutrient demand. Although the influences that impair fetal development and programme adult cardiovascular disease remain to be defined, there are strong pointers to the importance of maternal body composition and dietary balance during pregnancy.

The health of elderly people is often affected by inadequate nutritional intake. Psychosocial determinants and the higher prevalence of acute and chronic illnesses are risk factors for nutritional deficiencies in the elderly. Nutritional assessment (NA) or nutritional risk screening must be an important elements in care programmes for elderly people in the community and should be part of all geriatric assessment programmes.

In a successful pregnancy maternal health is maintained, a healthy baby is delivered and the mother is able to nurture her newborn adequately. Despite continued interest in the role and importance of maternal diet in this process, we do not have a clear understanding of how the nutritional status of the mother influences fetal growth and development. Recent epidemiological evidence of an association between poor fetal growth and adult disease highlights the need to reconsider the influences which act on the fetus, and the role maternal nutrition may play.

Nutrient needs are increased in pregnancy. For the mother to be solely dependent upon her dietary intake to meet these demands, would represent a very high risk strategy. Hence adequate reserves are important for a successful outcome. Whilst there are numerous observational studies of diet during pregnancy, there are only limited data from well-controlled, randomised supplementation studies. A recent systematic review showed only dietary supplements balanced in energy and protein content to result consistently in improved fetal growth. There is no strong evidence that nutrient supplements confer benefit in women without overt deficiency.

To interpret future dietary studies in pregnancy we need to consider metabolic differences between women which may influence their ability to meet fetal nutrient demand, to allow for nutrient–nutrient interactions, and to take account of differences in timing in gestation. Consideration of these factors in studies of pregnancy, will lead to a clearer understanding of the links between maternal diet and fetal growth and development. Until we have this understanding, it is reasonable to expect that women entering pregnancy are provided with a diet which is adequate, based upon our normal understanding of requirements, and it is not acceptable for women to be expected to carry a pregnancy with an obvious or overt nutritional deficiency.

Nutritional support in the elderly not only co-operates inpharmacological treatment but also very often is a primary therapy for their health. The type of artificial nutrition (AN) to use will depend on the present illness and the previous health record. Due to the fact that enteral feeding (EF) is less expensive and aggressive we should use EF whenever possible, leaving parenteral nutrition (PN) for specific situations where EF should not be used. AN, if properly prescribed, formulated, administered and monitored, is safe as long as qualified personnel are trained in its use. Combined AN (oral, enteral and parenteral) allows a step-by-step improvement that could lead to final oral feeding. Finally, while it is true that age should not be considered in isolation as a contraindication for AN, we should be aware that, in final life stages, oral feeding can be the only satisfaction left for the elderly.

The reviewed literature indicates that, even in industrialised countries, the nutrition of mature and aged subjects is often inadequate (because of deficiency or excess), which may lead to premature or pathological senescence.

Recent nutritional research on ageing laboratory animals shows that dietary restriction may be the most effective procedure to achieve along and disease-free life span, probably owing to a better protection against mitochondria-linked oxygen stress. Likewise, the experimental and clinical work from many laboratories, including our own, indicates that age-dependent changes in the cardiovascular and immune systems are linked to oxygen stress and that an adequate intake of dietary antioxidants may protect those systems against chronic degenerative syndromes in the physiopathology of which reactive oxygen species (ROS) play a key role.

The extant data indicate that the antioxidant vitamins C and E are centrally involved in defending the above two systems against ROS attack. Moreover, recent research suggests that the glutathione-related thiolic antioxidants, thiazolidine carboxylic acid (thioproline) and N-acetylcysteine, as well as the phenolic liposoluble ‘co-antioxidants’ of Curcuma longa, may have a significant protective effect against age-related atherogenesis and immune dysfunction.

Key messages from this paper are the following. (1) It is generally accepted that oxygen free radicals released in metabolic reactions play a key role in the physiopathology of ‘normal ageing’ and of many age-related degenerative diseases. (2) Consumption of adequate levels of antioxidants in the diet is essential in order to preserve health in old age. (3) A certain degree of protection against atherogenesis and immune dysfunction may be achieved by preventing vitamin E deficiency and an excessive oxidation of the glutathione-supported thiol pool.

Recommendations suggest exclusive breastfeeding for at least the first 4 to 6 months after birth. Paradoxically, an overwhelming proportion of breastfeeding (BF) data in Europe refers to all BF, i.e. not only exclusive but also partial BF (including formula, juices, water, sweetened water etc). This makes it difficult to estimate to what extent the recommendations are met. There is currently strong evidence for recommending exclusive breastfeeding for at least 6 months.

Exclusive BF has progressively gained scientific support. Prevention of infections, allergies and chronic diseases and a favourable cognitive development are highlighted in the recent scientific literature. Further long-term studies on the effects of BF on prevention of chronic disease in the adult are needed.

Great differences exist in BF prevalence and duration both within and between European countries. Trends point towards higher prevalence and duration, with some exceptions. Young mothers breastfeed less than older mothers; single and/or less educated mothers breastfeed less than married mothers with more education. However, inefficient and unreliable monitoring systems prevail, and the data are scarce, not only on exclusive BF but also on demographic, socio-economic, psychosocial and medical determinants of BF patterns. National BF co-ordinators have not been appointed in many countries, and only every second country has promotion of BF incorporated into their national plan of action for nutrition.

Effective population-based strategies require people trained and competent in the discipline of Public Health Nutrition. Since 1997, a European Master's Programme in Public Health Nutrition has been undergoing planning and implementation, by establishing initial quality assurance systems with the aid of funding from the European Commission (DG SANCO/F3). Partners from 17 European countries have been involved in the process. A European Network of Public Health Nutrition has been developed and accredited by the European Commission.

The aim of this paper is to highlight the importance of an evidence-based approach to the development, implementation and evaluation of policies aimed at improving nutrition-related health in the population. Public Health Nutrition was established to realise a population-level approach to the prevention of the major nutrition-related health problems world-wide. The scope is broad and integrates activity from local, national, regional and international levels. The aim is to inform and develop coherent and effective policies that address the key rate-limiting steps critical to improving nutrition-related public health. This paper sets out the rationale for an evidence-based approach to Public Health Nutrition developed under the umbrella of the European Network for Public Health Nutrition.

Data from household food budgetary surveys and regional, population-based, crosssectional studies show a declining trend in energy intake in the last decades, also applicable to protein, fat and carbohydrate intakes in absolute terms. The pattern suggests a lower fat content in the diet. Protein intake is 200% of the recommended level.

Spanish food patterns underwent dramatic changes between the 1960s and the 1980s, including an important increase in fat intake, up to 44% energy intake from fat in the 1980s. The trend changed in the 1990s, and current fat supply provides an average of 37% of energy intake. Main sources of fat in the Spanish diet are added fats for cooking (49% of total fat intake), especially olive oil; meat and meat products (25%); and a lower percentage provided by milk and dairy products. Most saturated fatty acids are supplied by meats (30%) and dairy products (27%).

Rapid urbanisation processes and the growing proportion of females in the active workforce have led to important changes in food patterns in the last decades. On the one hand, some changes had a positive impact, such as increasing variety in the diet and access to food; on the other hand, some changes moved the Spanish diet away from the traditional Mediterranean food pattern.

Current food patterns evidence high consumption of animal products: meat, fish, milk and dairy products. It seems advisable to increase consumption of plant foods, particularly whole-grain cereals, potatoes and pulses. Intake of fruit and vegetables shows a shift towards a greater consumption of processed foods rather than fresh products, and overall a greater consumption would be recommended.