Conference report.

2nd Sanitarium International Nutrition Symposium

Nutrition for Life's Stages: The Evidence Base, Melbourne, 18-19 April 2002

This was the second Sanitarium International Nutrition Symposium, the first was held in Sydney in 1999. As the name suggests, the symposium was organised by Sanitarium and included multiple international speakers. It was a good opportunity for Australians to hear a strong mix of speakers from many parts of the world. The symposium was held over two days and consisted of nine plenary sessions and two concurrent sessions. Presentation was by invitation only and there was no presentation of posters.

Highlights of Day One

The program for this symposium promised an interesting and stimulating two days and it lived up to those expectations. The day started with a thought provoking talk by Professor Geoffrey Cannon who, among his many roles, is international food and nutrition policy advisor to Brazil's Ministry of Health. He proposed a new world map for nutrition that 'gives equal value to personal, population and planetary health', in which he stressed the importance of an appreciation of societies and cultures which may not have accumulated large amounts of monetary capital. He challenged the concept that prosperity as measured by income only is valid and that social capital of countries should be valued. He also suggested that if the protein requirements were set at 5% of total energy, that we could feed the world on largely vegetarian diets. One of his most challenging questions posed was 'Who won the Vietnam War'? Was it the taller, bigger race of people with more ammunition and resources or the smaller people with fewer re sources? He challenged the premise that 'bigger is better'.

This theme was then taken up by Professor Philip James, International Obesity Taskforce, UK, who described the frightening, escalating problem of obesity (particularly central obesity) and type 2 diabetes in Asia and India, where 'bigger is not better'. He proposed that the increasing prevalence of obesity and type 2 diabetes in these populations is not due to genetic factors but due to pre and early postnatal programming. During pregnancy a mother is programming her child to cope with the environment that it is going to be born

into, accordingly if the mother experiences lack of access to food and particularly protein, she is programming the unborn child to be smaller at birth, and to require less food to survive in the prevailing environment. The problem occurs when the environment that the child is born into changes rapidly to one where foods, particularly high energy foods, are in abundance and physical activity is not required to access this food. These children experience rapid, dramatic changes in envi ronmental conditions during their growth, development and early to mid adulthood. Environmental changes of this magnitude have never been seen before in our history. These children grow up and give birth to large babies who are especially prone to excess weight gain and adolescent type 2 diabetes.

Dr Vivienne Moore, Department of Public Health, Adelaide University, and Professor John Newham, Department of Obstetrics and Gynaecology, University of Western Australia continued this theme through another two presentations in the afternoon. These two presentations provided evidence from human and animal studies indicating the increasing and compelling evidence that some of the most important chronic diseases of adult life have their origin in the intra-uterine environment. Two factors are now believed to be important activators of prenatal programming: foetal undernutrition and premature exposure of the foetus to cortisol (a stress hormone). At a cellular level, foetal undernutrition and premature exposure of the foetus to cortisol share a common pathway and predisposes the resulting child to changes in glucose metabolism and alterations in responsiveness of the hypothalamic-pituitary-axis.

Other speakers throughout the day outlined the situation in Australia. Associate Professor Louise Baur indicated the increasing prevalence of obesity in childhood and adolescence and Dr Antigone Kouris-Blazos reported on increased risk factors for chronic diseases, but reduced mortality in the Australian Greek community. Associate Professor Cindy Shannon outlined the issues related to the health of Aboriginal and Torres Strait Islander people. Professor Jim Mann, Department of Human Nutrition and Medicine, University of Otago gave a stimulating presentation on the problem in assessing levels of evidence in the field of nutrition and real limitation of randomised controlled trials in the field of nutrition. As in the case of some chronic disease, notably cancers, where nutritional factors may operate as promoter or protector many years before the onset of clinical disease. He also highlighted the lack of acceptance of a framework whereby obvious evidence could be cited as a contributor to disease e.g. the large increase in the serving sizes of French fries and Coca Cola in MacDonalds restaurants in the USA.

The final event of the day was a debate on genes, diet and social factors, with Professor Philip James, Professor Geoffrey Cannon and Professor John Hopper moderated by Geraldine Doogue. She did a great job of ensuring the debate was kept to a practical level, but it was rather difficult for Professor Hopper to respond to the other members as he was not party to the presentations that had dominated the day indicating the importance of environmental factors and particularly prenatal environmental factors to subsequent health.

Overall it was a stimulating day that really challenged the appropriateness of our current definitions of desirable growth and development in early life in trying to maximise growth.

Highlights of Day Two

The plenary speakers on the second day further developed the conference theme by addressing stages from early adulthood to old age. Globalisation remained a secondary theme throughout the day, with an early question raised about the relevance of individual behaviour in the context of globalisation. Along with the stated proviso that neglect of individual rights is unacceptable, this question was deliberately thought provoking and relevant. Each of the presentations was excellent, however the following five speakers are selected for special mention.

Professor Tony Worsley brought his considerable experience to bear on the question 'Can nutrition knowledge change food behaviour?'. Consideration of the question proved to be very enlightening--perhaps more so than the proferred answer (which was 'yes, a little'). Simple questions can be deceptively complicated--Professor Worsley pointed out that food behaviour covers a lot of different activities that are related to each other in dynamic chains. Chains of behaviours require a lot of knowledge and in this context it is not surprising that nutrition knowledge in particular only has a small effect. In relation to behaviour change, Professor Worsley recommended that people should be specific about the change, they should set behavioural goals and they should measure the behaviour (rather than something they believe may be related to the behaviour). Programs to change behaviour should take into account the personal goals of individuals and should be aware of effects other than those expected.

Professor Boyd Swinburn presented a stimulating comparison of progress towards addressing a range of public health issues over the last half century. Professor Swinburn uses a triad model consisting of host, vector and environment to explain the interrelating dimensions of public health problems. The host domain includes characteristics of the individual that allows the problem to develop, the vector domain represents factors that carry the problem to individuals and the environment domain represents all those factors outside the host and vector that allow (or even encourage) the occurrence of the problem. Successes in public health have usually involved action in all three domains. Professor Swinburn made the point that if this understanding is applied to the increasing public health problems of obesity and type 2 diabetes, much less progress has been made with environmental interventions than seeking solutions in the areas of individual susceptibility and proposed vectors. In relation to earlier themes of the conference, the paradigm of hierarchical evidence is more inappropriate for environment interventions.

Professor Karen Charlton from the University of Cape Town, South Africa summarised the evidence for particular benefits of dietary manipulation in older age. She concluded the case is strong for the development of specific dietary guidelines for the elderly.

Dr Tim Gill, the Asia-Pacific Co-ordinator of the International Obesity Task Force discussed the importance of preventing weight gain in adult life. Weight gain after the age of 21 years greatly increases the risk of type 2 diabetes independently of the initial body mass index. This is an important point that is not properly considered by the concept of a healthy BMI range. At any body weight, it is important to avoid weight gain over the course of adulthood.

Dr Noel Solomons was the speaker for the final plenary of the conference on the important topic of ethical principles. After noting the difference between values, morals and ethics, Dr Solomons outlined generally agreed ethical principles. While principles are generally agreed on, the priority accorded to each of the principles varies by stakeholders on issues of food governance. An action or event under consideration is rarely wholly good or wholly evil. This applies to the concept of globalisation and to foods generally. Foods can nourish and protect but also damage, infect and impoverish. Ethical principles provide a framework to assess actions, albeit one that may not be employed in the same way by everybody. This does not diminish the usefulness of ethical principles in determining actions.

The 2nd Sanitarium International Nutrition Symposium was a great success and appreciated by more than 270 delegates who attended. It had the hallmarks of a good scientific meeting--a strong program, time for open and frank plenary discussion and appropriate situations for networking at all levels among the delegates.

Caryl Nowson

Senior Lecturer in Nutrition and Dietetics 

Director Nutrition Education Programs

Deakin University, Melbourne

Malcolm Riley

Associate Professor

Nutrition and Dietetics

Department of Medicine

Monash University, Melbourne