Social determinants of dietary habits in Denmark

Childhood overweight and obesity prevalences levelling off in Stockholm but socioeconomic differences persist

BACKGROUND

Time trends in overweight, obesity and underweight among 10-year-old children were investigated between 1999 and 2003 with attention to gender and areas with different socioeconomic status (SES).

MATERIAL

The study was performed in Stockholm County, where schools within eight different SES areas were randomly sampled. In selected schools, data on height and weight were abstracted from school health records of 2416 ten-year-old boys and girls examined by school nurses in 1999 and 2183 examined in 2003.

RESULTS

Among boys, the prevalence of overweight was 21.6% in 1999 and 20.5% in 2003 (difference -1.1% (95% confidence interval (CI), -4.6; 2.4)) and for obesity 3.2 and 3.8% (difference 0.6% (95% CI, -0.9; 2.2)). Among girls overweight decreased from 22.1 to 19.2% (difference -2.9% (95% CI, -6.3; 0.6)) and obesity from 4.4 to 2.8% (difference -1.6% (95% CI, -3.1; 0.0)). There was a marginally significant difference in obesity trends in girls versus boys (P=0.051). The prevalence of underweight decreased nonsignificantly both in boys and in girls. Strong gradients, with more obesity and overweight in socioeconomically disadvantaged areas, were observed in both genders in 2003. Differences between SES areas were also seen in 1999 but were more pronounced in 2003. Among boys divergent trends in obesity were observed between 1999 and 2003, with evidence for increases in less affluent areas only.

CONCLUSION

This population-based study of 10-year-olds indicates that rates of obesity, overweight and underweight are stable in Stockholm County. However, obesity is more prevalent in relatively less advantaged SES.

Obesogenic environments--aspects on measurement and indicators

BACKGROUND

The focus in understanding the causes of and preventing obesity has broadened from the individual level to include the obesogenic environment. Proving a causal relationship between environmental factors and eating patterns poses a great challenge because randomised controlled trials are seldom possible or feasible to conduct. Interactions between the environment and individuals are beginning to be explored in multilevel studies and qualitative and sociological research.

AIM

The aim is to give an overview of the wider environmental determinants of diet such as the national food supply, food availability and accessibility in different settings as well as the economic food environment and in relation to socio-economic status.

RESULTS

The indicators suggested are based on the amount of data available in the scientific literature and the potential for intervention. They can be used to monitor societal interventions or evaluate 'natural' changes in the food environment. The indicators are of relevance to the Second WHO European Action Plan for Food and Nutrition Policy 2007-2012.

CONCLUSION

The relatively weak empirical evidence does not imply the absence of causal relationships between environmental factors and diet. Potentially relevant factors have not been evaluated due to the complexity of the task and to lack of political will to change the food environment in a more healthy direction by use of legislation or economic instruments. Future intervention research, targeting the wider environmental determinants of diet, will give us better evidence to propose societal actions to counteract obesity and to strike the right balance between individual and societal action.

Does social class predict diet quality?

A large body of epidemiologic data show that diet quality follows a socioeconomic gradient. Whereas higher-quality diets are associated with greater affluence, energy-dense diets that are nutrient-poor are preferentially consumed by persons of lower socioeconomic status (SES) and of more limited economic means. As this review demonstrates, whole grains, lean meats, fish, low-fat dairy products, and fresh vegetables and fruit are more likely to be consumed by groups of higher SES. In contrast, the consumption of refined grains and added fats has been associated with lower SES. Although micronutrient intake and, hence, diet quality are affected by SES, little evidence indicates that SES affects either total energy intakes or the macronutrient composition of the diet. The observed associations between SES variables and diet-quality measures can be explained by a variety of potentially causal mechanisms. The disparity in energy costs ($/MJ) between energy-dense and nutrient-dense foods is one such mechanism; easy physical access to low-cost energy-dense foods is another. If higher SES is a causal determinant of diet quality, then the reported associations between diet quality and better health, found in so many epidemiologic studies, may have been confounded by unobserved indexes of social class. Conversely, if limited economic resources are causally linked to low-quality diets, some current strategies for health promotion, based on recommending high-cost foods to low-income people, may prove to be wholly ineffective. Exploring the possible causal relations between SES and diet quality is the purpose of this review.

Dietary patterns in pregnancy and associations with socio-demographic and lifestyle factors

OBJECTIVE

To obtain distinct dietary patterns in the third trimester of pregnancy using principal components analysis (PCA); to determine associations with socio-demographic and lifestyle factors.

DESIGN AND METHODS

A total of 12 053 pregnant women partaking in a population-based cohort study recorded current frequency of food consumption via questionnaire in 1991-1992. Dietary patterns identified using PCA were related to social and demographic characteristics and lifestyle factors.

RESULTS

Five dietary patterns were established and labelled to best describe the types of diet being consumed in pregnancy. The 'health conscious' component described a diet based on salad, fruit, rice, pasta, breakfast cereals, fish, eggs, pulses, fruit juices, white meat and non-white bread. The 'traditional' component loaded highly on all types of vegetables, red meat and poultry. The 'processed' component was associated with high-fat processed foods. The 'confectionery' component was characterized by snack foods with high sugar content and the final 'vegetarian' component loaded highly on meat substitutes, pulses, nuts and herbal tea and high negative loadings were seen with red meat and poultry. There were strong associations between various socio-demographic variables and all dietary components; in particular, a 'health conscious' diet was positively associated with increasing education and age and non-white women. There was a negative association with increased parity, single, non-working women, those who smoked and who were overweight pre-pregnancy. Opposite associations were seen with the 'processed' component.

CONCLUSIONS

Distinct dietary patterns in pregnancy have been identified. There is clear evidence of social patterning associated with the dietary patterns, these social factors need to be accounted for in future studies using dietary patterns. This study will form the basis for further work investigating pregnancy outcome.

Women of lower educational attainment have lower food involvement and eat less fruit and vegetables

Women who leave school with few or no educational qualifications are less likely to have diets that meet current recommendations than women who attain more qualifications at school. We hypothesise that lower 'food involvement', meaning that food has a lower level of importance in their lives, explains the poorer quality diets of women of lower educational attainment. We administered Bell and Marshall [(2003). The construct of food involvement in behavioral research: Scale development and validation. Appetite, 40, 235-244.] Food Involvement scale to 242 women of varied educational attainment, of whom 127 were also asked how often they ate fruit and vegetables. Women's food involvement decreased with decreasing educational attainment. Forty-two percent of women who had no educational qualifications were in the lowest quarter of the food involvement score, compared with 12% of women with degrees. Women with lower scores on the food involvement scale also reported eating fruit and vegetables less often. The odds of eating fewer fruit and vegetables rose with lower educational attainment and with lower food involvement scores, suggesting that each has an independent effect. We have shown that the Food Involvement scale discriminates between women, is associated with other characteristics and predicts dietary quality. We now plan to use it in a larger, representative population of women of lower educational attainment to examine its role along with other psychological variables in determining dietary quality.

Do nutrition knowledge and beliefs modify the association of socio-economic factors and diet quality among US adults?

OBJECTIVES

We examined effects of socio-economic status (SES) factors on diet quality and fruits and vegetables intake among US adults and effect modification by nutrition knowledge and beliefs.

METHODS

We used national cross-sectional data (Continuing Survey of Food Intake by Individuals) on 4356 US adults, aged 20-65 years, collected in 1994-1996. Socio-economic factors considered were education and poverty income ratio. Nutrition knowledge and belief score was measured by principal components analysis of 11 question responses. We considered three binary and two continuous outcomes related to United States Department of Agriculture recommended intake of fruits and vegetables and overall diet quality through Healthy Eating Index and alternate Mediterranean Diet Score.

RESULTS

Multivariate analyses indicated that better SES independently improved likelihood of adequate fruits and vegetables intake and overall diet quality. In several cases, nutrition knowledge and beliefs acted as an effect modifier. In particular, education showed no association with diet quality among subjects in the lowest nutrition knowledge and belief tertile, while the association was consistently stronger in the highest tertile (Education x Nutrition knowledge and beliefs interaction term P<0.10 for Healthy Eating Index and both fruits and vegetables guidelines). A similar interaction was noted for poverty income ratio.

CONCLUSION

For improvement in overall diet quality, socio-economic interventions must be coupled with health education programs targeting all segments of the US population.

Dietary patterns in infancy: the importance of maternal and family influences on feeding practice

It is not known what constitutes an optimal diet in infancy. There are relatively few studies of weaning practice in the UK, and there is a need for prospective data on the effects of infant diet and nutrition on health in later life. We describe the dietary patterns, defined using principal components analysis of FFQ data, of 1434 infants aged 6 and 12 months, born between 1999 and 2003. The two most important dietary patterns identified at 6 and 12 months were very similar. The first pattern was characterised by high consumption of fruit, vegetables and home-prepared foods ('infant guidelines' pattern). The second pattern was characterised by high consumption of bread, savoury snacks, biscuits and chips ('adult foods' pattern). Dietary pattern scores were correlated at 6 and 12 months (r 0.46 'infant guidelines'; r 0.45 'adult foods'). These patterns, which reflect wide variations in weaning practice, are associated with maternal and family characteristics. A key influence on the infant diet is the quality of the maternal diet. Women who comply with dietary recommendations, and who have high intakes of fruit and vegetables, wholemeal bread and rice and pasta, are more likely to have infants who have comparable diets--with high 'infant guidelines' pattern scores. Conversely, women whose own diets are characterised by high intakes of chips, white bread, crisps and sweets are more likely to have infants who have high 'adult foods' pattern scores. The effects of these patterns on growth and development, and on long-term outcomes need to be investigated.

Trends of socioeconomic differences in daily vegetable consumption, 1979-2002

BACKGROUND

Studies from different time periods have shown that consumption of vegetables is more common in higher socioeconomic groups and among women. However, there are only few studies of changes of socioeconomic differences in vegetable consumption over time. Our aim was to determine whether socioeconomic differences, measured by educational level and household income, in daily vegetable consumption have increased, decreased or been stable over the last two decades among Finnish men and women.

METHODS

Data on daily consumption of fresh vegetables were derived from repeated annual cross-sectional surveys performed among representative samples of Finnish working aged (15-64 years) population. Data from the years 1979-2002 were linked with data on education and household income from Statistics Finland. Those under 25 years and all students were excluded, giving a total of 69 383 respondents. The main analyses were conducted with logistic regression.

RESULTS

Daily consumption of fresh vegetables became overall more prevalent during the study period. Daily consumption of fresh vegetables was more common among those with higher education and higher income during the whole study period. Both educational level and household income differences in daily vegetable consumption slightly narrowed since 1979 among men and women.

CONCLUSIONS

Women with high socioeconomic position have been initial trend setters, but the prevalence of daily consumers of vegetables in these groups has not increased since the early 1990s. The prevalence of daily consumption of fresh vegetables has increased more in lower educational and income groups during the 1980s and 1990s along with narrowing socioeconomic differences.

An exploration of socioeconomic variation in lifestyle factors and adiposity in the Ontario Food Survey through structural equation modeling

Title

An exploration of socioeconomic variation in lifestyle factors and adiposity in the Ontario Food Survey through structural equation models.

Background

Socioeconomic indicators have been inversely associated with overweight and obesity, with stronger associations observed among women. The objective of the present secondary analysis was to examine the relationships among socioeconomic measures and adiposity for men and women participating in the Ontario Food Survey (OFS), and to explore lifestyle factors as potential mediators of these associations.

Methods

The cross-sectional 1997/98 OFS collected anthropometric measurements, a food frequency questionnaire, data on socio-demographics (age, sex, income, and education) and physical activity from 620 women and 467 men, ages 18 to 75. Based on the 2003 Health Canada guidelines, waist circumference and BMI values were used to derive least risk, increased risk, and high risk adiposity groups. Structural equation modeling was conducted to examine increased risk and high risk adiposity in relation to education and income, with leisure time physical activity, fruit and vegetable intake, and smoking status included as potential mediators of these associations.

Results

The probability of high risk adiposity was directly associated with education (β-0.19, p < 0.05) and income (β-0.22, p < 0.05) for women, but not for men. Fruit and vegetable intake was a marginally significant mediator of the relationship between education and high risk adiposity for women. Increased risk adiposity was not associated with income or education for men or women.

Conclusion

The socioeconomic context of adiposity continues to differ greatly between men and women. For women only in the OFS, fruit and vegetable intake contributed to the inverse association between education and high risk adiposity; however, additional explanatory factors are yet to be determined.

Secular trends in the association of socio-economic position with self-reported dietary attributes and biomarkers in the US population: National Health and Nutrition Examination Survey (NHANES) 1971-1975 to NHANES 1999-2002

OBJECTIVE

Recent reports suggest persistence of health disparities related to socio-economic position (SEP). To understand if diet may be a contributor to these trends, we examined secular trends in the association of diet and indicators of SEP from 1971-1975 to 1999-2002.

DESIGN

We used data from the National Health and Nutrition Examination Surveys (NHANES) I (1971-1975), II (1976-1980), III (1988-1994) and 1999-2002 to examine the independent associations of poverty income ratio (PIR) and education with diet and biomarkers of diet and disease in 25-74-year-olds (n = 36,600). We used logistic and linear regression methods to adjust for multiple covariates and survey design to examine these associations.

RESULTS

A large PIR differential in the likelihood of reporting a fruit or all five food groups and vitamin C intake, and an education differential in likelihood of obesity and carbohydrate intake, was noted in 1971-1975 but narrowed in 1999-2002 (P < 0.007). The positive association of education with intake of a fruit, vegetable or all five food groups, vitamins A and C, calcium and potassium intake remained unchanged across surveys (P < 0.001). Similarly, the positive association of PIR with the amount of foods and intakes of energy and potassium remained unchanged over three decades (P < 0.001). The education and the PIR differential in energy density, and the PIR differential in the likelihood of obesity, persisted over the period of the four surveys (P < 0.001).

CONCLUSIONS

Persistence of unfavourable dietary and biomarker profiles in Americans with low income and education suggests continued need for improvement in the quality of diets of these high-risk groups.

How do socio-economic status, perceived economic barriers and nutritional benefits affect quality of dietary intake among US adults?

BACKGROUND

Socio-economic factors may affect diet quality, perhaps differentially across gender and ethnicity. The mechanism of this association is still largely unknown.

OBJECTIVES

We examined the independent effects of socio-economic status (SES), perceived barrier of food price (PBFP) and perceived benefit of diet quality (PBDQ) on diet quality indicators and indices (DQI(j,k)), across gender and ethnicity. Additionally, we estimated the mediation proportion of the effect of SES on DQI(j,k) through PBFP and PBDQ.

METHODS

Data from two cross-sectional surveys, the Continuing Survey of Food Intakes by Individuals (CSFII) and Diet and Health Knowledge Survey (DHKS) 1994-96 were used. Our sample consisted of 4356 US adults aged 20-65 years. With principal components analysis, SES (an index) was measured using household income per capita and education, and PBDQ was measured using an 11-item scale. PBFP was defined as the ratio of importance of food price score relative to nutrition. DQI(j,k) were assessed by a set of indicators and two indices including the Healthy Eating Index.

RESULTS

The associations between SES, PBFP, PBDQ and DQI(j,k) varied significantly across gender and ethnic groups. PBFP acted as a mediator in the association between SES and selected DQI(j) indicators, namely energy, fat intake, sodium and simple sugar consumption (mediation proportion >10%), but not PBDQ.

CONCLUSIONS

SES, PBFP and PBDQ all affect dietary intake, and vary by ethnicity and gender. Positive effect of SES on DQI(j,k) may be mediated by PBFP but not PBDQ which is an independent protective factor. Nutrition education is important to promote healthy eating.

Past food habit change is related to obesity, lifestyle and socio-economic factors in the Malmo Diet and Cancer Cohort

Objectives

To examine if obesity status and socio-economic and lifestyle factors are associated with self-reported past food habit change, and also whether the level of obesity depends on the reason for change.

Design

Cross-sectional analysis within the Malmo Diet and Cancer (MDC) study using data from the baseline examination and the extensive socio-economic and lifestyle questionnaire including questions of past food habit change. The risk of having changed food habits in the past was examined using logistic regression. Mean differences in obesity status across categories of reasons for past food habit change were examined using analysis of variance.

Setting

Malmö, the third largest city in Sweden.

Subjects

A sub-sample (15 282 women and 9867 men) from the MDC cohort recruited from 1992 to 1996.

Results

Individuals with body mass index (BMI) >30 kg m−2 had an increased risk of having reported past food habit change compared with individuals with BMI <25 kg m−2 (odds ratio (OR) = 1.63, 95% confidence interval (CI) = 1.48–1.83 for women; OR = 1.53, 95% CI = 1.32–1.76 for men). The highest level of obesity was observed among individuals who had changed their diet due to reasons related to the metabolic syndrome. Changers were more likely to be highly educated and to live alone, be retired, ex-smokers and non-drinkers at baseline.

Conclusions

Because past food habit change is related to obesity and other lifestyle and socio-economic factors, a complex confounding situation may exist that could seriously influence observed relationships between diet and disease. Studies need to collect information on past food habit change and take this information into account in the analysis and when interpreting study outcomes.

Correlates of diet quality in the Quebec population

Objective:

To determine the correlates of a high-fat diet in urban, suburban and rural areas of Quebec, Canada.

Design:

A secondary analysis of data collected as part of a 5-year multi-factorial, multi-setting, community-intervention project.

Setting:

Urban, suburban and rural settings of the province of Quebec, 1997.

Subjects:

Data were analysed from a sample of 5214 participants (2227 males, 2987 females). A food-frequency questionnaire was completed and a global index of food quality was calculated. Logistic regression was used to identify correlates of a diet high in total fats, saturated fat and cholesterol.

Results:

In both genders, lower level of education, smoking status, French and English languages compared with other languages spoken at home, and a rural environment were associated with poor diet quality. Having no intention to eat low-fat dairy products more often was associated with a high-fat diet. In men, obesity (body mass index >30 kg m−2) and absence of reported health problems were correlates of a high-fat diet, while, in women, lower physical activity was a correlate.

Conclusions:

Future health interventions in Quebec should target people with low education, smokers and those living in a rural environment. Obese men and sedentary women should have access to specific dietetic resources.

An examination of income-related disparities in the nutritional quality of food selections among Canadian households from 1986–2001

Socio-economic disparities in nutrition have been documented in numerous countries, and have been linked to health inequalities. Social and economic policy changes occurring over the last several years have resulted in growing levels of income inequality in many countries. However, the extent to which these temporal changes have affected nutrition disparities is largely unknown. Our research examined income-related disparities in the nutritional quality of food selections among Canadian households from 1986 to 2001. Data from the 1986, 1992, 1996 and 2001 Family Food Expenditure surveys were pooled together (n=35048). The relationships between household income and the nutritional quality of food purchases (considering nutrients both as absolute amounts and adjusted for energy, and total energy density) were estimated using general linear models, including tests of significance for differences across the survey years. Results revealed significant positive relationships between income and most nutrients, which persisted over time, and for some nutrients grew stronger. One exception was folate, where the positive relationship between income and folate (independent of energy) was no longer apparent in 2001; this could be attributed to the mandatory fortification of some cereal grain products with folic acid, which came into effect in 1998, resulting in greater availability of folate from grain products. There was also a significant negative relationship between income and total energy density (ratio of food energy to food weight), which persisted across the survey years. At a time of growing income inequality and worsening problems of poverty, food policy makers need to pay attention to the potential for policy interventions to exacerbate or improve nutrition disparities.

Impact of parental education and income inequality on children's food intake

Objective

To analyse the association between socio-economic indicators and diet among 2-year-old children, by assessing the independent contribution of parental education and equivalent income to food intake.

Design

The analysis was based on data from a prospective birth cohort study. Information on diet was obtained using a semi-quantitative food-frequency questionnaire. Low and high intake of food was defined according to the lowest and the highest quintile of food consumption frequency, respectively.

Setting

Four German cities (Munich, Leipzig, Wesel, Bad Honnef), 1999–2001.

Subjects

Subjects were 2637 children at the age of 2 years, whose parents completed questionnaires gathering information on lifestyle factors, including parental socio-economic status, household consumption frequencies and children's diet.

Results

Both low parental education and low equivalent income were associated with a low intake of fresh fruit, cooked vegetables and olive oil, and a high intake of canned vegetables or fruit, margarine, mayonnaise and processed salad dressing in children. Children with a low intake of milk and cream, and a high intake of hardened vegetable fat, more likely had parents with lower education. Low butter intake was associated with low equivalent income only.

Conclusions

These findings may be helpful for future intervention programmes with more targeted policies aiming at an improvement of children's diets.

Gender differences in the consumption of meat, fruit and vegetables are similar in Finland and the Baltic countries

BACKGROUND

Women's diets are healthier than men's. Finnish women eat more fruits and vegetables but less meat than men. Gender differences may be larger in the Baltic countries, which represent Eastern European transition societies than in Finland, a society characterized by the Scandinavian welfare ideology and a high degree of gender equality.

METHODS

The data are based on questionnaires to random samples of adults in Finland, Estonia, Latvia and Lithuania. The data provide a way of addressing gender differences at the turn of the century in the economically and culturally different countries. The purpose is to explore whether the consumption of foods classified as masculine or feminine-meat, fruits and vegetables-follow a similar gender pattern in Finland and the Baltic countries.

RESULTS

Men ate meat more often while women ate fruits and vegetables. A high educational level was associated with frequent consumption of fruits and vegetables. Educational differences in the consumption of meat were few and inconsistent. The consumption of fruits and vegetables was more common in urban areas except in Finland. Gender differences were similar in all countries throughout age and educational groups and in rural and urban areas.

CONCLUSION

The consistent association of gender and food and the similarity of gender patterning in population subgroups point to the stability of masculine versus feminine food habits. The similarity suggests that food habits contribute equally to the gender gap in health in the Baltic countries as they do in Finland.

Multiple socio-economic circumstances and healthy food habits

OBJECTIVE

To examine associations between seven indicators of socio-economic circumstances and healthy food habits, while taking into account assumed temporal order between these socio-economic indicators.

DESIGN AND SETTING

Data were derived from cross-sectional postal questionnaires in 2000-2002. Socio-economic circumstances were assessed by parental education, childhood economic difficulties, own education, occupational class, household income, home ownership and current economic difficulties. Healthy food habits were measured by an index consisting of consumption of fresh vegetables, fruit or berries, rye bread, fish and choosing vegetable fats on bread and oil in cooking. Sequential logistic regression models were used, adjusting for age and marital status.

PARTICIPANTS

Employees of the City of Helsinki, Finland (n=8960, aged 40-60 years).

RESULTS

Healthy food habits were reported by 28% of women and by 17% of men. Own education, occupational class, household income, home ownership and current economic difficulties were associated with healthy food habits. These associations were attenuated but mainly remained after mutual adjustments for the socio-economic indicators. Among women, a pathway was found suggesting that part of the effects of education on food habits were mediated through occupational class.

CONCLUSIONS

Employees in higher and lower socio-economic positions differ in their food habits, and those in lower positions and economically disadvantaged are less likely to report healthy food habits. Health promotion programmes and food policies should encourage healthier food choices among those in lower socio-economic positions and among those with economic difficulties in particular.

Correlates of fat intake behaviors in participants in the eating for a healthy life study

OBJECTIVE

This study identified socioeconomic correlates of total dietary fat intake in the Eating for a Healthy Life Study, a community-based dietary intervention study involving religious organizations.

SUBJECTS/DESIGN

To create our sampling frame for the Eating for a Healthy Life Study, a pool of religious organizations was identified from a list of religious faith organizations provided by the Church Council of Greater Seattle. Individual members were randomly selected from recruited religious organizations to complete a telephone-administered, baseline, cross-sectional survey. There were 2,507 respondents who were eligible, consenting participants. Dietary behavior was assessed using a modified version of the Fat- and Fiber-Related Diet Behavior Questionnaire. Socioeconomic status was assessed using individual demographic variables.

MAIN OUTCOME MEASURES

Fat-related behaviors indicated by fat summary score and stage of change.

STATISTICAL ANALYSES

A multivariable linear regression model was used to examine the association of individual demographic variables with the Fat- and Fiber-Related Diet Behavior Questionnaire-derived measure of dietary fat intake. The same individual variables were used in a multivariable logistic regression model of dietary stage of change.

RESULTS

Age, race, sex, education, and self-assessed health status were found to be statistically significant correlates of fat intake. Variables associated with stage of dietary fat change included sex, education, and religious organization cohesion.

CONCLUSIONS

Demographic variance is an important factor in understanding dietary fat intake.

Impact of a cost constraint on nutritionally adequate food choices for French women: an analysis by linear programming

OBJECTIVE

To predict, for French women, the impact of a cost constraint on the food choices required to provide a nutritionally adequate diet.

DESIGN

Isocaloric daily diets fulfilling both palatability and nutritional constraints were modeled in linear programming, using different cost constraint levels. For each modeled diet, total departure from an observed French population's average food group pattern ("mean observed diet") was minimized.

RESULTS

To achieve the nutritional recommendations without a cost constraint, the modeled diet provided more energy from fish, fresh fruits and green vegetables and less energy from animal fats and cheese than the "mean observed diet." Introducing and strengthening a cost constraint decreased the energy provided by meat, fresh vegetables, fresh fruits, vegetable fat, and yogurts and increased the energy from processed meat, eggs, offal, and milk. For the lowest cost diet (ie, 3.18 euros/d), marked changes from the "mean observed diet" were required, including a marked reduction in the amount of energy from fresh fruits (-85%) and green vegetables (-70%), and an increase in the amount of energy from nuts, dried fruits, roots, legumes, and fruit juices.

IMPLICATIONS

Nutrition education for low-income French women must emphasize these affordable food choices.

Socio-demographic influences on food purchasing among Canadian households

OBJECTIVE

To characterize the relationships between selected socio-demographic factors and food selection among Canadian households.

DESIGN

A secondary analysis of data from the 1996 Family Food Expenditure survey was conducted (n=10,924). Household food purchases were classified into one of the five food groups from Canada's Food Guide to Healthy Eating. Parametric and non-parametric modelling techniques were employed to analyse the effects of household size, composition, income and education on the proportion of income spent on each food group and the quantity purchased from each food group.

RESULTS

Household size, composition, income and education together explained 21-29% of the variation in food purchasing. Households with older adults spent a greater share of their income on vegetables and fruit (P<0.0001), whereas households with children purchased greater quantities of milk products (P<0.0001). Higher income was associated with purchasing more of all food groups (P<0.0001), but the associations were nonlinear, with the strongest effects at lower income levels. Households where the reference person had a university degree purchased significantly more vegetables and fruit, and less meat and alternatives and 'other' foods (P<0.0001), relative to households with the lowest education level.

CONCLUSIONS

Household socio-demographic characteristics have a strong influence on food purchasing, with the purchase of vegetables and fruit being particularly sensitive. Results reinforce concerns about constraints on food purchasing among lower income households. Furthermore, the differential effects of income and education on food choice need to be considered in the design of public health interventions aimed at altering dietary behaviour.

Growing social inequalities in the occurrence of overweight and obesity among young men in Sweden

AIMS

The aims of the present study are to investigate time trends and social inequalities in mean body mass index (BMI), overweight, and obesity among 18-year-old men in Sweden from 1970 to 2000 and to explore whether social inequalities in these conditions have increased.

METHODS

A record linkage was made between the Military Service Conscription Register, Population and Housing Censuses, the Register of Education and the Register of the Total Population. All 1,748,800 males born in 1952-82 who were living in Sweden at the age of 17 years in 1969-99 were eligible for this nationwide study. The study population comprises 1,500,499 18-year-old men with information on BMI (86% of eligible subjects).

RESULTS

During the study period from 1970 to 2000, mean BMI increased from 20.89 kg/m2 to 22.49 kg/m2, the prevalence of overweight increased from 6.6% to 13.6% and the prevalence of obesity increased from 1.0% to 3.8%. Mean BMI and the prevalence of overweight and obesity were higher among young men with low-educated mothers than among those with high-educated mothers. A noteworthy finding was that the socioeconomic gap increased over time.

CONCLUSIONS

Between 1970 and 2000, the prevalence of overweight increased twofold and the prevalence of obesity increased fourfold in this study population. The social inequalities in overweight and obesity have steadily increased among young men in Sweden during the past three decades.

Bone mineral density in relation to body mass index among young women: a prospective cohort study

AIM

To identify important predictors among lifestyle behaviours and physiological factors of bone mineral density (BMD) in relation to body mass index (BMI) among young women over a 2-year period. DESIGN, SAMPLE AND MEASUREMENTS: Data were collected in 1999 and 2001. Healthy young women (n=152) completed a questionnaire. BMD measurements were performed by DEXA in the calcaneus. The women were subdivided into three categories according to baseline BMI.

RESULTS

Baseline bodyweight explained 25% of the variability in BMD at follow-up in the BMI<19 category, and high physical activity seemed to hinder BMD development. In the BMI>24 category, a difference in time spent outdoors during winter between baseline and follow-up was the single most important factor for BMD levels. Overweight women with periods of amenorrhoea had lower BMD than overweight women without such periods.

CONCLUSIONS

Predictors and lifestyle behaviours associated with BMD are likely to be based on women of normal weight. BMI should be considered when advising on physical activity, since high physical activity seems to impair BMD development among underweight young women, possibly due to energy imbalance. Among overweight women, sleep satisfaction is the greatest predictor associated with BMD change and may indicate better bone formation conditions. Energy balance and sleep quality may be prerequisites of bone health and should be considered in prevention.

A Nutrient Density Standard for Vegetables and Fruits: Nutrients per Calorie and Nutrients per Unit Cost

OBJECTIVES

The Dietary Guidelines for Americans 2005 recommended that consumers give priority to nutrient-dense foods, those that contain substantial amounts of key nutrients in relation to the dietary energy they provide. This study developed a scoring system to estimate the nutritional adequacy of vegetables and fruits, on a per weight, per calorie, and per unit cost basis.

DATA

We used a French national food composition database for 637 foods, including 129 vegetables and fruits. Mean national retail prices were obtained for each food.

METHODS

The nutrient adequacy score was defined as the mean of percent daily values for 16 nutrients, based on 100 g of food. The nutrient density score and the nutrient-to-price ratio were the mean of percent daily values for 16 nutrients, expressed per 100 kcal and per 1 euro of food, respectively. Relationships between energy density of vegetables and fruits, nutrient adequacy score, nutrient density score, and nutrient-to-price ratio were tested using linear regression.

RESULTS

Energy density and nutrient density score were negatively correlated, confirming the widely accepted notion that energy-dense foods tend to be nutrient-poor. As expected, fruits and vegetables had the highest nutrient density score because they were nutrient-rich in relation to their low energy content. They also had a relatively high nutrient-to-price ratio, showing that they provided nutrients at a reasonable cost when compared with other foods.

CONCLUSIONS

Foods ranked differently when nutritional adequacy was calculated per weight (nutrient adequacy score), per calorie (nutrient density score), or per unit cost (nutrient-to-price ratio). The present results showed that although fruits and vegetables are an expensive source of dietary energy, they provide key nutrients at a reasonable cost.

Lifestyle, social class, and obesity-the Copenhagen Male Study

OBJECTIVE

With the implicit purpose of identifying relevant intervention targets, the aim of the study was to test if lifestyle factors associated with obesity are unevenly distributed across social groups, and whether an uneven distribution of such factors may contribute to the explanation of social differences in obesity.

DESIGN

Cross-sectional study of 3290 men aged 53-75 years (mean=63) carried out in 1985-1986 using in addition, data from a previous baseline established in 1970-1971. Information about lifestyle factors was obtained from a questionnaire validated during an interview. Potential risk factors were smoking history, alcohol consumption, leisure time physical activity (LTPA), and from the 1985-1986 study only: consumption of tea and coffee, use of sugar in tea or coffee, and avoidance of fat in foods. The clinical examination included measurements of height and weight. Obesity was defined as a body mass index > or =30 (BMI=kg/m2). Based on information about education and job profile the men were subdivided into five social classes.

RESULTS

Overall, 291 men (8.8%) were obese. The lower the social class the higher the proportion of obese men: in social classes I and II, 4.5% (of 953), social class III, 9.1% (of 636), social class IV, 11.1% (of 1353), and social class V, 11.6% (of 346), P<0.001 (trend test). Leisure time physical activity, alcohol consumption, smoking habits, use of sugar in hot beverages, and consumption of coffee and tea, were all significantly associated with obesity, either positively or negatively, and even significantly associated with social class. Based on these lifestyle factors it was possible to discriminate subgroups with highly different prevalences of obesity. Despite this, adjustment for identified obesity covariates in a multiple logistic regression analysis did in no way explain the association of social class with obesity.

CONCLUSION

Lifestyle factors in concert strongly associated with obesity are unevenly distributed across social classes, yet incapable of explaining the higher prevalence of obesity in lower social classes.

Maternal diet in pregnancy and offspring height, sitting height, and leg length

STUDY OBJECTIVE

To examine the association between maternal diet in pregnancy and offspring height, sitting height, and leg length.

DESIGN

Cohort study.

SETTING

South west England.

PARTICIPANTS

6663 singletons (51% male) enrolled in the Avon longitudinal study of parents and children, with information on their mother's diet in late pregnancy (obtained by food frequency questionnaire) and their own height recorded at age 7.5 years.

MAIN RESULTS

Before adjustment, maternal magnesium, iron, and vitamin C were the nutrients most consistently associated with offspring height and its components. However, adjusting for potential confounders weakened all relations considerably. For example, a standard deviation (SD) increase in magnesium intake was associated with a 0.10 (-0.07, 0.14) SD unit increase in height before adjustment, which was reduced to 0.05 (0.01, 0.08) SD units after adjustment, and a SD unit increase in iron intake was associated with 0.08 (0.05, 0.12) and 0.04 (0.01, 0.08) SD unit increases in height before and after adjustment respectively. No other dietary variables were associated with height or its components after adjustment.

CONCLUSIONS

These findings do not provide evidence that maternal diet in pregnancy has an important influence on offspring height, sitting height, or leg length in well nourished populations, although effects may emerge as offspring become older.

Associations between sociodemographic and lifestyle factors and dietary quality among adolescents in Palma de Mallorca

OBJECTIVE

We assessed associations between sociodemographic and lifestyle factors and dietary quality among adolescents.

METHODS

Subjects were 445 adolescents (171 boys, 274 girls; 14 to 18 y old) selected from the Palma de Mallorca (Balearic Islands, Spain) school census (96% participation) using two-stage probability sampling. The study protocol included dietary intake by means of a validated semiquantitative food-frequency questionnaire; sociodemographic factors of sex, maternal level of education, parental occupational status, and maternal region of origin; physical activity; and body weight and height measurements. Body mass index was calculated and energy intake expressed as multiples of basal metabolic rate.

RESULTS

Mean daily energy intakes were 12.9 MJ for boys and 12.0 MJ for girls. Boys showed a higher percentage of energy from carbohydrates but a lower percentage from proteins and fat than did girls (44.9 versus 41.6, 18.8 versus 19.8, and 36.3 versus 38.5, respectively). Dietary fiber intake was within the recommended levels. Mineral and vitamin intakes generally met their estimated needs, except for vitamins A and D, which covered less than two-thirds of the recommended intake. Maternal educational level was positively correlated with dietary mineral and vitamin intakes. A positive relation between physical activity and dietary intakes of carbohydrate and of mineral and vitamin was found.

CONCLUSIONS

Maternal level of education and physical activity are associated to the quality of diet among adolescents in Palma de Mallorca.

Impact of educational attainment on the quality of young women's diets

OBJECTIVE

New findings, that relate poor foetal growth to long-term outcomes, highlight the need to understand more about the nature of women's diets before and during pregnancy. This study examines the influence of sociodemographic and anthropometric factors on the quality of the diets of young women in the UK.

DESIGN

Diet was assessed by an interviewer-administered food frequency questionnaire. A single diet score was calculated for each woman using the first component defined by principal components analysis.

SETTING

Southampton, UK.

SUBJECTS

A total of 6125 non pregnant women aged 20-34 y.

RESULTS

The diets of women with low diet scores were characterised by low intakes of fruit and vegetables, wholemeal bread, rice and pasta, yogurt, and breakfast cereals, but high intakes of chips and roast potatoes, sugar, white bread, red, and processed meat and full-fat dairy products. Educational attainment was the most important factor related to the diet score. In all, 55% (95% CI 50-59%) of women with no educational qualifications had scores in the lowest quarter of the distribution, compared with only 3% (95% CI 2-4%) of those who had a degree. Smoking, watching television, lack of strenuous exercise, and living with children were also associated with lower diet scores. After taking these factors into account, no other factor including social class, the deprivation score of the neighbourhood, or receipt of benefits added more than 1% to the variance in the diet score.

CONCLUSIONS

Poor achievement at school defines a substantial group of women in the UK who may be vulnerable. Many of these women have poor diets that are not simply a result of the level of deprivation in their neighbourhood, or of living at a level of poverty that entitles them to benefits. We suggest that it is a priority to identify and to address the barriers that prevent these women from improving the quality of their diets.

SPONSORSHIP

The study was funded by the Dunhill Medical Trust, the University of Southampton and the Medical Research Council.

Residential area deprivation predicts fruit and vegetable consumption independently of individual educational level and occupational social class: a cross sectional population study in the Norfolk cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk)

STUDY OBJECTIVE

To investigate the independent association between individual and area based socioeconomic measures and fruit and vegetable consumption.

DESIGN

Cross sectional population based study.

SETTING AND PARTICIPANTS

22,562 men and women aged 39-79 years living in the general community in Norfolk, United Kingdom, recruited using general practice age-sex registers.

OUTCOME MEASURES

Fruit and vegetable intake assessed using a food frequency questionnaire.

MAIN RESULTS

Being in a manual occupational social class, having no educational qualifications, and living in a deprived area all independently predicted significantly lower consumption of fruit and vegetables. The effect of residential area deprivation was predominantly in those in manual occupational social class and no educational qualifications.

CONCLUSIONS

Understanding some of the community level barriers to changing health related behaviours may lead to more effective interventions to improving health in the whole community, particularly those who are most vulnerable.

Longitudinal changes in diet from childhood into adulthood with respect to risk of cardiovascular diseases: The Cardiovascular Risk in Young Finns Study

OBJECTIVE

To assess nutrient intakes relevant in the prevention of cardiovascular diseases (CVD) among young adults in Finland and to find past and present determinants of quality of diet.

DESIGN

Prospective study, 21 years of follow-up.

SETTING

The Cardiovascular Risk in Young Finns Study, Finland.

SUBJECTS

At baseline in 1980: 3569 children aged 3-18 y participated (83% of those invited), and every second of them (1780) were selected to the dietary study. At follow-ups in 1986 and 2001: 1200 and 1037 of the original sample, respectively, participated.

METHODS

Food consumption was assessed using 48-h dietary recall. Intakes in 2001 were compared with those obtained in 1980 and 1986. Nutrients selected for further examination were those implicated in the risk of CVD: saturated, monounsaturated, polyunsaturated and n-3 fatty acids, fibre and salt. An index describing the quality of adulthood diet was constructed. Multivariate logistic regression was used to identify independent childhood and adulthood determinants of the quality index.

RESULTS

The average intakes showed substantial changes since 1980. Intakes of fat and saturated fat had decreased, while the consumption of vegetables and fruit had increased. However, a great disparity was present between the recommended levels and actual intakes for many of the nutrients, particularly salt, saturated fat and fibre. Intake of fat and consumption of vegetables in childhood and physical activity in adulthood were important health behavioural determinants of the cardiovascular quality of the adult diet. Socio-demographic factors, including education of the subject and their parents, had no significant associations with diet.

CONCLUSIONS

While intakes of energy and nutrients have changed favourably in Finnish young adults between 1980 and 2001 with regard to the risk of CVD, they are still far from recommended levels. Childhood diet is a significant determinant of adult diet even after 21 y.

SPONSORSHIP

This study was supported by the Academy of Finland (grant 77841) and Juho Vainio Foundation.

Sociodemographic differences in dietary habits described by food frequency questions — results from Denmark

OBJECTIVES

To investigate whether a modest number of food frequency questions are sufficient to describe sociodemographic differences in dietary habits, and to identify sociodemographic characteristics of subjects adhering to food-based dietary guidelines operationalised in a "healthy-diet index".

DESIGN

Cross-sectional population survey.

SUBJECTS

A total of 480 men, 515 women, aged 15-90 y. Random sample of private telephone numbers drawn from regional telephone records, geographically stratified. Participation rate 62%.

METHODS

Computer-assisted telephone interviews, including six food frequency questions, a question on type of fat spreads used on bread, questions on seven sociodemographic variables.

RESULTS

The summary of the healthy-diet index showed that the subjects who adhered to food-based dietary guidelines (top quintile) compared to those who did not (bottom quintile) were most often women (odds ratio (OR)=6.07; confidence interval (CI): 3.91-9.43, women vs men), of older age (OR=9.72; CI: 3.02-31.31, old age vs young), highly educated (OR=3.69; CI: 1.53-8.92, high education vs low) and living in multiperson households including children (OR=4.66; CI: 2.47-8.80, multiperson household vs single household). The results also showed that gender difference in dietary habits is associated with other sociodemographic variables.

CONCLUSIONS

The selected food frequency questions proved sufficient to describe sociodemographic differences in dietary habits, and this method may be a valuable supplement to traditional quantitative dietary surveys in monitoring sociodemographic changes in eating patterns. The results also underline the influence of sociodemographic status on dietary habits.

SPONSORSHIP

The Danish Nutrition Council funded the study.

A systematic review of socioeconomic differences in food habits in Europe: consumption of cheese and milk

OBJECTIVE

To assess differences in cheese and milk consumption across socioeconomic groups in representative samples from several European countries.

DESIGN

A meta-analysis of published and unpublished surveys of food habits performed in nine European countries between 1985 and 1999. Educational and occupational levels were used as indicators of socio-economic status.

RESULTS

A higher socioeconomic status was associated with a greater consumption of cheese. The pooled estimate of the difference in cheese consumption between women in the highest vs the lowest educational level was 9.0 g/day (95% CI: 7.1 to 11.0). The parallel observation in men was 6.8 g/day (95% CI: 3.4 to 10.1). Similar results were obtained using occupation as an indicator of socioeconomic status. The pooled estimates of the higher cheese consumption among subjects belonging to the highest (vs the lowest) occupational level were 5.1 g/day (95% CI: 3.7 to 6.5) in women and 4.6 g/day (95% CI: 2.1 to 7.0) in men. No statistically significant associations were found for milk consumption concerning educational or occupational level.

CONCLUSIONS

Our findings suggest that consumption of cheese is likely to be higher among subjects belonging to higher socioeconomic levels. We did not find enough evidence to support that milk intake is different according to educational or social levels.

Fruits and vegetables intake differentially affects estrogen receptor negative and positive breast cancer incidence rates

Despite intensive research, the evidence for a protective effect of fruits and vegetables on breast cancer risk remains inconclusive. Other risk factors for breast cancer seem to vary with the estrogen receptor status of the breast tumor, and it is thus possible that the inconsistent results regarding a preventive effect of fruits and vegetables are due to lack of controlling for estrogen receptor status. The objective of this study was to investigate the effect of fruit and vegetable intake on postmenopausal breast cancer and explore whether the estrogen receptor status of the tumor modifies this relation. Postmenopausal women (n = 23,798; aged 50-64 y) provided information about diet and established risk factors for breast cancer in the cohort "Diet, Cancer and Health." During follow-up, 425 cases were diagnosed with breast cancer. Associations between intake of fruits and vegetables and the breast cancer rate were analyzed using Cox's regression model. The association for all breast cancers was an incidence rate ratio (IRR) of 1.02 (95% CI, 0.98-1.06) per 100 g/d increment of total intake of fruits, vegetables and juice. For estrogen receptor-positive (ER(+)) breast cancer, a borderline significant increase in the rate was seen, IRR: 1.05 (95% CI, 1.00-1.10), whereas a preventive effect was seen for estrogen receptor-negative (ER(-)) breast cancers, IRR: 0.90 (95% CI, 0.81-0.99). In conclusion, we did not find the overall breast cancer rate to be associated with the intake of fruits and vegetables, but there seemed to be different effects for ER(+) and ER(-) breast cancer.

Taste function in methadone-maintained opioid-dependent men

It has been shown repeatedly that opioid dependence is associated with increased consumption of refined sugars. It is possible that this association results from altered taste reactivity in opioid-dependent subjects. Thus, in the present study, we compared taste responses to sweet, bitter, sour and salty solutions in methadone-maintained opioid-dependent men and healthy control subjects. The two groups did not differ in terms of rated intensity or pleasantness of sucrose (1-30%), quinine (0.001-0.005%), citric acid (0.02-0.1%) and sodium chloride (0.18-0.9%) solutions. Proportions of 'sweet-likers', i.e. subjects rating a 30% sucrose (0.88 M) solution as the most pleasant, were also similar in both groups. In line with the previous findings, the methadone-maintained subjects reported adding more table sugar to caffeinated beverages. The results of the present study suggest that changes in taste reactivity may not be responsible for altered dietary choices in opioid addicts.