Selection of a food classification system and a food composition database for future food consumption surveys

FoodEx2 Harmonization of the Food Consumption Database from the Italian IV SCAI Children's Survey

Estimating the habitual food and nutrient intakes of a population is based on dietary assessment methods that collect detailed information on food consumption. Establishing the list of foods to be used for collecting data in dietary surveys is central to standardizing data collection. Comparing foods across different data sources is always challenging. Nomenclatures, detail, and classification into broad food groups and sub-groups can vary considerably. The use of a common system for classifying and describing foods is an important prerequisite for analyzing data from different sources. At the European level, EFSA has addressed this need through the development and maintenance of the FoodEx2 classification system. The aim of this work is to present the FoodEx2 harmonization of foods, beverages, and food supplements consumed in the IV SCAI children's survey carried out in Italy. Classifying foods into representative food categories predefined at European level for intake and exposure assessment may lead to a loss of information. On the other hand, a major advantage is the comparability of data from different national databases. The FoodEx2 classification of the national food consumption database represented a step forward in the standardization of the data collection and registration. The large use of FoodEx2 categories at a high level of detail (core and extended terms) combined with the use of descriptors (facets) has minimized information loss and made the reference food categories at country level comparable with different food databases at national and international level.

Is There a Convergence between the Food Classification Adopted by Food-Based Dietary Guidelines and Food Science and Technology?

The World Health Organization (WHO) proposed the dietary guidelines presented as the Food-based Dietary Guidelines (FBDG). The FBDG classify foods according to their origin, nature, nutrient source, food group, and processing level. Food science and technology (FST) ranks food according to its origin, perishability, nutrient source, processing, food group, and formulation. This paper aimed to compare the convergence points for food classification according to the FBDG and FST. This study was carried out in two phases. The first step was identifying the Food-Based Dietary Guidelines (FBDG). For each of the FBDG, food items were grouped as fruits, vegetables, cereals, sugars, fat and oils, legumes, foods from animals, dairy products, and others. The second step aimed to identify and describe the different food classification systems. The search was performed on PubMed®, Science Direct, and Web of Science and websites of international organizations such as the Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO), and the Codex Alimentarius. Our results show that the points of convergence between the classifications were the classification in terms of origin (animal and vegetable), nutrient sources, and food groups. However, inconsistencies were observed for the distribution of food items in each group in the 98 surveyed FBDG. As for nature, there was a convergence for in natura, minimally processed, and processed foods. However, the criteria adopted for minimally processed and processed foods described in the FBDG differ from those considered by the FST. FST also does not recognize the classification of foods concerning the level of processing.

Food portion sizes and their relationship with energy, and nutrient intakes in adolescents: The HELENA study

OBJECTIVES

This study aimed to investigate the associations between portion sizes (PSs) from different food groups and energy, as well as nutrient intakes in European adolescents.

METHODS

A sample of 1631 adolescents (54.2 % girls) were included from the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional (HELENA) study. Mean food PS was calculated by dividing the total intake of the items by the number of eating occasions of these consumed items. To determine the key items for analysis, foods were ranked by frequency of consumption. A one-way between-groups analysis of covariance was used to test for significant differences in means across tertiles. A multivariable linear regression analysis was carried out, adjusting for age, sex, maternal education, body mass index, and using country as a level.

RESULTS

Energy intake increased with elevated intakes of energy-dense foods. Large portions of rice and other grains, starch roots and potatoes, and meat substitutes, nuts, and pulses were associated with increased carbohydrate and fiber intake. Larger portions of cheese and butter and animal fat were significantly associated with a higher fat intake. Lower intakes of some vitamins and micronutrients were noticed with consumption of larger portions of high energy-dense foods, such as desserts and pudding, margarine and vegetable oil, and butter and animal fat.

CONCLUSIONS

Large food PSs may be associated with positive energy, as well as macro- and micronutrient intake. Moreover, the findings from this study may help the future development of dietary guidance in general and specific to PSs, and support targeted strategies to address intakes of certain nutrients in European adolescents.

Variations in the Strength of Association between Food Neophobia and Food and Beverage Acceptability: A Data-Driven Exploratory Study of an Arousal Hypothesis

The negative impact of food neophobia (FN) on food and beverage (F&B) liking extends beyond foods and beverages that are novel. In addition, F&Bs that are high in flavour intensity, perceived as dangerous, or have connections to other cultures are likely to elicit rejection by those high in FN. Each of these factors have been established as producing increased arousal, potentially to an unpleasant degree. The aim of this study was to explore the hypothesis that increased arousal underlies all causes of rejection due to FN. To do this, we analysed and interpreted existing data based on online surveys that measured FN and liking for a broad range of F&B names from 8906 adult consumers in the USA, United Kingdom, Australia, Germany and Denmark. Negative associations between FN and liking of varying strengths were evident for 90% of the F&Bs. Consistent with the arousal hypothesis, F&Bs (a) with high flavour intensity, whether produced by chilli, other spices, or flavours, (b) from other cultures, (c) often perceived as dangerous, or (d) that were novel or had novel ingredients showed the strongest negative relationships between FN and liking. Conversely, F&Bs whose liking scores were only very weakly related to FN had low arousal characteristics: high familiarity, sweetness, mild flavours, strong connections to national food cultures, or some combination of these factors. Since this study was exploratory and conducted on existing data, there was no direct measure of arousal, but this is recommended for future, stronger tests of this arousal hypothesis.

The Association between Portion Sizes from High-Energy-Dense Foods and Body Composition in European Adolescents: The HELENA Study

Obesity prevalence has been simultaneously increasing with high consumption of large food portion sizes (PS). However, there is scarce information on PS of energy-dense (ED) foods as a potential risk factor of obesity in adolescents. In the present study, we investigate the association between the PS of the most ED foods and body composition. A sample of 1889 adolescents (54.4% females) from the Healthy Lifestyle in Europe by Nutrition in Adolescence cross-sectional multicenter study (HELENA-CSS) study were included. Most ED foods (e.g., cheese) were selected according to higher fat and/or sugar content and low fiber and water. Linear and ordinal logistic regression models were adjusted for age, physical activity, total energy intake (TEI), and socioeconomic status (SES). Analysis was performed both in those adolescents reporting plausible energy intake according to the approach of Goldberg et al. and in the whole sample. In male plausible reporters, PS from "breakfast cereals" showed a significant and positive association with BMI (β = 0.012; 0.048). PS from "carbonated soft drinks" in males (OR = 1.001; 95% CI 1.000; 1.002) and "bread and rolls" in females (OR = 1.002; 95% CI 1.000; 1.004) were associated with higher probability of having obesity, while "sweet bakery products" were associated with lower probability of having obesity (OR = 0.996; 95% CI 0.991; 0.999) in females. The present study suggests association between PS of ED foods and obesity in European adolescents. Prospective studies are needed to examine the effect of prolonged exposure to large PS and obesity development.

Development of the Hellenic Food Thesaurus (HelTH), a branded food composition database: Aims, design and preliminary findings

The Hellenic Food Thesaurus (HelTH) is the first systematic attempt to create a Greek Branded Food Composition Database. Data on the nutritional composition of foods for up to 45 nutrients, on-pack claims (health, nutrition, social, environmental), quality indicators, and prices were recorded for more than 4,000 foods as they appear on the photographs of their packages available on retailers' websites. A group of trained researchers carried out data collection and classification using LanguaL. HelTH highlights the variability in nutritional compositions of packaged foods in Greece and the need for better labelling of key nutrients such as trans fatty acids. According to a preliminary analysis of on-pack communications (n = 2008 products), health claims are used rarely (4.1% of products analyzed) with greater prevalence of nutrition (~32%) and natural claims (~24%). HelTH is a key infrastructure for the implementation of food and nutrition policies, new product development, and nutrition and consumer research.

Healthy Advertising Coming to Its Senses: The Effectiveness of Sensory Appeals in Healthy Food Advertising

With increasing obesity rates and the daily overload of unhealthy food appeals, an important objective for advertising today is to promote healthy food consumption. According to previous research, sensory food advertisements referring to multiple senses—a combination of visual (sight), tactile (touch) and olfactory (smell) cues—evoke more positive sensory thoughts and, therefore, higher taste perceptions than advertisements referring to a single sense (e.g., only taste cues). However, this research only focused on sensory advertising for unhealthy food. The current research investigates how sensory advertising can promote healthy food. While multiple-sense ads for unhealthy food were shown to be more effective than single-sense ads, we find that, for healthy food, single-sense ads increase taste perceptions and advertising effectiveness compared to multiple-sense ads. In two laboratory experiments, we show a different underlying process for this effect—that is, single-sense ads evoke fewer negative thoughts than multiple-sense ads, which mediates the effect of single-sense versus multiple-sense ads on taste perceptions and advertising effectiveness. Moreover, we show that these effects occur not only for verbal ads but, importantly, also for visual ads, which are omnipresent today. This article closes with implications for theory and suggestions for food marketers, ad executives, and public policy.

Do dietary patterns determine levels of vitamin B6, folate, and vitamin B12 intake and corresponding biomarkers in European adolescents? The Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study

OBJECTIVES

To determine dietary patterns (DPs) and explain the highest variance of vitamin B6, folate, and B12 intake and related concentrations among European adolescents.

METHODS

A total of 2173 adolescents who participated in the Healthy Lifestyle in Europe by Nutrition in Adolescence study met the eligibility criteria for the vitamin B intake analysis (46% boys) and 586 adolescents for the biomarkers analysis (47% boys). Two non-consecutive, 24-h, dietary recalls were used to assess the mean intakes. Concentrations were measured by chromatography and immunoassay testing. A reduced rank regression was applied to elucidate the combined effect of food intake of vitamin B and related concentrations.

RESULTS

The identified DPs (one per vitamin B intake and biomarker and by sex) explained a variability between 34.2% and 23.7% of the vitamin B intake and between 17.2% and 7% of the biomarkers. In the reduced rank regression models, fish, eggs, cheese, whole milk and buttermilk intakes were loaded positively for vitamin B intake in both sexes; however, soft drinks and chocolate were loaded negatively. For the biomarkers, a higher variability was observed in the patterns in terms of food loads such as alcoholic drinks, sugars, and soft drinks. Some food items were loaded differently between intakes and biomarkers such as fish products, which was loaded positively for intakes but negatively for plasma folate in girls.

CONCLUSIONS

The identified DPs explained up to 34.2% and 17.2% of the variability of the vitamin B intake and plasma concentrations, respectively, in European adolescents. Further studies are needed to elucidate the factors that determine such patterns.

The Availability of Slow and Fast Calories in the Dutch Diet: The Current Situation and Opportunities for Interventions

Choosing foods that require more time to consume and have a low energy density might constitute an effective strategy to control energy intake, because of their satiating capacity. The current study assessed the eating rate of Dutch food, and investigated the associations between eating rate and other food properties. We also explored the opportunities for a diet with a low energy intake rate (kJ/min). Laboratory data on the eating rate of 240 foods-representing the whole Dutch diet-was obtained. The results show a wide variation in both eating rate (from 2 g/min for rice waffle to 641 g/min for apple juice) and energy intake rate (from 0 kJ/min (0 kcal/min) for water to 1766 kJ/min (422 kcal/min) for chocolate milk). Eating rate was lower when foods were more solid. Moreover, eating rate was positively associated with water content and inversely with energy density. Energy intake rate differed substantially between and within food groups, demonstrating that the available foods provide opportunities for selecting alternatives with a lower energy intake rate. These findings offer guidance when selecting foods to reduce energy intake.

Development of a harmonized food grouping system for between-country comparisons in the TEDDY Study

The Environmental Determinants of Diabetes in the Young (TEDDY) is an international study aiming to investigate associations between dietary and other environmental factors and the risk of developing islet autoimmunity and type 1 diabetes. Dietary intake was assessed using a 24-hour recall and repeated 3-day food records and analyzed using country-specific food composition databases (FCDBs) in Finland, Germany, Sweden, and the U.S. with respective in-house calculation programs. A food grouping harmonization process between four country-specific FCDBs was conducted to evaluate and achieve comparability on food group definitions and quantification of food consumption across the countries. Systematic review revealed that the majority of existing food groups of the TEDDY FCDBs were not comparable. Therefore, a completely new classification system of 15 mutually exclusive main food groups (e.g. vegetables) and 89 subgroups (e.g. root vegetables, leafy vegetables) was developed. Foods and beverages were categorized into basic foods (single ingredient) and composite dishes (multiple ingredients). Composite dishes were broken down to ingredients using food composition data available in the FCDBs or generic recipes created for the harmonization effort. The daily consumption of every food group across FCDBs was quantified consistently as either raw or prepared weight depending on the food group to achieve maximal comparability.

Food formulation and not processing level: Conceptual divergences between public health and food science and technology sectors

Observed changes in eating and drinking behaviors in economically developing countries are associated with increase of obesity and related chronic diseases. Researchers from field of public health (PH) have attributed this problem to food processing and have created new food classification systems to support their thesis. These classifications conceptually differ from processing level concepts in food science, and state to people that food processing is directly related to nutritional impact of food. Our work aims to compare the concept of food processing from the standpoint of food science and technology (FST) and public health and to discuss differences related to formulation or level of processing of products and their impact on nutritional quality. There is a misconception between food processing/unit operation/food technology and formulation or recipes. For the public health approach, classification is based on food products selection and the use of ingredients that results in higher consumption of sugar, sodium, fat, and additives, whereas in FST, processing level is based on the intensity and amount of unit operations to enhance shelf life, food safety, food quality, and availability of edible parts of raw materials. Nutritional quality of a product or preparation is associated with formulation/recipe and not with the level of processing, with few exceptions. The impact of these recommendations on the actual comprehension of food processing and quality must be considered by the population.

Foods contributing to vitamin B6, folate, and vitamin B12 intakes and biomarkers status in European adolescents: The HELENA study

PURPOSE

To examine the association between food groups consumption and vitamin B6, folate and B12 intakes and biomarkers in adolescents.

METHODS

In total 2189 individuals participating in the cross-sectional Healthy Lifestyle in Europe by Nutrition in Adolescence study met the eligibility criteria for analysis of dietary intakes (46 % males) and 632 for biomarker analysis (47 % males). Food intakes were assessed by two non-consecutive 24-h recalls. Biomarkers were measured by chromatography and immunoassay. Food groups which best discriminated participants in the extreme tertiles of the distribution of vitamins were identified by discriminant analyses. Food groups with standardised canonical coefficients higher or equal to 0.3 were selected as valid discriminators of vitamins intake and biomarkers extreme tertiles. Linear mixed model elucidated the association between food groups and vitamins intakes and biomarkers.

RESULTS

Vitamin B6 intakes and biomarkers were best discriminated by meat (males and females), margarine and mixed origin lipids only in males and breakfast cereals (females). Breakfast cereals (males), and fruits, margarine and mixed origin lipids, vegetables excluding potatoes, breakfast cereals, and soups/bouillon (females) determined the most folate intakes and biomarkers. Considering vitamin B12 intakes and biomarkers, meat, and white and butter milk (males and females), snacks (males), and dairy products (females) best discriminated individual in the extremes of the distribution. Fewer associations were obtained with mixed model for biomarkers than for vitamins intakes with food groups.

CONCLUSIONS

Whereas B-vitamin intakes were associated with their food sources, biomarkers did with overall food consumption. Low-nutrient-density foods may compromise adolescents' vitamin status.

Is fruit and vegetable intake associated with asthma or chronic rhino-sinusitis in European adults? Results from the Global Allergy and Asthma Network of Excellence (GA2LEN) Survey

Background

Fruits and vegetables are rich in compounds with proposed antioxidant, anti-allergic and anti-inflammatory properties, which could contribute to reduce the prevalence of asthma and allergic diseases.

Objective

We investigated the association between asthma, and chronic rhino-sinusitis (CRS) with intake of fruits and vegetables in European adults.

Methods

A stratified random sample was drawn from the Global Allergy and Asthma Network of Excellence (GA²LEN) screening survey, in which 55,000 adults aged 15–75 answered a questionnaire on respiratory symptoms. Asthma score (derived from self-reported asthma symptoms) and CRS were the outcomes of interest. Dietary intake of 22 subgroups of fruits and vegetables was ascertained using the internationally validated GA²LEN Food Frequency Questionnaire. Adjusted associations were examined with negative binomial and multiple regressions. Simes procedure was used to control for multiple testing.

Results

A total of 3206 individuals had valid data on asthma and dietary exposures of interest. 22.8% reported having at least 1 asthma symptom (asthma score ≥1), whilst 19.5% had CRS. After adjustment for potential confounders, asthma score was negatively associated with intake of dried fruits (β-coefficient −2.34; 95% confidence interval [CI] −4.09, −0.59), whilst CRS was statistically negatively associated with total intake of fruits (OR 0.73; 95% CI 0.55, 0.97). Conversely, a positive association was observed between asthma score and alliums vegetables (adjusted β-coefficient 0.23; 95% CI 0.06, 0.40). None of these associations remained statistically significant after controlling for multiple testing.

Conclusion and clinical relevance

There was no consistent evidence for an association of asthma or CRS with fruit and vegetable intake in this representative sample of European adults.

Folate and vitamin B12 concentrations are associated with plasma DHA and EPA fatty acids in European adolescents: the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study

This study aimed to examine the association between vitamin B6, folate and vitamin B12 biomarkers and plasma fatty acids in European adolescents. A subsample from the Healthy Lifestyle in Europe by Nutrition in Adolescence study with valid data on B-vitamins and fatty acid blood parameters, and all the other covariates used in the analyses such as BMI, Diet Quality Index, education of the mother and physical activity assessed by a questionnaire, was selected resulting in 674 cases (43 % males). B-vitamin biomarkers were measured by chromatography and immunoassay and fatty acids by enzymatic analyses. Linear mixed models elucidated the association between B-vitamins and fatty acid blood parameters (changes in fatty acid profiles according to change in 10 units of vitamin B biomarkers). DHA, EPA) and n-3 fatty acids showed positive associations with B-vitamin biomarkers, mainly with those corresponding to folate and vitamin B12. Contrarily, negative associations were found with n-6:n-3 ratio, trans-fatty acids and oleic:stearic ratio. With total homocysteine (tHcy), all the associations found with these parameters were opposite (for instance, an increase of 10 nmol/l in red blood cell folate or holotranscobalamin in females produces an increase of 15·85 µmol/l of EPA (P value <0·01), whereas an increase of 10 nmol/l of tHcy in males produces a decrease of 2·06 µmol/l of DHA (P value <0·05). Positive associations between B-vitamins and specific fatty acids might suggest underlying mechanisms between B-vitamins and CVD and it is worth the attention of public health policies.

Diet Quality Scores and Prediction of All-Cause, Cardiovascular and Cancer Mortality in a Pan-European Cohort Study

Scores of overall diet quality have received increasing attention in relation to disease aetiology; however, their value in risk prediction has been little examined. The objective was to assess and compare the association and predictive performance of 10 diet quality scores on 10-year risk of all-cause, CVD and cancer mortality in 451,256 healthy participants to the European Prospective Investigation into Cancer and Nutrition, followed-up for a median of 12.8y. All dietary scores studied showed significant inverse associations with all outcomes. The range of HRs (95% CI) in the top vs. lowest quartile of dietary scores in a composite model including non-invasive factors (age, sex, smoking, body mass index, education, physical activity and study centre) was 0.75 (0.72-0.79) to 0.88 (0.84-0.92) for all-cause, 0.76 (0.69-0.83) to 0.84 (0.76-0.92) for CVD and 0.78 (0.73-0.83) to 0.91 (0.85-0.97) for cancer mortality. Models with dietary scores alone showed low discrimination, but composite models also including age, sex and other non-invasive factors showed good discrimination and calibration, which varied little between different diet scores examined. Mean C-statistic of full models was 0.73, 0.80 and 0.71 for all-cause, CVD and cancer mortality. Dietary scores have poor predictive performance for 10-year mortality risk when used in isolation but display good predictive ability in combination with other non-invasive common risk factors.

Comparison of food and nutrient intakes between cohorts of the HAPIEE and Whitehall II studies

BACKGROUND

Differences in dietary habits have been suggested as an important reason for the large health gap between Eastern and Western European populations. Few studies have compared individual-level nutritional data directly between the two regions. This study addresses this hypothesis by comparing food, drink and nutrient intakes in four large population samples.

METHODS

Czech, Polish and Russian participants of the Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) study, and British participants in the Whitehall II study, altogether 29 972 individuals aged 45-73 years, were surveyed in 2002-2005. Dietary data were collected by customised food frequency questionnaires. Reported food, drink and nutrient intake data were harmonised and compared between cohorts using multivariable adjusted quantile regression models.

RESULTS

Median fruit and vegetable intakes were lower in the pooled Eastern European sample, but not in all country cohorts, compared with British subjects. Median daily consumption of fruits were 275, 213, 130 and 256 g in the Czech, Polish, Russian and Whitehall II cohort, respectively. The respective median daily intakes of vegetables were 185, 197, 292 and 246 g. Median intakes of animal fat foods and saturated fat, total fat and cholesterol nutrients were significantly higher in the Czech, Polish and Russian cohorts compared with the British; for example, median daily intakes of saturated fatty acids were 31.3, 32.5, 29.2 and 25.4 g, respectively.

CONCLUSION

Our findings suggest that there are important differences in dietary habits between and within Eastern and Western European populations which may have contributed to the health gap between the two regions.

Does the consumption of fruits and vegetables differ between Eastern and Western European populations? Systematic review of cross-national studies

BACKGROUND

Difference in fruit and vegetable consumption has been suggested as a possible reason for the large gap in cardiovascular disease (CVD) mortality rates between Eastern and Western European populations. However, individual-level dietary data which allow direct comparison across the two regions are rare. In this systematic review we aimed to answer the question whether cross-national studies with comparable individual-level dietary data reveal any systematic differences in fruit and vegetable consumption between populations in Central and Eastern Europe (CEE) and the Former Soviet Union (FSU) compared to Western Europe (WE).

METHODS

Studies were identified by electronic search of MEDLINE, EMBASE and Web of Science databases from inception to September 2014, and hand search. Studies which reported data on fruit, vegetable consumption or carotene and vitamin C intake or tissue concentrations of adult participants from both CEE/FSU and WE countries were considered for inclusion. Quality of the included studies was assessed by a modified STROBE statement. Power calculation was performed to determine the statistical significance of the comparison results.

RESULTS

Twenty-two studies fulfilled the inclusion criteria. Fruit consumption was found to be consistently lower in CEE/FSU participants compared to Western Europeans. Results on vegetable intake were less unambiguous. Antioxidant studies indicated lower concentration of beta-carotene in CEE/FSU subjects, but the results for vitamin C were not consistent.

CONCLUSION

This systematic review suggests that populations in CEE and FSU consume less fruit than Western Europeans. The difference in the consumption of fruit may contribute to the CVD gap between the two regions.

Contribution of Food Groups to Energy and Nutrient Intakes in Five Developed Countries

Economic growth in developing countries and globalization of the food sector is leading to increasingly similar food consumption patterns worldwide. The aim of this study was to describe similarities and differences in the contributions of main food groups to energy and nutrient intakes in five developed countries across three continents. We obtained summary reports of national food consumption survey data from Australia, France, Denmark, the Netherlands, and the United States. Survey years spanned 2003-2012; sample size ranged from 1444 to 17,386. To mitigate heterogeneity of food groups across countries, we recategorized each survey's reported food groups and subgroups into eight main food groups and, for three countries, a ninth "mixed dishes" group. We determined the percent contribution of each food group to mean daily intakes of energy, saturated fat, sodium, fiber, and ten vitamins and minerals that are commonly under-consumed. Differences in findings from surveys utilizing a foods-as-consumed versus a disaggregated or ingredients approach to food group composition and contributions from the milk and milk products group, a source of several under-consumed nutrients, were explored. Patterns of food group contributions to energy and nutrient intakes were generally similar across countries. Some differences were attributable to the analytical approach used by the surveys. For the meat/protein, milk and milk products, vegetables, and fruit groups, percent contributions to key nutrient intakes exceeded percent contributions to energy intake. The mixed dishes group provided 10%-20% of total daily energy and a similar 10%-25% of the daily intake of several nutrients. This descriptive study contributes to an understanding of food group consumption patterns in developed countries.

Nutrition and dietary intake and their association with mortality and hospitalisation in adults with chronic kidney disease treated with haemodialysis: protocol for DIET-HD, a prospective multinational cohort study

INTRODUCTION

Adults with end-stage kidney disease (ESKD) treated with haemodialysis experience mortality of between 15% and 20% each year. Effective interventions that improve health outcomes for long-term dialysis patients remain unproven. Novel and testable determinants of health in dialysis are needed. Nutrition and dietary patterns are potential factors influencing health in other health settings that warrant exploration in multinational studies in men and women treated with dialysis. We report the protocol of the "DIETary intake, death and hospitalisation in adults with end-stage kidney disease treated with HaemoDialysis (DIET-HD) study," a multinational prospective cohort study. DIET-HD will describe associations of nutrition and dietary patterns with major health outcomes for adults treated with dialysis in several countries.

METHODS AND ANALYSIS

DIET-HD will recruit approximately 10,000 adults who have ESKD treated by clinics administered by a single dialysis provider in Argentina, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Spain, Sweden and Turkey. Recruitment will take place between March 2014 and June 2015. The study has currently recruited 8000 participants who have completed baseline data. Nutritional intake and dietary patterns will be measured using the Global Allergy and Asthma European Network (GA(2)LEN) food frequency questionnaire. The primary dietary exposures will be n-3 and n-6 polyunsaturated fatty acid consumption. The primary outcome will be cardiovascular mortality and secondary outcomes will be all-cause mortality, infection-related mortality and hospitalisation.

ETHICS AND DISSEMINATION

The study is approved by the relevant Ethics Committees in participating countries. All participants will provide written informed consent and be free to withdraw their data at any time. The findings of the study will be disseminated through peer-reviewed journals, conference presentations and to participants via regular newsletters. We expect that the DIET-HD study will inform large pragmatic trials of nutrition or dietary interventions in the setting of advanced kidney disease.

Exposure assessment within a Total Diet Study: a comparison of the use of the pan-European classification system FoodEx-1 with national food classification systems

A Total Diet Study (TDS) consists of selecting, collecting and preparing commonly consumed foods purchased at retail level and analysing them for harmful and/or beneficial chemical substances. A food classification system is needed to link food consumption data with the contaminant concentration data obtained in the TDS for the exposure assessment. In this study a comparison was made between the use of a national food classification systems and the use of FoodEx-1, developed and recommended by the European Food Safety Authority (EFSA). The work was performed using data of six European countries: Belgium, Czech Republic, France, The Netherlands, Spain and the UK. For each population, exposure to contaminant A (organic compounds) and/or contaminant B (inorganic compound) was assessed by the Monte Carlo Risk Assessment (MCRA) software using the national classification system and FoodEx-1 for food consumption data and for TDS laboratory results. Minimal differences between both approaches were observed. This observation applied for both contaminant A and contaminant B. In general risk assessment will be similar for both approaches; however, this is not guaranteed. FoodEx-1 proved to be a valuable hierarchic classification system in order to harmonise exposure assessment based on existing TDS results throughout Europe.

Major food sources of calories, added sugars, and saturated fat and their contribution to essential nutrient intakes in the U.S. diet: data from the National Health and Nutrition Examination Survey (2003-2006)

BACKGROUND

The risk of chronic disease cannot be predicted simply by the content of a single nutrient in a food or food group in the diet. The contribution of food sources of calories, added sugars and saturated fat (SFA) to intakes of dietary fiber and micronutrients of public health importance is also relevant to understanding the overall dietary impact of these foods.

OBJECTIVE

Identify the top food sources of calories, added sugars and SFA in the U.S. diet and quantify their contribution to fiber and micronutrient intakes.

METHODS

Single 24-hour dietary recalls (Day 1) collected from participants ≥2 years (n = 16,822) of the What We Eat in America, National Health and Nutrition Examination Survey (WWEIA/NHANES 2003-2006) were analyzed. All analyses included sample weights to account for the survey design. Calorie and nutrient intakes from foods included contributions from disaggregated food mixtures and tabulated by rank order.

RESULTS

No one food category contributes more than 7.2% of calories to the overall U.S. diet, but half of the top 10 contribute 10% or more of total dietary fiber and micronutrients. Three of the top 10 sources of calories and SFA (beef, milk and cheese) contribute 46.3% of the calcium, 49.5% of the vitamin D, 42.3% of the vitamin B12 as well as other essential nutrients to the American diet. On the other hand, foods categorized as desserts, snacks, or beverages, contribute 13.6% of total calories, 83% of added sugar intake, and provide little or no nutritional value. Including food components of disaggregated recipes more accurately estimated the contribution of foods like beef, milk or cheese to overall nutrient intake compared to "as consumed" food categorizations.

CONCLUSIONS

Some food sources of calories, added sugars and SFA make major contributions to American dietary fiber and micronutrient intakes. Dietary modifications targeting reductions in calories, added sugar, or SFA need to take these key micronutrient sources into account so as not to have the unintended consequence of lowering overall dietary quality.

Evaluation of the Children's Eating Habits Questionnaire used in the IDEFICS study by relating urinary calcium and potassium to milk consumption frequencies among European children

BACKGROUND

Measuring dietary intake in children is notoriously difficult. Therefore, it is crucial to evaluate the performance of dietary intake assessment methods in children. Given the important contribution of milk consumption to calcium (Ca) and potassium (K) intakes, urinary calcium (UCa) and potassium (UK) excretions in spot urine samples could be used for estimating correlations with milk consumption frequencies.

OBJECTIVE

The aim of this study was to evaluate the assessment of milk consumption frequencies derived from the Food Frequency Questionnaire section of the Children's Eating Habits Questionnaire (CEHQ-FFQ) used in the IDEFICS (Identification and prevention of dietary- and lifestyle induced health effects in children and infants) study by comparing with UCa and UK excretions in spot urine samples.

DESIGN

This study was conducted as a setting-based community-oriented intervention study and results from the first cross-sectional survey have been included in the analysis.

SUBJECTS

A total of 10,309 children aged 2-10 years from eight European countries are included in this analysis.

METHODS

UCa and UK excretions were measured in morning spot urine samples. Calcium and potassium urine concentrations were standardised for urinary creatinine (Cr) excretion. Ratios of UCa/Cr and UK/Cr were used for multivariate regression analyses after logarithmic transformation to obtain normal distributions of data. Milk consumption frequencies were obtained from the CEHQ-FFQ. Multivariate regression analyses were used to investigate the effect of milk consumption frequencies on UCa and UK concentrations, adjusting for age, gender, study centre, soft drink consumption and frequency of main meals consumed at home.

RESULTS

A significant positive correlation was found between milk consumption frequencies and ratios of UK/Cr and a weaker but still significant positive correlation with ratios of UCa/Cr, when using crude or partial Spearman's correlations. Multivariate regression analyses showed that milk consumption frequencies were predictive of UCa/Cr and UK/Cr ratios, when adjusted for age, gender, study centre, soft drink consumption and frequency of main meals consumed at home. Mean ratios of UK/Cr for increasing milk consumption frequency tertiles showed a progressive increase in UK/Cr. Children consuming at least two milk servings per day had significantly higher mean UCa/Cr and UK/Cr ratios than children who did not. Large differences in correlations between milk consumption frequencies and ratios of UCa/Cr and UK/Cr were found between the different study centres.

CONCLUSION

Higher milk consumption frequencies resulted in a progressive increase in UK/Cr and UCa/Cr ratios, reflecting the higher Ca and K intakes that coincide with increasing milk consumption, which constitutes a major K and Ca source in children's diet.

Use of a common food frequency questionnaire (FFQ) to assess dietary patterns and their relation to allergy and asthma in Europe: pilot study of the GA2LEN FFQ

BACKGROUND/OBJECTIVES

Comparable international data on food and nutrient intake is often hindered by the lack of a common instrument to assess food intake. The objective of this study was within the Global Allergy and Asthma European Network of Excellence (GA(2)LEN), we developed and piloted a food frequency questionnaire (FFQ) to assess its validity in Europe.

SUBJECTS/METHODS

Five countries participating in GA(2)LEN took part in the pilot study. A total of 200 adults aged 31-75 years were invited to complete a FFQ in two occasions and to give a blood sample. The intra-class correlation coefficient (ICC) was used to assess repeatability of the FFQ. Plasma phospholipid fatty acids (FAs) were analysed by gas chromatography. Pearson correlation was used to analyse the correlation between estimated dietary FA intake and plasma phospholipid FA levels.

RESULTS

A total of 177 participants (89%) had complete data on FFQ(1) and plasma phospholipid FAs. In all, 152 participants (76%) completed both FFQs. ICCs between macronutrients ranged from 0.70 (saturated FAs) to 0.78 (proteins) and between 0.70 (retinol) and 0.81 (vitamin D) for micronutrients. Dietary n-3 FAs showed a good correlation with total plasma phospholipid n-3 FAs and with docosahexaenoic acid in the whole sample (0.40) and in individual countries. Poor correlations were observed for other FAs.

CONCLUSIONS

The GA(2)LEN FFQ is an appropriate tool to estimate dietary intake for a range of nutrients across Europe regardless of cultural and linguistic differences. The FFQ seems to be useful to estimate the intake of n-3 FAs but not other FAs.

Dietary survey methodology of FINDIET 2007 with a risk assessment perspective

A cross-sectional survey, FINDIET 2007, was carried out in Finland. Food intake data was collected by a 48 h recall interview. Additional food intake data was collected by a repeated 3 d food diary, a barcode-based product diary, a food frequency questionnaire and by a supplementary questionnaire on rarely eaten foods. The purpose of the present paper is to describe the methodology of the national dietary survey and to discuss the particular implications for the applications of food consumption data in risk assessment. The food consumption data of the FINDIET 2007 survey can be used in food risk assessment, due thanks to flexible data processing of individual food consumption, and a risk assessment point of view was taken into account. However, international standardisation projects are needed in order to estimate comparable food intakes.

The importance of harmonizing food composition data across Europe

OBJECTIVE

To examine the role of food composition data in Europe in four sectors, namely health, trade regulation and legislation, agriculture and the environment.

RESULTS

The need for further harmonization of data across Europe is clearly identified and evidenced from a number of previous successful European collaborations.

CONCLUSIONS

Data on the nutritional composition of foods are essential for a broad spectrum of activities, including public health nutrition, research, the food industry and government policy development and implementation. With the expansion of the European Union and the concomitant increase in cross border trade and cooperation harmonizing food composition data becomes a more important issue than ever. Harmonization is not solely a technical issue, but also involves creating durable and sustainable structures to maintain the viability of the data. These are some of the issues currently being addressed by the European Food Information Resource Network of Excellence.

Dietary intake and nutritional status of children and adolescents in Europe

The objective of this project was to collect and evaluate data on nutrient intake and status across Europe and to ascertain whether any trends could be identified. Surveys of dietary intake and status were collected from across Europe by literature search and personal contact with country experts. Surveys that satisfied a defined set of criteria – published, based on individual intakes, post-1987, adequate information provided to enable its quality to be assessed, small age bands, data for sexes separated above 12 years, sample size over 25 and subjects representative of the population – were selected for further analysis. In a small number of cases, where no other data for a country were available or where status data were given, exceptions were made. Seventy-nine surveys from 23 countries were included, and from them data on energy, protein, fats, carbohydrates, alcohol, vitamins, minerals and trace elements were collected and tabulated. Data on energy, protein, total fat and carbohydrate were given in a large number of surveys, but information was very limited for some micronutrients. No surveys gave information on fluid intake and insufficient gave data on food patterns to be of value to this project. A variety of collection methods were used, there was no consistency in the ages of children surveyed or the age cut-off points, but most surveys gave data for males and females separately at all ages. Just under half of the surveys were nationally representative and most of the remainder were regional. Only a small number of local surveys could be included. Apart from anthropometric measurements, status data were collected in only seven countries. Males had higher energy intakes than females, energy intake increased with age but levelled off in adolescent girls. Intakes of other nutrients generally related to energy intakes. Some north–south geographical trends were noted in fat and carbohydrate intakes, but these were not apparent for other nutrients. Some other trends between countries were noted, but there were also wide variations within countries. A number of validation studies have shown that misreporting is a major problem in dietary surveys of children and adolescents and so all the dietary data collected for this project should be interpreted and evaluated with caution In addition, dietary studies rely on food composition tables for the conversion of food intake data to estimated nutrient intakes and each country uses a different set of food composition data which differ in definitions, analytical methods, units and modes of expression. This can make comparisons between countries difficult and inaccurate. Methods of measuring food intake are not standardised across Europe and intake data are generally poor, so there are uncertainties over the true nutrient intakes of children and adolescents across Europe. There are insufficient data on status to be able to be able to draw any conclusions about the nutritional quality of the diets of European children and adolescents.

The influence of cereal and dairy consumption on the Irish diet: implications for developing food-based dietary guidelines

Objectives

To estimate the intakes of cereal and dairy products and their contribution to nutrient intakes in men and women from the Republic of Ireland with a view to formulating food-based dietary guidelines.

Design

The North/South Ireland Food Consumption Survey established a database of habitual food and drink consumption using a 7-day food diary. From this database all cereal and dairy products from recipes and identifiable sources were identified and a new database was generated from which analysis of the role of cereal and dairy products in the diet was carried out.

Results

Almost 100% of the population consumed cereal and dairy products over the course of the survey week. In general, men consumed significantly more cereal and dairy products than did women (P<0.05). Cereal products made an important contribution to the mean daily intakes of energy (26%), protein (21%), fat (13%), carbohydrate (41%), fibre (45%), iron (43%) and folate (27%). Dairy products also contributed largely to the mean daily intakes of energy (11%), protein (14%), fat (17%), calcium (48%), phosphorus (24%) and vitamin A (27%). Analysis of nutrient intakes across tertiles of cereal and dairy consumption showed that high consumers of wholemeal bread, breakfast cereals, reduced-fat milk and yoghurt had lower fat and higher carbohydrate, fibre and micronutrient intakes than low consumers of these foods.

Conclusions

Findings from the present study could be used to develop effective health strategies to implement changes in cereal and dairy consumption that could alter fat, fibre and micronutrient intakes in the diet.

Sodium in the Finnish diet: II trends in dietary sodium intake and comparison between intake and 24-h excretion of sodium

OBJECTIVE

To estimate cross-sectional and long-term dietary sodium intakes and sources in Finland, and to evaluate the validity of 48-h recall to assess sodium intake.

DESIGN

Cross-sectional dietary surveys and food availability data (Food Balance Sheets).

SETTING

Dietary surveys were carried out in Finland in 1992, 1997 and 2002. Food availability data were collected from 1980 to 1999.

SUBJECTS

A stratified random sample was drawn from the population register. The total number of participants in the three dietary surveys was 6730. In the subsample for urine collection, the number of participants was 879.

INTERVENTIONS

Nutrient intakes were estimated on the basis of a 3-day food diary in 1992, a 24-h recall in 1997 and a 48-h recall in 2002. The 24-h urinary excretion of sodium was used to validate sodium intake. In addition, salt intake was estimated based on Food Balance Sheets.

RESULTS

Sodium intake has slowly decreased since the early 1980s. Reported daily sodium intake correlated significantly with sodium excretion.

CONCLUSIONS

Sodium intake has decreased during the last two decades, but is still higher than the recommended daily intake. Sodium intake estimation based on dietary surveys and food availability data is a valid method provided that the food composition database is up to date and of good quality.

SPONSORSHIP

All surveys were funded by the National Public Health Institute in Finland and the Ministry of Social Affairs and Health.

Intake of added oils and fats among middle-aged French adults: relationships with educational level and region of residence

OBJECTIVE

To describe the relative contribution of 10 created food groups to total fat intake in middle-aged subjects. The relationship of added oil and fat intake with region of residence and educational level was also assessed.

DESIGN

Cross-sectional study.

SUBJECTS/SETTING

Participants of the French Supplémentation en Vitamines et Minéraux Antioxydants study who completed at least six 24-hour dietary records after inclusion into the study (N=6,572).

RESULTS

Added oils and fats were the main source of total fat intake. Animal fat and margarine intakes showed a significant inverse association with educational level, whereas oils with monounsaturated fatty acids (MUFA) were positively associated with education level. Animal fat intake was significantly higher in the western and northern parts of France (54.2% and 50.4%) and lower in the Mediterranean Coast (39.0%). A significant inverse gradient was found with oils with polyunsaturated fatty acids or MUFA in the southwest and the Mediterranean Coast compared with the northern part of France.

CONCLUSIONS

We showed a north to south gradient for animal fat intake and the opposite for oils with MUFA and polyunsaturated fatty acid in France. This gradient parallels the known disparities for cardiovascular mortality in this country. This should contribute to adapting dietary guidelines for dietary change in a public health perspective.

Fitness-for-purpose of dietary survey duration: a case-study with the assessment of exposure to ochratoxin A

The duration of food consumption survey may have a marked effect on estimates of usual nutrient intakes in individuals and groups. This arises from a high degree of within-person variability in food intakes, primarily on a day-to-day basis. Both the level of observation-populations versus individuals-and the desirable level of precision decide upon the 'fitness-for-purpose' of dietary survey duration. Though similar from a methodological standpoint, the question was rarely addressed in the case of non-nutrients. Our work aims at estimating the number of days of food records needed for the assessment of usual intakes of food chemicals as a function of research purpose. Focusing on the French population exposure to food mycotoxin ochratoxin A, we implement a range of well-established methods borrowed from the field of nutrient intakes assessment. Our results on OTA show that: (a) at the population level, as low as three days give satisfactory distributional estimates; yet, the implementation of variance reduction methods is of particular relevance when higher percentiles of exposure are at stake; (b) the estimation of individual usual intakes based on food records is behind practical possibilities, which calls for alternative options such as biomarkers of exposure.

Handling of contamination variability in exposure assessment: A case study with ochratoxin A

The contamination of foods dedicated to human consumption varies over space and time. In exposure assessment, this is usually addressed through probabilistic modelling. The present work explores how the variability and uncertainty of exposures estimated at the population level are affected by: (a) the (non-)parametric nature of input contamination distributions; (b) the time-window used to sample contamination values within those distributions. Focusing on exposure of the French population to food mycotoxin ochratoxin A, we implement a range of second-order Monte-Carlo simulations that allow distinguishing variability of exposures from uncertainty of distributional parameters estimates. A simulation runs 10,000 iterations. Overall estimates of parameters are given by the median across iterations and 95%CI by 2.5th and 97.5th percentiles. Our results show that: (a) parametric (log-normal) input distributions may lead to over-estimation of variability and greater uncertainty as compared to non-parametric ones (P97.5 [95%CI] of 7.1 [6.6;7.7] for Parametric-Occasion, 4.6 [4.3;5.0] for Non-Parametric-Occasion), and that (b) the 'Occasion' time-window combines better estimate of variability and lower uncertainty when exposure modelling is applied to populations living in developed countries with complex agri-food systems (P97.5 [95%CI]: 7.3 [6.2;8.9] for Non-Parametric-Week, 4.6 [4.3;5.0] for Non-Parametric-Occasion). A deterministic approach is nevertheless preferred to probabilistic modelling every time input data quality is questionable.

Methodologic Considerations in Descriptive Food-Consumption Surveys in Developing Countries

This paper reviews some methodologic issues relative to food-consumption studies in developing countries, including sampling considerations; capturing temporal variation in food consumption; choice of dietary instruments and protocols; and food-composition databases and needs for adequate software interfaces. Increasingly, issues of cross-country and regional comparability in food-consumption data are now coming into the decision mix. Comparability of data across countries requires comparability of several fundamental systems. Specific countries and cultural contexts must tackle problems of how to estimate individual intakes when one-dish serving is the norm; how to keep up with rapidly changing food supplies; how to capture ingredients added at the table that may be concentrated sources of nutrients or other components of interest; and how to document out-of-home eating. Assumptions about error, bias, and intra-individual variation in food intake need to be thoroughly tested in developing-country contexts. There is an urgent need for improvement in the availability of appropriate food-composition databases and software interfaces for developing-country use.

Assessment of the safety of foods derived from genetically modified (GM) crops

This paper provides guidance on how to assess the safety of foods derived from genetically modified crops (GM crops); it summarises conclusions and recommendations of Working Group 1 of the ENTRANSFOOD project. The paper provides an approach for adapting the test strategy to the characteristics of the modified crop and the introduced trait, and assessing potential unintended effects from the genetic modification. The proposed approach to safety assessment starts with the comparison of the new GM crop with a traditional counterpart that is generally accepted as safe based on a history of human food use (the concept of substantial equivalence). This case-focused approach ensures that foods derived from GM crops that have passed this extensive test-regime are as safe and nutritious as currently consumed plant-derived foods. The approach is suitable for current and future GM crops with more complex modifications. First, the paper reviews test methods developed for the risk assessment of chemicals, including food additives and pesticides, discussing which of these methods are suitable for the assessment of recombinant proteins and whole foods. Second, the paper presents a systematic approach to combine test methods for the safety assessment of foods derived from a specific GM crop. Third, the paper provides an overview on developments in this area that may prove of use in the safety assessment of GM crops, and recommendations for research priorities. It is concluded that the combination of existing test methods provides a sound test-regime to assess the safety of GM crops. Advances in our understanding of molecular biology, biochemistry, and nutrition may in future allow further improvement of test methods that will over time render the safety assessment of foods even more effective and informative.