EURRECA-Evidence-based methodology for deriving micronutrient recommendations

Validation of the minimum dietary diversity for women as a predictor of micronutrient adequacy among lactating women in Ethiopia

Background

The Minimum Dietary Diversity for Women (MDD-W) indicator is used as a proxy indicator for assessing micronutrient adequacy among women of the reproductive age group. Variations were observed in studies, and there was also a lack of evidence regarding the performance of this proxy indicator in Ethiopia, a country with diverse dietary consumption practices. This study aimed to validate the performance of the MDD-W in predicting micronutrient intake adequacy among lactating women in Ethiopia.

Methods and materials

A community-based cross-sectional study was conducted among randomly selected 457 lactating women in Northwest Ethiopia from February 2 to 18, 2023. A multistage sampling technique was used to select 457 study participants. A single multiphasic interactive 24-h dietary recall was used to collect dietary intake data. Ten food groups were used to compute the Minimum Dietary Diversity for Women, and the Mean Adequacy Ratio was used to assess nutrient intake adequacy. Spearman's rank correlation test, Cohen's kappa statistics, and ROC curve analysis were conducted. The optimal cutoff points for Minimum Dietary Diversity for Women were determined by selecting the points that maximized the Youden index.

Results

MDD-W had poor positive correlation (ρ = 0.19, p < 0.001) and poor predictive ability (AUC = 0.62, 95% CI: 0.56, 0.67) (p < 0.001) with the Mean Adequacy Ratio in determining micronutrient intake adequacy. The sensitivity and specificity of the MDD-W in the ≥5 food groups standard cutoff were 25.2 and 82.3%, respectively. The optimal cutoff point for MDD-W to predict micronutrient intake adequacy was ≥3 food groups.

Conclusion

Minimum Dietary Diversity for Women had a poor correlation and poor predictive ability in predicting micronutrient intake adequacy. The variations noted in studies and differences from the Food and Agriculture Organization recommendations regarding the cutoff and level of performance of MDD-W in defining micronutrient adequacy warrant further investigation.

Micronutrient intake inadequacies in Northwest Ethiopian children aged 6-23 months

The early stages of childhood are a crucial period of life for health, with inadequate nutrition impacting physical growth, cognitive development, and the immune system. A considerable proportion of children are affected by micronutrient intake inadequacy and deficiency across the globe. Evidence on micronutrient intake among children aged 6-23 months is limited in Northwest Ethiopia, where there is a divergence between production and dietary consumption practices compared to other regions of the country. This study aimed to determine micronutrient inadequacy and associated factors among children aged 6-23 months. From February 1 to February 18, 2023, 435 children aged 6-23 months participated in a community-based cross-sectional study in the North Mecha District of the Amhara Region, Northwest Ethiopia. The study participants were selected using a multistage sampling technique. A multiphasic interactive 24-h dietary recall was used to collect dietary intake data via an interviewer-administered questionnaire. The interviews were conducted with the mothers of the selected children. Nutrient values for the selected 12 micronutrients were calculated using the NutriSurvey 2007 software and food composition tables from Ethiopia, Tanzania, and Kenya. SPSS version 25 was used for the remaining parts of the analysis. The Nutrient Adequacy Ratio and Mean Adequacy Ratio were calculated to evaluate the nutrient intakes. To identify the factors associated with overall micronutrient intake inadequacy, a binary logistic regression analysis was performed, with statistical significance determined at a p-value < 0.05. The overall prevalence of micronutrient intake inadequacy was 64.7% (95% CI 59.9, 69.2). The odds of inadequacy of micronutrient intake were 2.8 times higher among children aged 6-8 months than children aged 9-23 months (AOR = 2.80, 95% CI 1.71, 4.59). Children with paternal education unable to read and write and primary school incomplete were 3.1 (AOR = 3.12, 95% CI 1.26, 7.70) and 2.4 (AOR = 2.40, 95% CI 1.01, 5.73) times more likely to have micronutrient intake inadequacy, respectively, compared to children with paternal education of primary school completed and above. The likelihood of micronutrient intake inadequacy was 1.8 times higher among children from mothers who had an unfavorable nutrition-related attitude than those from mothers who had a favorable attitude (AOR = 1.76, 95% CI 1.02, 3.05). Inadequate intake of micronutrients was shown to be highly prevalent among children aged 6-23 months. Child age, paternal education, and maternal nutrition-related attitude were significantly associated with micronutrient intake inadequacy. Integrating community-guided nutrition interventions targeting nutrition-related knowledge and attitudes of parents is critical in addressing the inadequate micronutrient intake of children in the study community, where production is not a major problem.

Micronutrient inadequacy among lactating mothers in rural areas of North Mecha District, Amhara Region, Ethiopia

Background

Lactating mothers are frequently at risk for nutritional deficiencies due to the physiological requirements of lactation. Throughout the world, a significant number of lactating mothers have micronutrient intake inadequacy. Evidence on micronutrient intake during lactation is limited in rural Ethiopia. Therefore, this study aimed to determine micronutrient intake inadequacy and associated factors among lactating mothers.

Methods and materials

A community-based cross-sectional study was conducted from February 1 to 18, 2023, among lactating mothers in rural areas of the North Mecha District of Amhara Region, Northwest Ethiopia. A multistage sampling technique was used to select 449 study participants. An interviewer-administered questionnaire was employed to collect dietary intake data by using a single multiphasic interactive 24-h dietary recall. The NutriSurvey 2007 software and Ethiopia, Tanzania and Kenya food composition tables were used to calculate nutrient values for the selected 12 micronutrients. For the remainder of the analysis, SPSS version 25 was employed. The Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) were calculated by dividing all NAR values by the number of micronutrients computed to evaluate the nutrient intakes. A logistic regression analysis was conducted to determine the factors contributing to the overall micronutrient intake inadequacy, and statistical significance was determined at a p value <0.05.

Result

A total of 430 lactating mothers participated in the study, with a 96% response rate and a mean age of 29.46 ± 5.55 years. The overall prevalence of micronutrient intake inadequacy was 72.3% (95% CI: 67.9, 76.5). The odds of micronutrient intake inadequacy were 2.5 times higher among lactating mothers aged 18-25 years old as compared to mothers in the age group ≥36 years old (AOR = 2.52, 95% CI: 1.09, 5.83). Mothers with the educational status of unable to read and write and primary school incomplete were 3.5 (AOR = 3.49, 95% CI: 1.24, 9.83) and 3.6 (AOR = 3.56, 95% CI: 1.06, 11.99) times more likely to have micronutrient intake inadequacy than mothers with secondary school completed or above educational status, respectively. Mothers whose partner's occupation was other than farming were 3.3 times more likely to have micronutrient intake inadequacy as compared to mothers whose partners were engaged in farming (AOR = 3.32, 95% CI: 1.08, 10.27). Lactating mothers who were from food-insecure households were 83% more likely to have high micronutrient intake inadequacy as compared to lactating mothers from food-secure households (AOR = 1.83, 95% CI: 1.04, 3.23). Lactating mothers with nutrition-related unfavorable attitudes were 77% more likely to have inadequate intake of micronutrients compared to lactating mothers with favorable attitudes (AOR = 1.77, 95% CI: 1.07, 2.93).

Conclusion

The prevalence of micronutrient intake inadequacy among lactating mothers was high. Age of the mothers, educational status of the mothers, occupation of the partner, household food security, and nutrition-related attitude were significantly associated with micronutrient intake inadequacy. Community driven nutrition education and interventions are needed to address the high micronutrient intake inadequacy among lactating mothers in rural Ethiopia.

The imprecision of micronutrient requirement values: the example of vitamin D

Food, not nutrients, is the fundamental unit in nutrition. Nutrient requirement values and recommended daily intakes have long been determined and organized in tables by several regulators. These figures, however, overlook the complexity of mixing different foods in a diet and the mediation by human gut microbiota on digestion, metabolism, and health. The microbiome molecular mechanisms and its potential influence on nutrient requirements are far from clear. Guidelines should depend on the sort of intake, along with the dietary habits, rather than focusing on single nutrients. Despite many decades of attempts to investigate the proximate nutrient composition of foods consumed by different world populations, there are still neither standardization of food composition databases nor harmonized dietary intake methods of assessment of nutrients. No all-inclusive attempt was yet made to emphasize the requirements of the various micronutrients, phytonutrients, and non-nutrients on gut microbiota and vice versa, and thereafter reflected into dietary guidelines. New multifaceted methods have been advanced to reevaluate the way nutrients and nutrient requirements are assessed within the intricate biological systems. Our main goal here was to enhance the fact that existing food guidelines hold inherent strengths and limitations but fail, in many aspects, namely, in not taking into account essential geographical, ethnic and cultural differences, and the different stages of life, infant nutrition, and the microbiota impact on several micronutrient requirements. Vitamin D is given as an illustration on present inaccuracy of its requirements. Defining dietary reference intakes is therefore an ongoing process specific for each population.

Increased SIRT1 Concentration Following Four Years of Selenium and Q10 Intervention Associated with Reduced Cardiovascular Mortality at 10-Year Follow-Up-Sub-Study of a Previous Prospective Double-Blind Placebo-Controlled Randomized Clinical Trial

Background: Selenium and coenzyme Q₁₀ (SeQ₁₀) possess antioxidant and anti-inflammatory properties, potentially mediated via Sirtuin1 (SIRT1). We aimed to investigate the influence of a SeQ₁₀ intervention on SIRT1 concentration, with potential interactions with microRNAs. Methods: In this sub-study of a prospective double-blind placebo-controlled clinical trial, healthy subjects (mean age 76 years) were randomized to receive an active treatment (n = 165, combined 200 µg/day of Se and 200 mg/day of Q₁₀) or a placebo (n = 161). SIRT1 concentration and microRNAs were measured with ELISA and PCR, respectively. Results: After four years, SIRT1 concentration was increased in the active treatment group, with mean (SD) ng/mL of 469 (436) vs. 252 (162), p < 0.001, and decreased in the placebo group, 190 (186) vs. 269 (172), p = 0.002, and the differences between the groups were significant (p = 0.006, adjusted). Those who suffered CV death during a 10-year follow-up (n = 25 and n = 52 in the active treatment and placebo groups, respectively) had significantly lower baseline SIRT1 concentrations compared to the survivors (p < 0.001). MiR-130a-3p was significantly downregulated during the intervention and correlated inversely with SIRT1 at baseline (r = -0.466, p = 0.007). Conclusion: The increased SIRT1 concentration after the SeQ₁₀ intervention associated with reduced CV mortality, partly mediated via miR-1303a-3p, suggests that SIRT1 is an additional mediator of the intervention, preventing vascular ageing.

Statistical modeling of health space based on metabolic stress and oxidative stress scores

Background

Health space (HS) is a statistical way of visualizing individual’s health status in multi-dimensional space. In this study, we propose a novel HS in two-dimensional space based on scores of metabolic stress and of oxidative stress.

Methods

These scores were derived from three statistical models: logistic regression model, logistic mixed effect model, and proportional odds model. HSs were developed using Korea National Health And Nutrition Examination Survey data with 32,140 samples. To evaluate and compare the performance of the HSs, we also developed the Health Space Index (HSI) which is a quantitative performance measure based on the approximate 95% confidence ellipses of HS.

Results

Through simulation studies, we confirmed that HS from the proportional odds model showed highest power in discriminating health status of individual (subject). Further validation studies were conducted using two independent cohort datasets: a health examination dataset from Ewha-Boramae cohort with 862 samples and a population-based cohort from the Korea association resource project with 3,199 samples.

Conclusions

These validation studies using two independent datasets successfully demonstrated the usefulness of the proposed HS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14081-0.

Selenium and Coenzyme Q10 Intervention Prevents Telomere Attrition, with Association to Reduced Cardiovascular Mortality-Sub-Study of a Randomized Clinical Trial

Short telomeres have been associated with ageing and cardiovascular disease. The influence on leukocyte telomere length (LTL) of long-term intervention with combined selenium and coenzyme Q10 is unknown. Our aim was to determine whether 42 months of selenium and coenzyme Q10 supplementation prevented telomere attrition and further cardiovascular mortality. The investigation is an explorative sub-study of a double-blind, placebo-controlled, randomized trial. Swedish citizens low in selenium (n = 118), aged 70−80 years, were included. Intervention time was 4 years, with 10 years’ follow-up time. LTL was relatively quantified with PCR at baseline and after 42 months. At baseline, LTL (SD) was 0.954 (0.260) in the active treatment group and 1.018 (0.317) in the placebo group (p = 0.23). At 42 months, less shortening of LTL was observed after active treatment compared with placebo (+0.019 vs. −0.129, respectively, p = 0.02), with a significant difference in change basing the analysis on individual changes in LTL (p < 0.001). Subjects suffering future death presented with significantly shorter LTL at 42 months than survivors [0.791 (0.190) vs. 0.941 (0.279), p = 0.01], with a significant difference in change of LTL according to cardiovascular mortality and survival (p = 0.03). To conclude, preservation of LTL after selenium and coenzyme Q10 supplementation associated with reduced cardiovascular mortality.

Micronutrient intake inadequacy and its associated factors among lactating women in Bahir Dar city, Northwest Ethiopia, 2021

Background

Inadequate intake of micronutrients in lactating women was prevalent worldwide. In particular, to our knowledge, there has been little report concerning Ethiopian lactating women regarding their micronutrient intake. Our objective was to assess micronutrient intake inadequacy and its associated factors among lactating women in Bahir Dar city, Northwest Ethiopia, 2021.

Methods

Community-based cross-sectional study was conducted from February 15 to March 05, 2021. Four hundred thirteen respondents were selected through systematic random sampling. Data were collected by interviewer-administered semi-structured questionnaire and a single multiphasic 24 hours dietary recall was used to assess dietary assessment. Data entry and analysis were carried out using EpiData and SPSS respectively. The ESHA food processor, Ethiopian food composition table, and world food composition table have used the calculation of nutrient values of the selected micronutrient. The nutrient intakes were assessed by Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR). Multivariable binary logistic regression analysis was done to identify the factors of overall micronutrient intake inadequacy.

Result

The overall prevalence of micronutrient intake inadequacy across 12 nutrients was 39.9% [95% CI (34.9, 45.0)]. The inadequate intake of vitamin A was 98.2%. Similarly, the inadequate intake of B vitamins ranges from 13.4% to 68.5%. The insufficient intakes of calcium, iron, and zinc were 70.9%, 0%, and 4.7%, respectively. Around 36 and 91.6% of the respondents had inadequate intake of selenium and sodium, respectively. On multivariable logistic regression analysis; Being divorced was 2.7 times more likely to have overall micronutrient intake inadequacy than being married [AOR = 2.71, 95% CI (1.01, 7.33)]. The odds of overall micronutrient intake inadequacy were 2.6 higher in merchants than in housewives [AOR = 2.63, 95% CI (1.40, 4.93)]. Lactating women who had poor nutritional knowledge were 2.7 times more likely to have overall micronutrient intake inadequacy than those who had good nutritional knowledge [AOR = 2.71, 95% CI (1.47, 4.99)].

Conclusion and recommendation

Overall, the micronutrient intake in lactating women was lower than the recommended levels. Therefore; educating lactating women about appropriate dietary intake is essential.

Framework of Methodology to Assess the Link between A Posteriori Dietary Patterns and Nutritional Adequacy: Application to Pregnancy

This study aimed to explore the nutritional profile of 608 women during the second trimester of pregnancy, in terms of nutrient patterns, dietary quality and nutritional adequacy. Dietary data were collected using a validated Mediterranean-oriented, culture-specific FFQ. Principal component analysis was performed on 18 energy-adjusted nutrients. Two main nutrient patterns, “plant-origin” (PLO) and “animal-origin” (ANO), were extracted. Six homogenous clusters (C) relative to nutrient patterns were obtained and analyzed through a multidimensional methodological approach. C1, C5 and C6 scored positively on PLO, while C1, C2 and C3 scored positively on ANO. When dietary quality was mapped on food choices and dietary indexes, C6 unveiled a group with a distinct image resembling the Mediterranean-type diet (MedDiet Score = 33.8). Although C1–C5 shared common dietary characteristics, their diet quality differed as reflected in the HEI-2010 (C1:79.7; C2:73.3; C3:70.9; C4:63.2; C5:76.6). The appraisal of nutritional adequacy mirrored a “nutritional-quality gradient”. A total of 50% of participants in C6 had almost 100% adequate magnesium intake, while 50% of participants in C4 had a probability of adequacy of ≤10%. Our methodological framework is efficient for assessing the link between a posteriori dietary patterns and nutritional adequacy during pregnancy. Given that macro- and micronutrient distributions may induce metabolic modifications of potential relevance to offspring’s health, public health strategies should be implemented.

Implementation of Harmonized Food Consumption Data Collection in the Balkan Region According to the EFSA EU Menu Methodology Standards

Initiatives in the Capacity Development in Nutrition Research in the Balkan region in the last decade have been toward the creation of contemporary, harmonized Research Infrastructure (RI) compliant with European standards. This study describes the process of creation and implementation of the European Food Safety Authority (EFSA) EU Menu methodology in the Balkan region during the EFSA support projects for food consumption data collection in four countries (Serbia, Montenegro, Bosnia and Herzegovina, and North Macedonia). This process entailed the application and improvement of an innovative tool, the DIET ASSESS and PLAN (DAP), a platform for standardized food consumption data collection and dietary intake assessment. DAP comprises computerized food consumption, anthropometric measurements, and physical activity questionnaires, validated food picture book, and FoodEx2 exposure hierarchy with sets of facet descriptors of the interest. It hosts the Balkan food platform with a Serbian food composition database (FCDB) and Regional FCDB, compliant with European Food Information Resource (EuroFIR™) standards. The implementation of the DAP platform in national dietary surveys conducted with the support of the EFSA EU Menu project in Balkan countries enabled harmonized food consumption data compilation and reporting. Application of the methodology entailed the development of study protocol and extensive education and training of study personnel. The entire data collection process was managed by internal and external survey coordinators. A pilot study was conducted to test the entire data collection and control process and was afterward used to make necessary improvements and adjustments to meet EU Menu requirements. Data collected are internationally comparable with food consumption data in other European countries within the framework of the EU Menu program. The existence of such data in the Balkan region will catalyze research activities in emerging topics, such as identification of dietary patterns, the establishment of national nutrient reference values and food-based dietary guidelines (not only in Serbia, but in the whole Balkan region), dietary exposure assessments, the endorsement and evaluation of new food legislations, the environmental and other effects of diet on the food system. The developed and implemented methodology underpins evidence-based policy-making processes lacking in the field of public health nutrition in the region.

Positive Association Between Nutrient Adequacy and Waist Circumference: Results of a Cross-Sectional Study

Metabolic syndrome (MetS) is a multifactorial disease with its exact causes not completely clear. Micronutrients such as vitamin A, vitamin D, zinc, and magnesium have been associated with MetS components. Our objective was to investigate the association of nutrient adequacy (NA) with MetS components. The present cross-sectional study consisted of 850 adults between 18-59 years from Tehran, Iran. Dietary intake, socio-demographic data, medical history, and anthropometric indices were collected by trained personnel. NA was calculated as the mean intake ratio to the recommended amount of 16 micronutrients. MetS were defined by the consensus of National Cholesterol Education Program-Adult Treatment Panel III criteria. The association between NA and MetS was examined using linear regression analyses after controlling potential confounders. More participants in the highest quartile were obese in terms of general obesity (p = 0004) and abdominal obesity (p = 0.003) compared with subjects in the least quartile. A significant positive correlation was found between waist circumference (WC) and NA even after controlling for all potential confounders (p < 0.001). NA was positively associated with WC among adults living in Tehran.

The Nordic Nutrition Recommendations 2022 - prioritisation of topics for de novo systematic reviews

Background

As part of the process of updating national dietary reference values (DRVs) and food-based dietary guidelines (FBDGs), the Nordic Nutrition Recommendations 2022 project (NNR2022) will select a limited number of topics for systematic reviews (SRs).

Objective

To develop and transparently describe the results of a procedure for prioritisation of topics that may be submitted for SRs in the NNR2022 project.

Design

In an open call, scientists, health professionals, national food and health authorities, food manufacturers, other stakeholders and the general population in the Nordic and Baltic countries were invited to suggest SR topics. The NNR2022 Committee developed scoping reviews (ScRs) for 51 nutrients and food groups aimed at identifying potential SR topics. These ScRs included the relevant nominations from the open call. SR topics were categorised, ranked and prioritised by the NNR2022 Committee in a modified Delphi process. Existing qualified SRs were identified to omit duplication.

Results

A total of 45 nominations with suggestion for more than 200 exposure-outcome pairs were received in the public call. A number of additional topics were identified in ScRs. In order to omit duplication with recently qualified SRs, we defined criteria and identified 76 qualified SRs. The NNR2022 Committee subsequently shortlisted 52 PI/ECOTSS statements, none of which overlapped with the qualified SRs. The PI/ECOTSS statements were then graded 'High' (n = 21), 'Medium' (n = 9) or 'Low' (n = 22) importance, and the PI/ECOTSS statements with 'High' were ranked in a Delphi process. The nine top prioritised PI/ECOTSS included the following exposure-outcome pairs: 1) plant protein intake in children and body growth, 2) pulses/legumes intake, and cardiovascular disease and type 2 diabetes, 3) plant protein intake in adults, and atherosclerotic/cardiovascular disease and type 2 diabetes, 4) fat quality and mental health, 5) vitamin B12 and vitamin B12 status, 6) intake of white meat (no consumption vs. high consumption and white meat replaced with red meat), and all-cause mortality, type 2 diabetes and risk factors, 7) intake of n-3 LPUFAs from supplements during pregnancy, and asthma and allergies in the offspring, 8) nuts intake and cardiovascular disease (CVD) and type 2 diabetes in adults, 9) dietary fibre intake (high vs. low) in children and bowel function.

Discussion

The selection of topics for de novo SRs is central in the NNR2022 project, as the results of these SRs may cause adjustment of existing DRVs and FBDGs. That is why we have developed this extensive process for the prioritisation of SR topics. For transparency, the results of the process are reported in this publication.

Conclusion

The principles and methodologies developed in the NNR2022 project may serve as a framework for national health authorities or organisations when developing national DRVs and FBDGs. This collaboration between the food and health authorities in Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway and Sweden represents an international effort for harmonisation and sharing of resources and competence when developing national DRVs and FBDGs.

Nutritional Inadequacy: Unraveling the Methodological Challenges for the Application of the Probability Approach or the EAR Cut-Point Method-A Pregnancy Perspective

The aim of this study was to unravel the methodological challenges when exploring nutritional inadequacy, involving 608 healthy pregnant women. The usual intake of twenty-one nutrients was recorded by employing a validated FFQ. Simulated datasets of usual intake were generated, with randomly imposed uncertainty. The comparison between the usual intake and the EAR was accomplished with the probability approach and the EAR cut-point method. Point estimates were accompanied by bootstrap confidence intervals. Bootstrap intervals applied on the risk of inadequacy for raw and simulated data tended in most cases to overlap. A detailed statistical analysis, aiming to predict the level of inadequacy, as well as the application of the EAR cut-point method, along with bootstrap intervals, could effectively be used to assess nutrient inadequacy. However, the final decision for the method used depends on the distribution of nutrient-intake under evaluation. Irrespective of the applied methodology, moderate to high levels of inadequacy, calculated from FFQ were identified for certain nutrients (e.g., vitamins C, B6, magnesium, vitamin A), while the highest were recorded for folate and iron. Considering that micronutrient-poor, obesogenic diets are becoming more common, the underlying rationale may help towards unraveling the complexity characterizing nutritional inadequacies, especially in vulnerable populations.

Childcare Food Provision Recommendations Vary across Australia: Jurisdictional Comparison and Nutrition Expert Perspectives

Early childhood is a critical stage for nutrition promotion, and childcare settings have the potential for wide-reaching impact on food intake. There are currently no Australian national guidelines for childcare food provision, and the comparability of existing guidelines across jurisdictions is unknown. This project aimed to map and compare childcare food provision guidelines and to explore perspectives amongst early childhood nutrition experts for alignment of jurisdictional childcare food provision guidelines with the Australian Dietary Guidelines (ADG). A desktop review was conducted and formed the basis of an online survey. A national convenience sample of childhood nutrition experts was surveyed. Existing guideline recommendations for food group serving quantities were similar across jurisdictions but contained many minor differences. Of the 49 survey respondents, most (84-100%) agreed with aligning food group provision recommendations to provide at least 50% of the recommended ADG serves for children. Most (94%) agreed that discretionary foods should be offered less than once per month or never. Jurisdictional childcare food provision guidelines do not currently align, raising challenges for national accreditation and the provision of support and resources for services across jurisdictions. Childhood nutrition experts support national alignment of food provision guidelines with the ADG.

Effect modification of FADS2 polymorphisms on the association between breastfeeding and intelligence: results from a collaborative meta-analysis

Background

Accumulating evidence suggests that breastfeeding benefits children’s intelligence, possibly due to long-chain polyunsaturated fatty acids (LC-PUFAs) present in breast milk. Under a nutritional adequacy hypothesis, an interaction between breastfeeding and genetic variants associated with endogenous LC-PUFAs synthesis might be expected. However, the literature on this topic is controversial.

Methods

We investigated this gene × environment interaction through a collaborative effort. The primary analysis involved >12 000 individuals and used ever breastfeeding, FADS2 polymorphisms rs174575 and rs1535 coded assuming a recessive effect of the G allele, and intelligence quotient (IQ) in Z scores.

Results

There was no strong evidence of interaction, with pooled covariate-adjusted interaction coefficients (i.e. difference between genetic groups of the difference in IQ Z scores comparing ever with never breastfed individuals) of 0.12[(95% confidence interval (CI): −0.19; 0.43] and 0.06 (95% CI: −0.16; 0.27) for the rs174575 and rs1535 variants, respectively. Secondary analyses corroborated these results. In studies with ≥5.85 and <5.85 months of breastfeeding duration, pooled estimates for the rs174575 variant were 0.50 (95% CI: −0.06; 1.06) and 0.14 (95% CI: −0.10; 0.38), respectively, and 0.27 (95% CI: −0.28; 0.82) and −0.01 (95% CI: −0.19; 0.16) for the rs1535 variant.

Conclusions

Our findings did not support an interaction between ever breastfeeding and FADS2 polymorphisms. However, subgroup analysis suggested that breastfeeding may supply LC-PUFAs requirements for cognitive development if breastfeeding lasts for some (currently unknown) time. Future studies in large individual-level datasets would allow properly powered subgroup analyses and further improve our understanding on the breastfeeding × FADS2 interaction.

Systematic Review of Observational Studies with Dose-Response Meta-Analysis between Folate Intake and Status Biomarkers in Adults and the Elderly

BACKGROUND

Dietary reference values for folate intake vary widely across Europe.

METHODS

MEDLINE and Embase through November 2016 were searched for data on the association between folate intake and biomarkers (serum/plasma folate, red blood cell [RBC] folate, plasma homocysteine) from observational studies in healthy adults and elderly. The regression coefficient of biomarkers on intake (β) was extracted from each study, and the overall and stratified pooled β and SE (β) were obtained by random effects meta-analysis on a double log scale. These dose-response estimates may be used to derive folate intake reference values.

RESULTS

For every doubling in folate intake, the changes in serum/plasma folate, RBC folate and plasma homocysteine were +22, +21, and -16% respectively. The overall pooled regression coefficients were β = 0.29 (95% CI 0.21-0.37) for serum/plasma folate (26 estimates from 17 studies), β = 0.28 (95% CI 0.21-0.36) for RBC (13 estimates from 11 studies), and β = -0.21 (95% CI -0.31 to -0.11) for plasma homocysteine (10 estimates from 6 studies).

CONCLUSION

These estimates along with those from randomized controlled trials can be used for underpinning dietary recommendations for folate in adults and elderly.

Profile of Trace Elements in Selected Medicinal Plants Used for the Treatment of Diabetes in Eritrea

This study was designed to investigate the profile of certain trace elements having therapeutic properties related to diabetes mellitus. The investigated plants were Aloe camperi, Meriandra dianthera, Lepidium sativum, Brassica nigra, and Nigella sativa. These plants are traditionally used in the management of diabetes in Eritrea. The elemental analysis was conducted using inductively coupled plasma optical emission spectrometry (ICP-OES) and flame atomic absorption spectroscopy (FAAS) techniques. The accuracy of the methods was verified using in-house reference materials (CRMs) and no significant differences were observed between the measured and certified values. The analysis displayed variable concentrations of the different trace elements including Zn, Cr, V, Mn, and Se in the plants. Moreover, the levels of major elements, such as Mg, Ca, K, Na, and Ba, and heavy metals, such as Fe, Cu, Ni, Co, As, and Pb, were determined and found to be in the permissible limit defined by WHO. Among the plants, Meriandra dianthera showed the highest levels of Mn, Cr, V, and other elements and the values were significantly different (P < 0.05).

Diet quality as measured by the Diet Quality Index-International is associated with prospective changes in body fat among Canadian children

OBJECTIVE

To quantify the association of dietary quality with prospective changes in adiposity.

DESIGN

Children participating in the QUALITY (QUebec Adipose and Lifestyle InvesTigation in Youth) study underwent examination at baseline and at 2-year follow-up. Dietary quality was assessed by the Diet Quality Index-International (DQII) using three non-consecutive 24 h diet recalls at baseline. The DQII has four main categories: dietary adequacy, variety, moderation and overall balance. Fat mass index (FMI; [fat mass (kg)]/[height (m)]2), central FMI (CFMI; [trunk fat mass (kg)]/[height (m)]2), percentage body fat (%BF; [total fat mass (kg)]/[total mass (kg)]) and percentage central BF (%CBF; [trunk fat mass (kg)]/[total mass (kg)]) were assessed through dual-energy X-ray absorptiometry.

SETTING

Children were selected from schools in the greater Montreal, Sherbrooke and Quebec City metropolitan areas between 2005 and 2008, Quebec, Canada.

SUBJECTS

A total of 546 children aged 8-10 years, including 244 girls and 302 boys.

RESULTS

Regression analysis adjusting for age, sex, energy intake, physical activity and Tanner stage revealed that every 10-unit improvement in overall DQII score was associated with lower gain in CFMI (β=-0·08; 95 % CI -0·17, -0·003) and %BF (β=-0·55; 95 % CI -1·08, -0·02). Each unit improvement in dietary adequacy score was associated with lower gain in FMI (β=-0·05; 95 % CI -0·08, -0·008), CFMI (β=-0·03; 95 % CI -0·05, -0·007), %BF (β=-0·15; 95 % CI -0·28, -0·03) and %CBF (β=-0·09; 95 % CI -0·15, -0·02).

CONCLUSIONS

Promotion of dietary quality and adequacy may reduce weight gain in childhood and prevent chronic diseases later in life.

The genomics of micronutrient requirements

Healthy nutrition is accepted as a cornerstone of public health strategies for reducing the risk of noncommunicable conditions such as obesity, cardiovascular disease, and related morbidities. However, many research studies continue to focus on single or at most a few factors that may elicit a metabolic effect. These reductionist approaches resulted in: (1) exaggerated claims for nutrition as a cure or prevention of disease; (2) the wide use of empirically based dietary regimens, as if one fits all; and (3) frequent disappointment of consumers, patients, and healthcare providers about the real impact nutrition can make on medicine and health. Multiple factors including environment, host and microbiome genetics, social context, the chemical form of the nutrient, its (bio)availability, and chemical and metabolic interactions among nutrients all interact to result in nutrient requirement and in health outcomes. Advances in laboratory methodologies, especially in analytical and separation techniques, are making the chemical dissection of foods and their availability in physiological tissues possible in an unprecedented manner. These omics technologies have opened opportunities for extending knowledge of micronutrients and of their metabolic and endocrine roles. While these technologies are crucial, more holistic approaches to the analysis of physiology and environment, novel experimental designs, and more sophisticated computational methods are needed to advance our understanding of how nutrition influences health of individuals.

Communication of scientific uncertainty: international case studies on the development of folate and vitamin D Dietary Reference Values

OBJECTIVE

Transparent evidence-based decision making has been promoted worldwide to engender trust in science and policy making. Yet, little attention has been given to transparency implementation. The degree of transparency (focused on how uncertain evidence was handled) during the development of folate and vitamin D Dietary Reference Values was explored in three a priori defined areas: (i) value request; (ii) evidence evaluation; and (iii) final values.

DESIGN

Qualitative case studies (semi-structured interviews and desk research). A common protocol was used for data collection, interview thematic analysis and reporting. Results were coordinated via cross-case synthesis.

SETTING

Australia and New Zealand, Netherlands, Nordic countries, Poland, Spain and UK.

SUBJECTS

Twenty-one interviews were conducted in six case studies.

RESULTS

Transparency of process was not universally observed across countries or areas of the recommendation setting process. Transparency practices were most commonly seen surrounding the request to develop reference values (e.g. access to risk manager/assessor problem formulation discussions) and evidence evaluation (e.g. disclosure of risk assessor data sourcing/evaluation protocols). Fewer transparency practices were observed to assist with handling uncertainty in the evidence base during the development of quantitative reference values.

CONCLUSIONS

Implementation of transparency policies may be limited by a lack of dedicated resources and best practice procedures, particularly to assist with the latter stages of reference value development. Challenges remain regarding the best practice for transparently communicating the influence of uncertain evidence on the final reference values. Resolving this issue may assist the evolution of nutrition risk assessment and better inform the recommendation setting process.

Use and applications of systematic reviews in public health nutrition

Decisions related to a spectrum of nutrition-related public health and clinical concerns must consider many factors and are best informed by evaluating the totality and quality of the evidence. Systematic review (SR) is a structured process to evaluate, compare, and synthesize relevant evidence for the SR-specific question(s). Applications of SR are exemplified here through the discussion of four case studies: research agendas, nutrient reference intakes, dietary guidance, and practice guidelines. Concerns that SR cannot be effectively applied to nutrition evidence because of the lack of an unexposed comparator and the complex homeostasis in nutrition are discussed. Central to understanding the applicability of SR is its flexibility in defining key inclusion criteria and rigorous elements as appropriate for the SR-specific question(s). Through the reduction of bias and random error by explicit, reproducible, comprehensive, and rigorous examination of all of the evidence, SR informs the scientific judgment needed for sound evidence-based public health nutrition.

EURRECA-Estimating selenium requirements for deriving dietary reference values

Current reference values for selenium, an essential micronutrient, are based on the intake of selenium that is required to achieve maximal glutathione peroxidase activity in plasma or erythrocytes. In order to assess the evidence of relevance to setting dietary reference values for selenium, the EURRECA Network of Excellence focused on systematic searches, review, and evaluation of (i) selenium status biomarkers and evidence for relationships between intake and status biomarkers, (ii) selenium and health (including the effect of intake and/or status biomarkers on cancer risk, immune function, HIV, cognition, and fertility), (iii) bioavailability of selenium from the diet, and (iv) impact of genotype/single nucleotide polymorphisms on status or health outcomes associated with selenium. The main research outputs for selenium and future research priorities are discussed further in this review.

EURRECA-Principles and future for deriving micronutrient recommendations

The EURopean micronutrient RECommendations Aligned (EURRECA) Network of Excellence (NoE) explored an approach for setting micronutrient recommendations, which would address the variation in recommendations across Europe. Therefore, a framework for deriving and using micronutrient Dietary Reference Values (DRVs) has been developed. This framework comprises four stages (defining the problem-monitoring and evaluating-deriving dietary reference values-using dietary reference values in policy making). The aim of the present paper is to use this framework to identify specific research gaps and needs related to (1) knowledge available on specific micronutrients (folate, iodine, iron, selenium, vitamin B12, vitamin D, and zinc) and (2) the methodology presented in the framework. Furthermore, the paper describes the different outputs that support the process like protocols, guidelines, systematic review databases, and peer-reviewed publications, as well as the principal routes of dissemination of these outputs to ensure their optimal uptake in policy, practice, and research collaborations. The importance of ensuring transparency in risk assessment and risk management, systematic searching the literature, and taking into account policy options is highlighted. [Supplementary materials are available for this article. Go to the publisher's online edition of Critical Reviews in Food Science and Nutrition for the following free supplemental files: Additional tables.].

EURRECA-Framework for Aligning Micronutrient Recommendations

There is currently no standard approach for deriving micronutrient recommendations, and large variations exist across Europe, causing confusion among consumers, food producers, and policy makers. More aligned information could influence dietary behaviors and potentially lead to a healthier population. Funded by the European Commission, EURRECA (EURopean micronutrient RECommendations Aligned) has developed methods and applications to guide Nutrient Recommendation Setting Bodies through the process of setting micronutrient reference values. The EURRECA approach is crystallized into its framework that outlines a standard process for deriving and using dietary reference values for micronutrients in a transparent, systematic, and scientific way. The 9 activities of the framework can be clustered into four stages (i) defining the problem, (ii) monitoring and evaluating, (iii) deriving dietary reference values, and (iv) using dietary reference values in policy making. The EURRECA framework should not be interpreted as a prescriptive description of a linear process, but as a structured guide for checking that all issues essential for deriving requirements have at least been considered.

EURRECA-Estimating zinc requirements for deriving dietary reference values

Zinc was selected as a priority micronutrient for EURRECA, because there is significant heterogeneity in the Dietary Reference Values (DRVs) across Europe. In addition, the prevalence of inadequate zinc intakes was thought to be high among all population groups worldwide, and the public health concern is considerable. In accordance with the EURRECA consortium principles and protocols, a series of literature reviews were undertaken in order to develop best practice guidelines for assessing dietary zinc intake and zinc status. These were incorporated into subsequent literature search strategies and protocols for studies investigating the relationships between zinc intake, status and health, as well as studies relating to the factorial approach (including bioavailability) for setting dietary recommendations. EMBASE (Ovid), Cochrane Library CENTRAL, and MEDLINE (Ovid) databases were searched for studies published up to February 2010 and collated into a series of Endnote databases that are available for the use of future DRV panels. Meta-analyses of data extracted from these publications were performed where possible in order to address specific questions relating to factors affecting dietary recommendations. This review has highlighted the need for more high quality studies to address gaps in current knowledge, in particular the continued search for a reliable biomarker of zinc status and the influence of genetic polymorphisms on individual dietary requirements. In addition, there is a need to further develop models of the effect of dietary inhibitors of zinc absorption and their impact on population dietary zinc requirements.

The Mediterranean diet and nutritional adequacy: a review

The Mediterranean dietary pattern, through a healthy profile of fat intake, low proportion of carbohydrate, low glycemic index, high content of dietary fiber, antioxidant compounds, and anti-inflammatory effects, reduces the risk of certain pathologies, such as cancer or Cardiovascular Disease (CVD). Nutritional adequacy is the comparison between the nutrient requirement and the intake of a certain individual or population. In population groups, the prevalence of nutrient inadequacy can be assessed by the probability approach or using the Estimated Average Requirement (EAR) cut-point method. However, dietary patterns can also be used as they have moderate to good validity to assess adequate intakes of some nutrients. The objective of this study was to review the available evidence on the Nutritional Adequacy of the Mediterranean Diet. The inclusion of foods typical of the Mediterranean diet and greater adherence to this healthy pattern was related to a better nutrient profile, both in children and adults, with a lower prevalence of individuals showing inadequate intakes of micronutrients. Therefore, the Mediterranean diet could be used in public health nutrition policies in order to prevent micronutrient deficiencies in the most vulnerable population groups.

EURRECA-Estimating iodine requirements for deriving dietary reference values

Iodine is an essential component of thyroid hormones, and current recommendations for intake are based on urinary iodine excretion, assessment of thyroid size, thyroidal iodine accumulation and turnover, radioactive iodine uptake, balance studies, and epidemiological studies. Dietary iodine is rapidly and almost completely absorbed. The prevalence of inadequate iodine intake is high: 29% of the world's population lives in iodine-deficient areas and 44% of Europe remains mildly iodine deficient. To assess current data and update evidence for setting dietary recommendations for iodine, the EURRECA Network of Excellence has undertaken systematic review and evaluation of (i) the usefulness of iodine status biomarkers (ii) the relationship between iodine status biomarkers and dietary iodine intake, and (iii) the relationship between iodine intake and health outcomes (endemic goiter, hypothyroidism, and cognitive function). This review summarizes the main research outputs: the key findings of the literature review, results of the meta-analyses, and discussion of the main conclusions. Currently, data for relevant intake-status-health relationships for iodine are limited, particularly for population groups such as children under two years, pregnant women, and the elderly. The EURRECA Network developed best practice guidelines for the identification of pertinent iodine studies based on a systematic review approach. This approach aimed to identify comparable data, suitable for meta-analysis, for different countries and across all age ranges. When new data are available, the EURRECA Network best practice guidelines will provide a better understanding of iodine requirements for different health outcomes which could be used to set evidence-based dietary iodine recommendations for optimal health.