If we are what we eat, the Israeli population has a split personality. While fast-food restaurants are packed, so are health-food stores. Cola is the most popular soft drink, but many people bring home mineral water or purchase expensive water purifiers. High-calorie junk-food is snapped up at supermarket checkouts, but customers are willing to pay extra for organic eggs or whole-grain breads.
The Health Ministry's nutrition department, whose new permanent director - clinical dietitian Dr. Ziva Stahl - was appointed a few months ago, is responsible for encouraging Israelis to think before they eat. It also makes recommendations on nutrition to ministry management; conducts nutritional surveys; prepares and distributes educational material; and ensures that institutions from kindergartens and special-education schools to psychiatric and geriatric hospitals supply healthful food to those in their care.
AS THE type of food consumed can - in addition to regular exercise - have a major role in determining life expectancy, whether an individual will be overweight or develop serious chronic diseases, one would think the government would invest substantial resources in the department. But Stahl, in the first interview since her appointment, says with some embarrassment that she has only eight professionals on her staff, including just two nationwide inspectors. When I interviewed her predecessor, Dr. Dorit Nitzan in 1999, the department had 13 professionals.
Stahl - who was born in Brooklyn, New York and came on aliya with her family in 1971 when she was seven - explains: "There is a government freeze on hiring, so we can't replace those who leave. But we try to work efficiently," she adds. When asked how many more clinical dietitians and other professional staffers she needs, she says: "I'd be grateful if we could have 13 again."
A nurse's daughter, Stahl is married to a safety and environment consultant with whom she has raised two gifted teenagers. They moved for Zionistic reasons to Yerocham, the Negev development town, and she travels daily to her office in Jerusalem's King David Street, an old stone building opposite Hebrew Union College.
Stahl, who served in the Israel Air Force as an electronics technician and went on to receive advanced degrees at Ben-Gurion University of the Negev, served as acting department director for nearly three years. Just the mention of the name of her predecessor, Dr. Nitzan, produces sad faces in the building, as the pediatrician is on trial for her performance as former head of the ministry's Food Service in the Remedia formula scandal. Three babies died and others suffered irreversible neurological damage in 2003 when they were fed solely with the imported non-dairy formula that lacked essential vitamin B1. Nitzan, who has since the tragedy been working as head of the World Health Organization's country office in Serbia and returning periodically for the long judicial procedures, has been indicted along with some ministry inspectors for alleged negligence in allowing the defective formula into the country; all of them maintain they are innocent.
After the affair, the ministry's Nutrition and Food Service was split in two, with Stahl in charge of the former and an engineer, Eli Gordon, in charge of the latter. Rules set down by ministry management, she says, mandate both planned and surprise visits to institutions requiring inspection. When asked why all visits are not made to catch administrators by surprise, Stahl says she wishes it could be so.
TO KEEP the department's finger on the pulse of public health, it hired the survey company Geocartography to conduct its second MABAT study of 5,000 Israelis aged 18 to 65 who were visited at home, weighed, measured and asked to undergo lab tests. The first was held a decade ago, when Nitzan was director, but "we want to get the latest results, as obviously there have been changes in Israelis' diet since then." Her department also conducts telephone surveys of mothers who agree in hospital obstetrics departments to volunteer and answer questions about what their children eat and when they start solids.
One of the things Stahl is looking for among the future findings of MABAT-2 is how much vitamin D the average Israeli has in his blood. Deficiency of this vitamin is known to significantly increase the risk of a variety of diseases, from osteoporosis and premature dementia to falling by the elderly and ovarian cancer. Doctors and public health experts used to think that having a sunny climate most of the year, few Israelis would lack vitamin D, which is produced in the skin responding to ultraviolet rays from the sun. But as kids increasingly stay indoors in front of their computer and TV screens; many women and men are covered up due to religion; and many people use sunscreen to avoid skin cancer and premature ageing, many apparently have deficiencies. Although the ministry officially recommends vitamin D only for small children, Stahl said there is enough proof of its benefits that it be taken lifelong.
THE HEALTH FUNDS test blood for deficiencies and excesses of many elements, but they have not been required to test for vitamin D. At present, blood is screened for vitamin D only if a doctor specifically requests it. Queried by this reporter, Stahl said she would discuss it with Dr. Yoel Lipschitz, the ministry director-general in charge of supervising the health funds.
He later told The Jerusalem Post that setting such a requirement would not be difficult. "If professionals in the ministry, such as public health department head Dr. Itamar Grotto, believe the health funds should automatically test blood samples for vitamin D, we can do so. It will not add to their costs," he said. Requiring periodic testing by the health insurers would obviously be more accurate for getting a national picture of deficiency than the small Mabat-2 study, although those who go to health funds for blood tests may have more chronic illness than the average person.
Stahl says that in a few months, all dairies will be required to fortify 3%-fat milk with vitamin D. The ministry has thus finally taken action through an official standard that will insert the vital but very cheap vitamin into bags, cartons and bottles of 3% milk, which is the most widely consumed type. At present, only 1% fat milk has to be fortified with vitamin D. Milk has been fortified for decades in the US and many other countries, but Israeli dairy companies have long opposed forced fortification because they market "specialty" milks with vitamin D plus calcium - for which they can charge more. Forcing them to add the vitamin at the same price causes them to lose income.
Yet a requirement that they fortify all their products - including soft white cheeses and yogurts - is quite a way off, as this will require a different standard, she said. The companies oppose mandatory enrichment of these dairy products because it would require some complicated technological changes.
A ministry policy encourages all women of childbearing age take folic acid to minimize their risk of neural-tube disorders in their infants. These include spina bifida (incomplete closure of the neural tube) and anacephaly (being born with virtually no brain). Her department is also considering the possibility of requiring the addition of folic acid to all flour. A regulation based on the Canadian model is now being prepared. Stahl cannot say why this move, adopted years ago in Canada, New Zealand, Australia and other countries, has been taking so long, as she herself has been involved for only a year.
The addition of iodine to salt, widely required abroad, is voluntary for Israeli salt manufacturing companies. Iodine is an essential trace element needed for the normal functioning of the thyroid. The gland's hormones control the body's basic metabolic rate.
Stahl says that the salt company located in Eilat adds iodine to its products, but the company in Atlit does not. The nutrition chief notes that "salt is problematic, because it's better not to eat a lot due to the risks of high blood pressure. But iodine can also be added to rice, flour and cooked cereals."
Stahl, who tries to get nightly exercise after a busy day by walking the dog with her husband, notes that Israelis buy lots of vitamin and mineral supplements, "but they don't know exactly what or how much they are getting. People who eat healthful meals usually don't have to take supplements, except for vitamin D, folic acid or iodine."
HER DEPARTMENT recently produced a new official "food pyramid" to educate people what to eat much of and what to avoid. The new version has water at the base, which means the public should drink plenty instead of a lot of juices, natural or otherwise, as these have an abundance of sugar. The latest version also stresses the benefits of whole-grain foods and legumes. It is produced in Hebrew, and will eventually be in Arabic and Russian (but not English). It can be ordered from the ministry Web site at www.health.gov.il by looking for the nutrition department (Mahleket Hatezuna). Stahl is trying to educate the public to prefer fresh or frozen foods, and when they buy processed foods, they should be as free from artificial color and other chemical additives as possible.
The growing desalination of water for drinking requires changes, as the authorities add only calcium to this water, but not the important mineral magnesium and not fluoride, which helps reduce dental caries, especially in children. She urges parents not to give mineral or other bottled water to infants without heating it, as such water is not sterile. It also lacks fluoride. But when I ask why bottled water companies are not required to state on their labels what is missing and that it is not suitable for infant formula, she says: "You are right; I will have to get that done."
As for schools, the nutrition department is empowered only to recommend to the Education Ministry what should be served if there are organized hot meals for schoolchildren, but not to send in inspectors. "We do not have this mandate, but we would like to have it. Our two inspectors are obviously not enough." There is also no national council for nutrition, even though the ministry has set a wide variety of other national advisory councils. "We have asked for it," adds Stahl. "It is up to the ministry director-general to decide."
FINALLY, the department head is happy that starting in March, clinical dietitians like herself will be licensed by the ministry. At present, anyone who has taken only a short course in nutrition can call himself (usually herself) a clinical dietitian, without having graduated from an academic course. Changing this will raise the level of the profession around the country, Stahl concludes.