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From dentistry to obesity

Fat mouse and thin mouse
Professor Berit Lilienthal Heitmann sets new standards for research in nutrition and obesity; she has also achieved international recognition by looking at the issue of gender in relation to her research. FORUM has spoken with the dentist who came to nutrition epidemiology research quite by chance – with a helping hand from the 1998 FREJA funding programme for women researchers.
KVINFO/2.12.2005 The acronym ‘FREJA’ is voiced with particular pleasure every time Professor Berit Lilienthal Heitmann refers to ‘Female Researchers in Joint Action’ during our interview. She was one of 16 women researchers who received funding from the DKK 78 million (approx. €10.5 million) granted between 1998 and 2001 by the FREJA programme.

Criticism citing positive discrimination gradually subsided as FREJA proved to be an unqualified success. Former Minister of Research and Information Technology Jytte Hilden was the women behind the initiative to earmark funds in support of female researchers – and interest was overwhelming: 327 applications were received.

From the many qualified research proposals, Berit Lilienthal Heitmann’s was one of 16 selected for funding. Her project on nutrition epidemiology involves, in brief, the study of the role played by diet in the development of lifestyle diseases.

The professor is a dentist
Initially trained as a dentist, 42-year-old Heitmann gives FREJA much of the credit for the fact that she is now Professor and research leader of the Enheden for Epidemiologisk Kostforskning (Research Unit for Dietary Studies) at the Institute of Preventive Medicine, Copenhagen University Hospital. The unit did not exist before Berit Lilienthal Heitmann and her network of four women doctors – all specialising in research in nutrition epidemiology – applied for funding for their project and received a grant of DKK 5 million (approx. €672,000) in 1999.

- Epi means upon/among and demos means people, so epidemiology is the study of the causes and distribution of disease in populations. There are a number of epidemiologic categories/environments – for example, in relation to cancer and infection. Nutrition research is also a specific area of study and has its own department at Landbohøjskolen (Royal Veterinary and Agricultural University), but nutrition epidemiology was not a combination that attracted any serious interest whatsoever. So we nutrition epidemiologists felt that there wasn’t really anyone fighting our corner. We didn’t have a profile. There weren’t any new candidates who could be trained in the subject, so we had a pressing wish to do something special for the training and research that we think is so crucial and interesting and we wanted to upgrade it to an independent area of research.

- And when the FREJA funding was announced it was just perfect because our little informal network already had lots of ideas. It was an extension of something we had been discussing but which, of course, we hadn’t had the resources to do anything about, says Heitmann. This network, which is now the managing team of the unit, is made up of, besides Heitmann herself, Marianne Schroll, Agnes Petersen, Lilian Mørk Jørgensen and Merete Osler; all have a background in medicine and all are today employed elsewhere.

- Yes, I’m a bit of an outsider, smiles Berit Lilienthal Heitmann, referring to the fact that she is not a doctor by training, but a dentist, which possibly makes her present position all the more strange. And she makes no secret of being something of an opportunist and thinks that many of the decisive moments in her career have occurred because things have fallen conveniently into place.

Nutrition epidemiologist by chance
- My interest in nutrition epidemiology evolved quite by chance. I qualified as a dentist in 1987 and after that I wanted to do research far more than I wanted to work as a dentist. The trouble was – I hadn’t been involved in any research projects during my time at the School of Dentistry, so I was an unknown face at the research institutes. They, of course, had other candidates who they knew and who it would be far more natural to advance through the system. But, as chance would have it, at the same time as I qualified as a dentist, Institut for Human Ernæring (Department of Human Nutrition) was set up at the Royal Veterinary and Agricultural University.

- At that time there was no one in Denmark with the research qualifications to fulfil a professorship or senior lectureship in human nutrition, so a Swedish professor and a Swedish senior lecturer were recruited to get the Institute going. They wanted three post-graduate researchers and advertised three research fellowships in 11 different disciplines: physiology, medicine, food science, odontology etc., says Berit Lilienthal Heitmann. After a lot of reflection, she came up with the idea of “using some of the oral bacteria strains as an indicator of sugar intake”.

- And I was awarded a research scholarship, says Heitmann when explaining how she made the link between odontology and nutrition.

- So you could say that my interest in nutrition came quite by chance and was the result of a strong desire to engage in research.

We’re getting fatter while the pig’s getting slimmer
After researching oral bacteria strains, the Swedish professor sent young Heitmann to the Center for sygdomsforebyggelse (Centre for Preventive Medicine) at Glostrup University Hospital. Here she was responsible for a major study of the population’s diet and body mass index.
- I gathered data from 3,000 people. Once this information had been assembled it was a natural step to carry on with the research – so interest in nutrition epidemiology was also opportune. There is now a completely new way in which to measure obesity, but what I was doing at the end of the 1980s was new at that point. I was among the first researchers in the world to work in this way. It was fascinating to have the opportunity to develop the method and it actually ended up being the subject of my PhD thesis. So it had nothing to do with teeth!

The harmonisation of various valuable collections of data pertaining to the population’s diet was a key aspect of the FREJA-funded project. The work was complex and is not something normally done with large population groupings. It is expensive, time-consuming and if you want good data then there is no room for compromise.

- There are many parameters to consider. Just the differences in the time period – for example, pigs have slimmed down over the years. So if you ate a kilo of pork and calculated the nutritional value, the calculation would depend on whether you ate it in 1980 or 1995. If you make a study of smoking, then you’re working within a single parameter. If you study diet, then you might be dealing with several hundred parameters. We don’t have to smoke, but we do have to eat. Because of the complexity of the issues involved, very sophisticated methodology is crucial to nutrition epidemiologic research. And as there are so few of us working in this field in Denmark, we are constantly exchanging knowledge across the borders.

- We have set up an affiliated-network in Sweden and hope soon to be able to set up a Nordic network in which all the Scandinavian countries are represented – both with a view to methodological development and also because in Scandinavia we are very similar in terms of dietary intake, dietary recommendations and lifestyle in general. So it’s quite logical that we compare data and collaborate with one another.

FREJA was a crucial factor in establishing the research field
A large portion of the FREJA grant was used on a thorough harmonisation of the assembled data. Once this was done, the Unit had a foundation upon which to build its research.
- We then began recruiting post-graduate researchers to work on all this data we had assembled from 4,000 individuals. We developed courses in nutrition epidemiology and arranged symposia with the participation of speakers from abroad. We tried to communicate and spread our fervent belief in the importance of nutrition epidemiology. And it was particularly essential to enthuse researchers who were just starting out on their careers and could be involved in the early stages of the project and then carry on the tradition, says Berit Lilienthal Heitmann.

Today there are 15 members of staff at the Research Unit for Dietary Studies, but only the director’s salary is guaranteed by Hovedstadens Sygehusselskab (Copenhagen Hospital Corporation). Others are paid from funds and grants to which the Unit applies. The Unit has so far worked with 14-15 PhD students and, in addition, many graduate students and trainees have been affiliated.

The FREJA grant was used up long ago. Other research funding now supports the Unit, but Berit Lilienthal Heitmann is in no doubt that the FREJA funding and the way in which the grant was designed have been of vital significance for the launch of nutrition epidemiology as a separate field of research.

- FREJA had such a wonderful structure. It’s extremely satisfying to get an injection of project funding that is not rigidly specified, but is a framework grant that allows you to say: ‘now we need to hold a networking conference’, ‘now we need to send our PhD students on a course in the US’ or ‘now we need to employ secretarial assistance’. That really is very conducive to first-rate research – because you never know where research is going to lead. You might think, right we’re going from here to there, but research often shows that actually we have to go somewhere else first – and funding might not always have been secured for that particular route.
- The possibility of channelling some funds into another area that is actually proving to be more interesting – that’s really a golden opportunity in research. So I think that my opportunity to develop the research field, and in so doing my own profile too, has been largely thanks to FREJA. So I’m also convinced that FREJA has played a key role in my professorship, because the grant afforded me the opportunity to pursue fundamental research in epidemiology, explains Berit Lilienthal Heitmann, who in 2001 was appointed Adjunct Professor of Nutrition Epidemiology at the University of Southern Denmark.

International reputation for gender awareness
Nutrition epidemiology appeared, as mentioned, quite by chance on Berit Lilienthal Heitmann’s path, but there is no questioning the sincerity of her interest in the subject.

- Well, it’s such an incredibly fascinating and very important area. We all have to eat, and the choices we make have consequences – but which and for whom? For me the essence of the matter is to find out how we can prevent the healthy person from becoming ill, but prevention might have to be tailor-made. Perhaps this is where my training as a dentist comes into play. Odontology is concerned with prevention, whereas the medical world focuses on illness once it is manifest, says Heitmann and goes on:
- I’m very interested in the determinants of obesity – what makes us become overweight and what implications obesity has for our health. And I always start out from an awareness that there is a difference – between genders, for example – says Berit Lilienthal Heitmann, but stresses that she is not a gender researcher.
- I seem to have gained a reputation as one, and in international contexts I’ve quite often been asked to speak about the gender aspect of research into obesity – but I am an obesity researcher. Actually I’m rather surprised to be thought of as a gender researcher.

Could this be because Berit Lilienthal Heitmann is in fact one of the few people within her sphere who acknowledges that there is a difference between men and women?
- My starting point, at least, is that there can be a difference, and if there is a difference I would like to clarify it so that our preventative measures can be more targeted. Heart epidemiology is also very aware of the difference but, apart from that, basing your research on the possibility of a difference is probably a very new concept. In physiology, the human being is still described exclusively as a slim 25-year-old male – I remember that very clearly from the text books we used when I was a student, and it wasn’t even considered politically incorrect. There’s the human…. And then, oh yes, then there are the women too, says Berit Lilienthal Heitmann with a laugh.

The hourglass figure is healthy
Next year Heitmann will be out in the world speaking about the gender aspects in obesity research – this time in Australia at the International Conference on Obesity. And the Danish professor has enough to talk about. For example, that not all body fat is unhealthy. She is responsible for a number of new studies which have attracted much international attention because they show that both men and women benefit from extra fat on buttocks and thighs. The studies show quite clearly that fat in these areas provides a great deal of protection against cardiovascular diseases, cancer, diabetes and early death.

The studies also challenge the current ideal of female beauty.

- It’s interesting seen in relation to the ideal woman. If we take, for example, Miss World as she looked in the 1950s – she was shaped like an hourglass. And think of Marilyn Monroe – she didn’t have much fat around her waist, but on her hips instead. Looked at from the perspective of health, the rounder female form was healthy. Today’s Miss World figure is very boyish. It might very well be that this is the ideal in terms of beauty, but not in terms of health, emphasises Heitmann. 

Women are fat – men have authority
At the moment Berit Lilienthal Heitmann is particularly occupied by a study of whether certain groups have a genetically-determined sensitivity to a specific lifestyle. She explains that this is based on the hypothesis that we might indeed all benefit from exercise, but it might also be the case that exercise is particularly beneficial for some, but has a limited effect for others. If we can identify these subgroups, then we would have the opportunity to offer tailor-made recommendations and thereby improve the efficacy of our preventative measures.

- Our research indicates that people’s reaction to their lifestyle is dependent on their genetic make-up, which again to a certain extent is dependent on gender. Genes are very significant – for example, it might well be that genes play no role if men are inactive, whereas the opposite might be the case for inactive women. So I am strongly opposed to the attitude that overweight people are slackers who eat too much and take too little exercise – the issue can be far more complicated than that.

Berit Lilienthal Heitmann always works, as mentioned, from the basis that there is a difference, and this is also the case when she takes a more sociological approach. She reports that a Finnish study shows that overweight, well-educated women find it much harder to get established in the labour market than their male counterparts.

- Overweight men are ascribed a positive attribute – they have authority! A well-educated overweight woman is fat! – And it’s undoubtedly her own fault. That, unfortunately, is the view, says Berit Lilienthal Heitmann, who has recently shown that, while the Nordic population as a whole has become increasingly overweight since the mid-1960s, middle-aged women have become slimmer.

- Maybe this is because women entered the labour market on a large scale in the 1970s and ’80s – that’s the only common denominator we can see. They have presumably had the incentive to stay slim. And again: overweight well-educated women are not as acceptable as overweight men. The factors that make it important for women to stay slim are different to those for men. There are completely different pictures of the appropriate conduct and appearance of men and of women in the same type of job.

One of Denmark’s 114 women professors
Berit Lilienthal Heitmann, who is one of Denmark’s 114 women professors – out of a national total of 1,181 professors – says that she has not personally experienced discrimination either in terms of professional competence or gender.

- But, on the other hand, I think I’ve seen it happen. It’s easy enough in many contexts to name male candidates for this and that. And then it’s not until someone says ‘hey, don’t you think it’s a bit odd that all your six nominees are men?’ that you remember the women.

In 2000 the proportion of women professors in Denmark was 7%; the most recent calculation, in 2003, came in at 10%.
- Well, of course that’s progress, says Berit Lilienthal Heitmann with dry irony, and then immediately points out that FREJA was the catapult that launched her professorial career.

Women in their 30s are viewed as young 
Following the unqualified success of the FREJA programme, the large number of applications and the poor numbers of female research directors – the proportion of women lecturers 2000-2003, for example, also registers a minimal increase from 22% to 24% – it might seem surprising that a similar scheme has been so long coming. Seven years after Jytte Hilden’s idea was put into action, a cross-party agreement has been made to initiate a programme in which DKK 45 million (approx. €6 mil.) will be distributed according to the FREJA model. This time grants will be awarded for 2006-2008 to post-graduate women researchers working in the fields of technology and natural sciences.

Berit Lilienthal Heitmann considers herself lucky “because it’s all gone very well – someone must be watching over me”. FREJA is one of them, but there is a limit to how many a new FREJA-like project can watch over.

- I think that in the research field it’s very easy to lose ground if you are a 35-year-old women who has to compete with well-established men of 50. Young women are overlooked, and there is a strange tendency to view women in their 30s as younger than their male contemporaries. We can, of course, claim that if the same number of women as men were to enter at lecturer and assistant professor level then the problem of far too few women professors would be resolved in the long term. But, unfortunately, I have strong doubts that it will happen, because progress in this respect over the last 25 years is not encouraging. In Sweden and Norway, for example, pro-active measures have been taken to increase the number of women professors, and I rather lean to the opinion that we need to do something similar here in Denmark if we are to reach a reasonably balanced level.

- Our qualified and very talented women have huge potential. Women are also in the majority on higher education courses, so if women continue to be overlooked we’re heading for disaster – a patent waste of resources. Oh yes, I could easily champion positive discrimination, or whatever it should be called. Along, that is, with equally qualified candidates, so it would be a case of ‘right, now we have to fill the women’s quota’.

Anne-Mette Klausen is a freelance journalist and regular contributor to FORUM.

Translation: Gaye Kynoch 
Related sites
Research Unit for Dietary Studies 
EU facts and figures on women and science: She Figures 2003

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