Guide for Population Nutrition in the Republic of Macedonia

Dietary Guidelines for the Population of the Republic of Macedonia

Introduction

The dietary guidelines for the population of the Republic of Macedonia represent recommendations on dietary components, the consumption of which would help establish a diet that contributes to health benefits for the population. They include recommendations based on evidence from the sciences of nutrition, food, physical activity, and of course, health. The aim of the Guidelines is to improve the health of the general population in our country, as well as the health of future generations, by promoting healthy eating and physical activity habits so that these habits become rules and norms for everyone. The recommendations are intended for healthy people over the age of 2. However, these guidelines are being introduced during a time of increasing health risks within our population, particularly those related to chronic non-communicable diseases (NCDs). Therefore, these guidelines are also useful for people who are at an increased risk of chronic diseases.

Poor diet and low physical activity are the most important factors contributing to the global epidemic of overweight and obesity. The situation in our country suggests that these problems are increasingly present among the population of the Republic of Macedonia (RM). The numbers show that 60.5% of men and 47.8% of women over the age of 20 are overweight, and about 20% of adults in the country are obese. Even in the absence of excess weight and obesity, poor diet and physical inactivity are linked to the highest risks of morbidity and mortality. These include cardiovascular diseases (CVD), hypertension, type 2 diabetes, osteoporosis, and some types of cancer.

Children are a particularly important group on which these guidelines are focused. Increasing evidence shows the key role that optimal nutrition plays throughout life. One-third of children aged 6 to 7 in the Republic of Macedonia are overweight or obese, and 13% are obese. More and more, risk factors for the development of diseases are being discovered in childhood—much earlier than would normally be expected. Eating habits formed in childhood often carry over into later life, making the early adoption of healthy eating and physical activity habits a high priority.

The guidelines before you, although divided into several chapters that mostly address specific aspects of the population's nutrition, should be viewed as one document—as integrated recommendations for health. Those who read and implement them should see them as a whole and as part of the overall guidance on nutrition and health.

1. Maintaining an Appropriate Body Weight

Achieving and maintaining a healthy body weight throughout life is an important component in preserving quality of life. Many behavioral, genetic, and environmental factors influence body weight maintenance. Caloric balance is defined by the relationship between the calories consumed through food and drink and the calories expended through maintaining normal body functions (metabolism) and those spent on physical activity. Calories burned for metabolic processes cannot be controlled, but one can control what is eaten and drunk, as well as how many calories are burned through physical activity.

Calories consumed must equal those expended in order to maintain the same body weight. Consuming more calories than are burned results in weight gain. Conversely, consuming fewer calories than are expended leads to weight loss. This can be achieved by reducing calorie intake, increasing physical activity, or ideally, a combination of both. Maintaining a healthy body weight and preventing weight gain and obesity is more advisable than losing weight after weight gain has occurred. Once a person becomes overweight, reducing weight to healthy levels requires significant effort over a period of time, which may last for years.

Overweight and Obesity

People who are overweight or obese are at increased risk for many health problems. Some of these include type 2 diabetes, heart disease, and certain types of cancer. Obesity increases the risk of premature death. These risks are not limited only to adults in the population. Health problems and conditions associated with obesity that were previously seen primarily in adults are now appearing in children as well—for example, a higher prevalence of children with high cholesterol and blood pressure, and type 2 diabetes.

What Are Overweight and Obesity?

Based on body weight, an individual can be categorized as underweight, having a healthy weight, overweight, or obese. Body Mass Index (BMI) is a useful tool to assess an individual's weight status. BMI is calculated as the ratio of body weight in kilograms to the square of height in meters. For children and adolescents—since they are still growing—their BMI is defined using growth standards and references, and is expressed through z-scores of standard deviations or percentiles.

Table 1.1. Defining Nutritional Status

Environmental Influence: Obesogenic Environment

The environment in which the population of the so-called Western world lives—whose influences are increasingly present in our surroundings as well—plays a significant role in the state of body weight. Of course, each person chooses how much food to eat and how physically active to be. However, those choices are often limited by what is available in the environment where the individual lives—what food is accessible near their home, workplace, or school. The environment affects both sides of the energy balance equation—it can promote increased calorie intake and discourage physical activity. [5]

The food supply chain has changed dramatically in recent decades. The availability of food has seen continuous growth since the 1970s. Most notably, there has been an increase in the availability of added fats and oils, grains, milk and dairy products, and concentrated sugars. [6] Portion sizes have also increased. Studies show that when larger portions are served, people tend to eat more. Regarding the relationship between BMI and the food available in the environment, it has been shown that people who live near fast food restaurants have higher BMI. Additionally, the proportion of calories consumed from food eaten outside the home—compared to food prepared and eaten at home—has increased. [7] Children, adolescents, and adults who eat outside the home, especially in fast food restaurants, are at increased risk of becoming overweight or obese.

On the other hand, many people spend their workdays sitting, which makes it harder for them to engage in physical activity that helps maintain calorie balance. Many homes, schools, and workplaces do not support physical activity because they lack sidewalks, walking paths, or parks in the area. And if outdoor environments are not safe for physical activity, people living in such areas will have fewer opportunities to be active. Technological development and transportation have led to people burning fewer calories during daily activities. As a result, people today must make an extra effort to be physically active during their free time. Unfortunately, physical activity during leisure time is at a very low level. Some studies estimate that less than 5% of adults engage in 30 minutes of moderate physical activity per day, and only slightly more meet the recommendation of at least 150 minutes per week. [8]

Maintaining Healthy Weight for Specific Subgroups of the Population

• Women should maintain a healthy weight before becoming pregnant. This can reduce their risk of complications during pregnancy, increase the chances of a healthy birth weight for the newborn, and improve long-term health outcomes for both mother and child.

• Pregnant women should gain weight according to specific guidelines and recommendations.[9] Weight gain beyond these recommendations is associated with increased risk for both mother and baby.

• Adults over 65 years who are overweight should avoid further weight gain. Those who are obese should reduce their weight if they want to achieve health benefits.

Food and Beverage Intake

Controlling calorie intake through food and beverages is key to achieving caloric balance. To do this, one must understand their personal calorie needs, which depend on age, sex, height, weight, and level of physical activity. Calorie needs range approximately from 1,600 to 2,400 calories per day for adult women and 2,000 to 3,000 for adult men. People with sedentary lifestyles need fewer calories, while the most active individuals need the most. Due to reduced basal metabolic rates with aging, energy needs decline with age. Estimated needs for small children range from 1,000 to 2,000 calories per day, while older children and adolescents range from 1,400 to 3,200 calories daily—typically higher for males than females.

The best way to determine whether calorie intake is appropriate is to monitor body weight and adjust food intake and physical activity accordingly. A reduction of 500 calories per day is a common starting point for adult weight loss. The weight loss from a caloric deficit does not depend on how the deficit is achieved—through reduced intake, increased physical activity, or both. However, research shows that calorie deficits most commonly result from reduced intake, with increased activity playing a smaller role.

Carbohydrates, Proteins, Fats, and Alcohol

Carbohydrates, proteins, and fats are the main sources of calories in the diet. Most foods contain different combinations of these macronutrients.

Carbohydrates provide 4 calories per gram and are a primary energy source. They are classified as simple (e.g., sugars) and complex (e.g., starches and dietary fiber). Some sugars occur naturally in foods (lactose in milk, fructose in fruit), while others are added (e.g., sugar in coffee or high-fructose corn syrup in sweetened drinks). Similarly, dietary fiber may be naturally present (e.g., legumes, whole grains) or added to foods. Although most people consume an adequate amount of total carbohydrates, many consume too much added sugar and refined grains, and not enough dietary fiber.

Table 1.2. Estimated Daily Caloric Needs by Age, Sex, and Physical Activity Level

Estimated calories needed per day to maintain energy balance for different age and sex groups at three activity levels. Rounded to the nearest 200 calories. Individual needs may vary.

Summary:

This section of the guidelines explains how estimated energy requirements are calculated using average reference height and weight for each age/sex group, based on formulas from the Institute of Medicine (2002). It outlines physical activity levels: sedentary (minimal movement), moderately active (equivalent to walking 2.4–4.8 km/day), and active (more than 4.8 km/day). It also highlights the caloric values of macronutrients: carbohydrates and proteins provide 4 kcal/g, fats provide 9 kcal/g, and alcohol provides 7 kcal/g. It is noted that protein and fat intake is generally adequate among the population in North Macedonia.

Table 1.3: Recommended proportions of macronutrient intake (by age)

Source: Institute of Medicine, 2002

Impact of specific foods and beverages on body weight

• Focus on caloric intake: To maintain energy balance, total calorie intake is most important, but attention should also be given to the types of foods and drinks consumed. It is recommended to replace calorie-dense foods with nutrient-rich foods and to consume beverages with relatively low calories.

• Increase intake of whole grains, vegetables, and fruits:

  • Adults consuming more whole grains, especially those high in dietary fiber, tend to have lower body weight.

  • Limited evidence exists for a similar effect in children and adolescents.

  • Increasing fruit and vegetable intake helps maintain a healthy weight.

• Reduce intake of sugar-sweetened beverages:

  • Strong evidence shows children and adolescents consuming more sugar-sweetened drinks have higher body weight.

  • Moderate evidence supports this for adults.

  • Such drinks should be consumed only when nutritional needs are met and daily calorie limits are not exceeded.

  • Intake of unsweetened beverages (like 100% juices) should be monitored, especially in children and adolescents with overweight or obesity.

• Caloric intake from alcoholic beverages in adults:

  • Moderate drinking is not linked to weight gain.

  • Long-term excessive alcohol consumption can lead to weight gain.

• Intake of milk and dairy products:

  • Strong evidence in adults and moderate evidence in children and adolescents show no significant impact on body weight.

• Intake of meat, poultry, legumes, and soy:

  • No independent association with body weight.

  • These foods remain important nutrient sources and are recommended as part of a healthy diet.

Separate Food Products and Beverages in Overall Eating Habits

Since people consume different types of food throughout the day, in the form of meals or snacks, research today focuses on an integrated view of eating habits—that is, choosing an overall dietary pattern that contributes to better health. There is strong evidence that dietary habits involving lower calorie intake, higher consumption of fruits, vegetables, and dietary fiber, and lower intake of fats and added sugars positively impact the risk of developing type 2 diabetes in adults.

The glycemic index is a measure of the effects of carbohydrate-containing food products and beverages on blood sugar levels. There is strong evidence that the glycemic index is not related to body weight and therefore should not be considered when choosing food and beverages to maintain body weight.

The population in the Republic of North Macedonia should adopt healthier dietary habits. Generally, as long as food products and beverages meet nutritional needs and caloric intake is appropriate, everyone can choose a way of eating they enjoy and can maintain. Calories consumed from all food products or beverages should be considered, regardless of when and where they were consumed.

Physical Activity

There is strong evidence that regular physical activity helps people maintain a healthy body weight and prevents excessive weight gain. Additionally, when physical activity is combined with reduced caloric intake, the effect on body weight is even greater. Reducing sedentary time is also important. There is strong evidence that increased sitting, especially while watching TV, is associated with increased body weight and obesity in children.

To maintain a healthy weight and positive health effects, adults should engage in at least 150 minutes of moderate physical activity weekly or 75 minutes of vigorous activity or a combination of both.

Children and adolescents aged 5 to 17 should engage in at least 60 minutes of moderate to vigorous physical activity daily.

Both children and adults should include muscle- and bone-strengthening activities 2-3 times per week.

Moderate physical activity includes aerobic activities that moderately increase heart rate and breathing. On a scale of intensity from 0 to 10, this activity would be at level 5 or 6. Examples include brisk walking, dancing, swimming, or cycling on flat terrain.

Vigorous physical activity strongly increases heart rate and breathing. On the intensity scale, it would be 7 or 8. Examples include jogging, singles tennis, swimming multiple laps, or cycling uphill.

Muscle-strengthening activity involves exercises that increase skeletal muscle strength, endurance, and mass through training.

Bone-strengthening activity involves impact loading that promotes bone growth and strength, such as jumping rope or controlled weightlifting.

Principles for Promoting Caloric Balance and Maintaining Healthy Body Weight

Several behaviors have been proven very useful for maintaining a healthy weight and strongly contributing to individual and population health. Below are some with solid evidence:

• Focus on total calories consumed — Eating habits with appropriate calorie intake can help maintain healthy weight and overall health.

• Monitoring food intake — Nutrition labels show calories per serving or 100 grams, helping to track calorie intake. Monitoring weight and regular physical activity also help.

• When eating out, choose smaller portions — Ordering smaller portions, sharing meals, or saving part of a meal for later helps control weight.

• Eat a nutrient-rich breakfast — Skipping breakfast is linked to overweight, especially in children and adolescents. Eating breakfast is associated with weight loss and better nutritional intake.

• Limit screen time — Time spent watching TV is linked to increased weight and obesity in children, adolescents, and adults. Children and adolescents should spend no more than 1-2 hours daily on TV, video games, or computer use. Avoid watching TV while eating to prevent overeating.

Improving Public Health through Nutrition and Physical Activity

This chapter focused on two main elements of caloric balance — calories consumed and expended — key factors in achieving and maintaining healthy weight throughout life. Although excess weight and obesity are linked to many health problems, they are not the only risk factors. Consuming calorie-dense but nutrient-poor food can lead to malnutrition. Nutrition, physical activity, and nutritional status relate to the most common and costly health problems in North Macedonia, especially heart diseases and type 2 diabetes. Improved nutrition, healthy eating habits, and increased physical activity have great potential to reduce the prevalence of overweight and obesity, morbidity, premature death, and improve public health overall. Importantly, they can also significantly reduce state healthcare costs.

2. Foods and Ingredients to Avoid

Certain foods and ingredients, when consumed excessively, increase the risk of chronic diseases. These include sodium, solid fats (main sources of saturated and trans fatty acids), added sugars, and refined grains. Excessive consumption occurs in children, adolescents, adults, and the elderly. Many men also exceed cholesterol intake recommendations. Some people also overconsume alcohol.

Excessive consumption of these ingredients reduces intake of nutrient-rich foods, making it harder to meet recommended nutrient intake and control excess calorie intake.

Besides saturated and trans fats linked to cardiovascular disease risk, solid fats in large amounts also contribute to excess calorie intake.

Sodium

Sodium is an essential nutrient required in small amounts unless there is significant sweating. Generally, higher sodium intake is linked to higher blood pressure. Strong evidence in adults shows reducing sodium lowers blood pressure; moderate evidence supports this in children too. Maintaining normal blood pressure reduces risk of cardiovascular diseases, congestive heart failure, and kidney disease. Both adults and children should limit sodium intake.

Sodium mainly comes from table salt (sodium chloride). Salt is widely used for curing meat, baking, retaining moisture, masking odors, enhancing flavor, etc. Salt added during cooking or at the table contributes little to overall sodium intake. Most sodium comes from salt added during food processing. Many processed foods increase sodium intake.

Ways to reduce sodium intake include:

• Reading nutrition labels for sodium content and choosing low-sodium foods

• Eating more fresh and less processed foods

• Preparing homemade meals with controlled salt use

• Requesting no added salt when eating out or choosing low-sodium menu items

Sodium is found in many food products, and calorie intake is related to sodium intake (more food and drink consumed = more sodium). Reducing calorie intake can help reduce sodium intake and associated health benefits.

Fats

Fats are found in both plant and animal foods. They provide energy, essential fatty acids, and help absorb fat-soluble vitamins A, E, D, and K. Acceptable total fat intake ranges are:

• 30-40% of total calories for children 1-3 years

• 25-35% for children and adolescents 4-18 years

• 20-30% for adults over 18 years

These limits aim to reduce chronic disease risk while ensuring adequate essential nutrient intake. Total fat intake should stay within these limits.

Fatty acids are classified as saturated, monounsaturated, and polyunsaturated. Fats are mixtures of these. Trans fats are unsaturated but structurally different from natural unsaturated fatty acids in plants and have different health effects.

For cardiovascular risk, the type of fatty acids consumed matters more than total fat amount. Animal foods generally have more saturated fats (except seafood), while plant foods have more mono- and/or polyunsaturated fats (except coconut and palm oil).

Fats high in saturated and trans fats are solid at room temperature (“solid fats”), while fats with more unsaturated fatty acids are liquid at room temperature (“oils”). Solid fats occur in most animal-derived products but can also be made from plant oils through hydrogenation.

Saturated Fatty Acids

The human body uses some saturated fatty acids for physiological and structural functions, but these needs are easily met. Thus, minimal dietary intake of saturated fats is necessary. Strong evidence links high saturated fat intake with higher total and LDL cholesterol, increasing cardiovascular disease risk.

Consuming less than 10% of calories from saturated fats and replacing them with mono- and/or polyunsaturated fats is linked to lower blood cholesterol and cardiovascular risk.

To reduce saturated fat intake, limit major sources and replace them with foods rich in mono- and/or polyunsaturated fats.

Trans Fatty Acids

Trans fats occur naturally in some foods but mostly form during food processing. They are non-essential in the diet. Many studies link higher trans fat intake with increased cardiovascular risk, partly due to raised LDL cholesterol. Therefore, trans fat intake should be as low as possible.

Some trans fats are created by hydrogenation, which makes unsaturated fats solid at room temperature, preventing rancidity. Partial hydrogenation converts some but not all unsaturated fats to saturated fats. This process also converts some cis to trans configuration, producing industrial trans fats. These are found in partially hydrogenated oils used in some margarines, snacks, and desserts as a substitute for saturated fats. Trans fats also naturally occur in ruminant animal products (milk, meat) in small amounts, called natural or ruminant trans fats.

Cholesterol

Dietary cholesterol has been shown to increase LDL cholesterol in the blood in some individuals. However, this effect is reduced when intake of saturated fatty acids is low. The potential negative effects of dietary cholesterol are smaller compared to those from saturated and trans fats. There is moderate evidence of a link between high cholesterol intake and increased risk of cardiovascular diseases. Consuming one egg daily (egg yolk) is not considered a risk for raising blood cholesterol or cardiovascular disease in healthy individuals. Consuming less than 300 mg cholesterol per day may help maintain normal blood cholesterol levels, and less than 200 mg per day is beneficial for those at higher cardiovascular risk.

Solid Fats

Fats contain mixtures of fatty acids, and many studies link saturated and trans fats with chronic diseases, especially cardiovascular diseases. Most fats high in saturated and/or trans fatty acids are solid at room temperature and are called "solid fats" (e.g., butter, beef tallow, chicken fat, pork fat, solid margarine). Milk fat is also considered a solid fat. Processed meat is a major source of saturated fats and has been linked to colorectal cancer and cardiovascular disease. Limiting intake of solid fats by reducing these foods or replacing them with lower-fat alternatives can help reduce saturated and trans fat intake and calories.

Added Sugars

Sugars naturally occur in fruit (fructose) and milk (lactose). Most sugars in modern diets come from sugars added during food processing or preparation, improving taste, preservation, texture, and other properties. Reducing consumption of foods high in added sugars lowers calorie intake without compromising nutrient adequacy. Sweetened drinks can be replaced with water or unsweetened beverages.

Refined Grains

Refining whole grains leads to loss of vitamins, minerals, and fiber. Some refined grains are enriched with iron and B vitamins to replace some lost nutrients but not all. Unlike solid fats and added sugars, enriched refined grains can have positive effects due to some added nutrients. However, overconsumption of refined grains, especially those rich in solid fats and added sugars (e.g., cakes, pastries), contributes to excess calories.

Alcohol

Alcohol consumption can have both beneficial and harmful effects depending on amount, age, and individual characteristics. Moderate consumption is linked to reduced risk of cardiovascular diseases and mortality and may support cognitive function in older adults. However, alcohol also increases risks of breast cancer, violence, drowning, falls, and traffic accidents. Certain groups should avoid alcohol entirely, such as those under 18, pregnant women, people with certain medical conditions, or those who cannot limit intake.

Foods to Increase

A diet rich in fruits, vegetables, whole grains, low-fat dairy, fish, and healthy oils promotes health. Nutrient-rich foods provide vitamins, minerals, and other beneficial substances with relatively low calories. These foods typically have low or no added fats, sugars, and salt. Examples include fruits, vegetables, whole grains, low-fat dairy, fish, lean meats, eggs, legumes, nuts, and seeds.

Fruits and Vegetables

There are three main reasons to eat more fruits and vegetables: they are sources of nutrients often under-consumed (folate, magnesium, potassium, fiber, vitamins A, C, K); they reduce risk of chronic diseases like cardiovascular diseases and some cancers; and they are low-calorie foods which help maintain healthy body weight. Fresh, frozen, canned (in own juice), and dried fruits count, with preference for whole fruits over juices.

Grains and Cereals

Whole grains are rich in iron, magnesium, selenium, B vitamins, and fiber. There is moderate evidence that whole grain intake reduces cardiovascular risk and is linked to lower body weight. At least half of grain intake should come from whole grains.

Milk and Dairy

Milk and dairy provide important nutrients, especially calcium, and moderate evidence links their intake to better bone health, reduced risk of cardiovascular diseases, type 2 diabetes, and lower blood pressure. Recommended intake varies by age, with emphasis on low-fat or fat-free options. For those intolerant to lactose or who avoid dairy, alternative sources of calcium and other nutrients are recommended.

Protein Foods

Protein foods include meat, poultry, eggs, fish, legumes, soy products, nuts, and seeds. Besides protein, these provide B vitamins, vitamin E, iron, zinc, and magnesium. Meat and eggs mostly contain solid fats, while nuts, seeds, and fish are sources of oils. Balanced consumption of various protein sources supports nutrient intake and health. Nuts and peanuts can reduce cardiovascular risk when consumed in moderation as substitutes for meat or poultry.

Fish and Seafood

Seafood is a source of nutrients, especially omega-3 fatty acids EPA and DHA. Consuming 200-250 g of seafood per week providing 250 mg of EPA/DHA reduces risk of cardiovascular death. Seafood consumption in pregnancy and early childhood supports brain development. Pregnant and breastfeeding women are advised to eat 200-340 g of low-mercury seafood weekly and avoid high-mercury fish (shark, swordfish, king mackerel).

Fats

Fats that contain more monounsaturated and polyunsaturated fatty acids are liquid at room temperature and are called oils. They are important in the diet because they are a source of essential fatty acids and vitamin E. Replacing saturated fatty acids with unsaturated ones reduces total and LDL cholesterol levels in the blood.

Oils naturally occur in various foods such as olives, nuts, or seafood. Many oils are extracted from plants like canola, corn, olive, peanut, safflower, soybean, and sunflower. Coconut oil and palm oil, which contain more saturated fatty acids, as well as partially hydrogenated oils, contain trans fatty acids. From a nutritional perspective, these are considered solid fats.

Potassium

Potassium in the diet can lower blood pressure by counteracting the negative effects sodium has on blood pressure. Other positive effects of potassium-rich diets include reduced risk of kidney stones and decreased bone loss. Adults should consume 4700 mg of potassium per day. The adequate intake is a quantity suitable for nearly all population groups.

Sources of potassium are found in almost every food group, especially in vegetables, fruits, milk, and dairy products. It is better to consume potassium from diverse potassium-rich foods rather than supplements in tablet form to meet recommended intake.

Fiber

Fiber represents carbohydrates that are not digested in the digestive system. Fiber is naturally present in plants. It provides a feeling of fullness and is important for intestinal peristalsis. Important sources of fiber include beans, peas, and other legumes. Other sources are vegetables, fruits, whole grains, and nuts. Although bran is not a whole grain, it is an excellent source of fiber. This food is not represented in recommended quantities in typical diets.

Naturally occurring fiber in food can reduce the risk of cardiovascular disease, obesity, and type 2 diabetes. Children and adults should consume fiber-rich foods to maintain healthy lipid status, glucose tolerance, and normal gastrointestinal function. Sometimes fiber is added to food, but it is unclear if these have the same health effects as naturally occurring fiber.

Adequate fiber intake is 14 g per 1000 calories or 25 g per day for women and 38 g per day for men.

Calcium

Calcium is important for maintaining healthy bones. It also plays a role in nerve impulse transmission, blood vessel constriction and dilation, and muscle contraction. People with low bone mass have increased risk of osteoporosis and bone fractures. Especially vulnerable age groups due to insufficient calcium intake include children over 9 years, adolescents, adult women, and adults over 51 years. For all adult groups, meeting the recommended daily calcium intake (RDI = 800 mg) is advised.

Milk and dairy products significantly contribute to meeting calcium needs. Calcium recommendations can be met by consuming low-fat or fat-free milk and dairy products and/or alternative calcium sources. If milk and dairy are excluded, they must be replaced with other calcium sources, including fortified foods. Calcium from some plant foods is well absorbed, but eating enough plant foods to meet daily calcium needs is unrealistic.

Vitamin D

Adequate vitamin D intake is essential for health. Vitamin D deficiency in children causes rickets, and in adults, softening of bones. Adequate intake reduces the risk of bone fractures.

The recommended daily intake of vitamin D, considering our country has many sunny days, ranges from 5 to 10 µg in the form of cholecalciferol. Variations may occur if health conditions indicate increased needs. Intake above 100 µg per day increases the risk of overdose effects.

Other Nutrients Important for Specific Groups

Iron

Many women of reproductive age, including adolescent girls, have iron deficiency. They can improve iron status by consuming food rich in heme iron, which is absorbed faster and easier by the body, as well as additional iron sources and enhancers like vitamin C-rich foods. Sources of heme iron include lean meat, poultry, and seafood. Pregnant women are advised to take iron supplements under medical supervision.

Folic Acid

Many women of reproductive age do not meet recommendations for sufficient folic acid intake, which is 400 µg synthetic folic acid daily. Folate-rich foods include beans, peas, oranges, and dark green leafy vegetables like spinach. Recommended folic acid intake, especially in the first trimester of pregnancy, should be met with guidance from a primary care doctor or gynecologist.

How to develop healthy eating habits?

Healthy eating habits are not rigid rules that everyone must follow, but rather choices that include traditional, ethnic, cultural, and personal preferences regarding the types of food we prefer, their cost, and availability. Fortunately, nowadays there is a wide variety of food available that can meet nutritional needs while staying within recommended calorie limits.

There are different dietary patterns around the world with various health effects. Research has identified several diets associated with short- and long-term health benefits, including reduced risk of certain chronic diseases. Many traditional diets contribute positively to health, showing that healthy eating can be achieved in different ways.

Some well-studied diets include:

• DASH diet emphasizes vegetables, fruits, low-fat dairy, whole grains, poultry, seafood, and nuts, with low intake of sodium, red and processed meat, sweets, and sugary drinks. It is linked to lower blood pressure, improved blood lipids, and reduced cardiovascular risk.

• Mediterranean diet is a traditional diet from Mediterranean countries, rich in vegetables, fruits, nuts, olive oil, and whole grains, with moderate amounts of meat and full-fat dairy. It is associated with lower cardiovascular risk and reduced overall mortality.

• Vegetarian diets vary by consumption of animal products (vegans consume none, lacto-ovo vegetarians consume dairy and eggs). Vegetarian diets are linked to lower risks of obesity, cardiovascular diseases, and mortality.

To develop healthy habits, it is important to choose a dietary pattern that fits your lifestyle and tastes, focusing on more plant-based foods, moderate animal products, and limiting processed and high-calorie foods.

Principles for Achieving a Healthy Diet

Healthy diets include nutritionally rich foods such as vegetables, fruits, whole grains, low-fat or fat-free milk and dairy products, lean meat and poultry, seafood, eggs, legumes, and nuts, prepared without adding solid fats, sugars, and sodium. These foods, combined in a diet, can provide almost all essential nutrients and dietary fiber without excessive calorie intake. The oils present in seafood, nuts, and seeds also contribute to the intake of essential nutrients. It is important to note that beverages also contribute a certain number of calories to the diet. The number of calories varies from beverage to beverage, but commonly consumed drinks such as sodas, fruit nectars, or alcoholic beverages contain calories but provide very few or no essential nutrients. Some other drinks, such as fat-free or low-fat milk, as well as 100% fruit juices, provide significant nutrient intake along with calories. Water and unsweetened beverages, such as coffee or tea, contribute to total water intake without adding extra calories. To limit excessive calorie intake, one should primarily drink water and other beverages with no or very low calories, along with the recommended intake of fat-free or low-fat milk.

Following Food Safety Principles

Food safety is an important principle in creating healthy eating habits. Washing hands, washing fruits and vegetables, preventing cross-contamination, cooking to safe internal temperatures, and safely storing food at home are some of the most important principles of food safety. WHO promotes and adheres to the Five Keys to Safer Food as simple guidelines upon which the safety of the food we eat depends. The Five Keys to Safer Food are:

• Maintaining cleanliness of hands, surfaces, and utensils used for food preparation;

• Separating raw food from cooked food;

• Cooking food to sufficiently high temperatures to ensure safety inside the food;

• Storing food at safe temperatures (below 5°C), and when reheating, above 60°C;

• Using safe water for drinking and food preparation and using fresh food products.

The Role of Supplements and Food Fortification

The basic recommendation of these Dietary Guidelines is that all nutrients should primarily be obtained from food through diet. Nutrient-rich foods provide not only most of the required vitamins and minerals but also dietary fiber and other substances naturally present in food that have positive health effects.

Supplements or food fortification with certain micronutrients can have positive effects in certain cases when it is not possible to obtain a specific vitamin or mineral in adequate amounts through diet alone. For example, WHO recommends daily intake of supplements containing 400 micrograms of folic acid and 30–60 milligrams of elemental iron during pregnancy.

There is insufficient strong evidence to support or oppose the recommendation of taking multivitamin and multimineral supplements for primary prevention of chronic diseases in the adult population. Supplements containing combinations of certain nutrients may be useful in reducing the risk of some chronic diseases in specific population groups. For example, supplements containing calcium and vitamin D may be beneficial for postmenopausal women with low levels of these micronutrients in their diet to prevent early onset of osteoporosis. Conversely, excessive intake of certain nutrients may have negative health effects if the tolerable upper intake levels are exceeded.

5. How to Achieve Healthier Living?

The choice of food consumed is made every day. People think about what to eat, drink, and how much physical activity to engage in. These choices are often made in the context of the environment in which one lives. Today’s environment promotes excessive calorie intake and discourages physical activity. Such an environment, along with individual choices regarding activity, has contributed to a dramatic increase in rates of overweight and obesity worldwide. Along with these rates, there has been an increase in health problems such as cardiovascular diseases, type 2 diabetes, and some types of cancer. Improving these trends requires a coordinated system with a comprehensive approach, involving all sectors—from individuals and families, schools, communities and organizations, health professionals, small and large businesses, to policymakers. Everyone should be involved in the movement to make Macedonia a healthier society. Through joint work via policies, programs, and partnerships, we can improve the health of the current generation and take responsibility for giving future generations the chance for a healthy and productive life.

One way to think about how we arrived at the current situation and how it can be improved is through the social-ecological model. This model, shown in Figure 5.1, illustrates how all elements in society combine to influence individual choices about food and physical activity, resulting in a certain state of energy (im)balance and risk of chronic diseases. The factors shown in the model are:

• Individual factors: Age, sex, income, ethnicity, genetics, and presence of certain disabilities. All of these affect levels of physical activity and food intake. To change someone’s knowledge, beliefs, attitudes, and behavior, these factors must be considered;

• Environment: Decisions about food, nutrition, and physical activity are made while surrounded by a particular environment. This environment includes schools, workplaces, religious institutions, recreation areas, and places where food is sold or served. This environment influences choices related to diet or physical activity along with policies connected to nutrition and the information available to consumers;

• Sectors of influence: Various sectors can affect communities. These may include government, public health and healthcare systems, agriculture, industry, and media. Many of these sectors influence the availability of healthy food and the opportunity to be physically active;

• Social and cultural norms and values: Social norms guide our thoughts, beliefs, and behaviors. These commonly accepted norms for appropriate behavior are based on the values of the society we live in and are reflected in nearly everything around us—from laws to personal expectations. Regarding diet and physical activity, cultural norms can be key in what is eaten or drunk, how much is eaten or drunk, acceptable body weight ranges, and how much physical activity is included in free time. Healthy behavior can be much harder if it is not accepted and valued in society.

The social-ecological model helps in understanding the role that different parts of society play in shaping the choices and frameworks available for healthy living. It takes into account the interactions between individuals and families, the environment, various sectors of influence, and the impact of social and cultural norms and values. Therefore, it can be used to design and evaluate comprehensive intervention measures at all levels. By adopting coordinated and multifaceted, primarily preventive strategies, society can move toward reducing the risk of chronic diseases. Efforts to improve diet and physical activity will be more successful and faster if such a coordinated, comprehensive approach involving all key stakeholders is implemented.

CALL TO ACTION

Decisions about what to eat or drink are made individually or at the family level. However, to make the right choices, people must have access to healthy food and opportunities to engage in physical activity. While individual behavior change is crucial, truly effective and sustainable improvements in population health require a multisectoral approach that applies the social-ecological model to improve diet and physical activity. This approach requires building coordinated partnerships, programs, and policies in public health to support healthy eating and active living. Interventions must go far beyond traditional individual education about healthy eating and should include skills development, environmental reforms, and revisions of social norms toward healthy living.

In previous sections of this guide, strategies for meeting healthy eating recommendations at the individual and family level were described. The strategies in this chapter cover coordinated action measures from various sectors of society.

It is important to emphasize that positive health outcomes can only be expected if there is joint, broad, and comprehensive action from all.

The guiding principles upon which changes related to nutrition and physical activity should be based aim to ensure that the population of the Republic of Macedonia has access to nutritionally rich food and opportunities to practice physical activity, encourages individual behavior change through environmental changes, and establishes prerequisites for healthy eating, physical activity, and appropriate body weight throughout the life cycle.

These principles can be achieved through the implementation of certain measures. Some of these measures include:

At the Level of General Policies

• Creating local plans to implement the nutrition and physical activity recommendations described in this guide;

• Recognizing differences in health status among sub-populations and ensuring equitable access to healthy and affordable food, as well as opportunities for physical activity;

• Increasing access to stores, green markets, and other places where healthy food is sold;

• Developing and expanding safe, effective, and sustainable agricultural and water management practices that ensure availability of recommended amounts of healthy food for all population segments;

• Providing access to food for vulnerable populations through specific forms of assistance for adequate nutrition;

• Implementing and maintaining nutrition, food safety, and physical activity standards described in this guide and the Health Strategy 2020.

At the Level of Behavior Change through Environmental Changes

• Improving knowledge of individuals and families about better understanding of nutrition, home-growing fruits and vegetables, and improving knowledge about food preparation;

• Initiating partnerships with food producers and sellers to promote appropriate portions and meals of accessible and nutritionally rich food (including, but not limited to, food with reduced sodium, solid fats, and added sugars) in food sales and service chains;

• Developing policies, laws, and systemic solutions in key sectors such as public health, healthcare, retail, school nutrition, recreation, transport, and volunteer/nonprofit organizing to prevent increases in overweight and obesity;

• Supporting science and research to examine individual, community, and systemic factors contributing to adopting healthy eating habits and identifying and adopting best practices.

At the Level of Establishing Prerequisites for Healthy Eating, Physical Activity, and Appropriate Body Weight Throughout the Life Cycle

• Ensuring that all meals and snacks served or sold in schools and child care facilities comply with recommendations or legal acts related to nutrition for these populations;

• Providing comprehensive educational programs on health, nutrition, and physical activity, with emphasis on skills for food preparation, food safety, and physical activity throughout life;

• Implementing systematic programs to monitor the nutritional status of children in Macedonia and identify rates of overweight and obesity in order to assess risk and implement appropriate intervention programs;

• Encouraging physical activity in kindergartens and schools through physical activity programs and supporting active transport initiatives (e.g., walking to school programs);

• Reducing screen time (TV, computers, smartphones) for children;

• Creating and adopting effective policies to limit children’s exposure to food and beverage advertising;

• Supporting programs promoting healthy eating and physical activity year-round, including summer.

[1] WHO Global Health Observatory Data Repository. Available at http://apps.who.int/gho/data/node.main.A900?lang=en.

[2] Public Health Institute of the Republic of Macedonia. Data obtained from the third round of the obesity survey in school children, within the Childhood Obesity Surveillance Initiative (COSI) of WHO Europe.

[3] WHO growth standards for children aged 0 to 5 years. Available at: http://www.who.int/childgrowth/en/.

[4] WHO growth references for children aged 5 to 19 years. Available at: http://www.who.int/growthref/en/.

[5] Department of Agriculture, Department of Health and Human Services. Dietary Guidelines for Americans 2010. Washington, DC: USDA and HHS; 2010.

[6] Adjusted for spoilage and other waste. ERS Food Availability (Per Capita) Data System. Available at: http://www.ers.usda.gov/Data/FoodConsumption/.

[7] Stewart H, Blisard N, Jolliffe D. Let’s eat out: Americans weigh taste, convenience, and nutrition. U.S. Department of Agriculture, Economic Research Service; 2006. Economic Information Bulletin No. 19. Available at: http://www.ers.usda.gov/publications/eib19/eib19.pdf.

[8] Troiano RP, Berrigan D, Dodd KW, Mâsse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc. 2008;40(1):181–188.

[9] Institute of Medicine (IOM) and National Research Council (NRC). Weight gain during pregnancy: reexamining the guidelines. Washington (DC): The National Academies Press; 2009.

[10] Moderate alcohol intake is defined as one drink per day for women and up to two drinks per day for men. One drink is defined as 350 milliliters of beer with 5% alcohol, 150 milliliters of wine with 12% alcohol, or 45 milliliters of a spirit with 40% alcohol. One drink contains 18 milliliters of alcohol.

[11] World Health Organization. Food and nutrition policy for schools. A tool for the development of school nutrition programmes in the European Region. Copenhagen, WHO Regional Office for Europe, 2006. Available at: http://www.schoolsforhealth.eu/upload/WHO_tool_development_nutrition_program.pdf

[12] Dimitrovska Z, Spiroski I, Memeti Sh, Kendrovski V. Handbook for proper nutrition of infants and young children. Skopje: Public Health Institute of the Republic of Macedonia; 2012.

[13] Regulation on specific safety requirements for food supplements. Skopje, Official Gazette of the Republic of Macedonia No. 12/2012.

[14] Dietary Approaches to Stop Hypertension (DASH).

[15] Five keys to safer food. Available at: http://www.who.int/foodsafety/consumer/5keys_macedonian.pdf

[16] WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva, World Health Organization, 2012.

[17] Tolerable upper intake level = The highest daily intake level of a nutrient that is unlikely to pose risk of adverse health effects to almost all individuals in the general population.