Validation of a semiquantitative food frequency questionnaire for estimation of intakes of energy, fats and cholesterol among Singaporeans

The aim of this study was to assess the relative validity of a 159-item semiquantitative food frequency questionnaire (FFQ) for use among adult Singaporeans. This FFQ should be able to classify intakes of energy, total fat, saturated fat, polyunsaturated fat, monounsaturated fat and cholesterol into quintiles of intakes for purposes of epidemiological studies. A total of 126 subjects (84 women and 42 men) took part in the study which included an interview using the newly developed FFQ (assess past month's intake) and three 24-h (24 h) recalls (reference method, collected over a period of 1 month). Subjects also collected two 24 h urinary samples for urea from which total nitrogen excretion was assessed to validate protein intake. When compared to the reference method, the FFQ slighty overestimated the intakes of energy, total fat and types of fat as reflected by the difference in means and the ratio of FFQ to 24 h intakes. The overestimation ranged from 1 to 11% of the reference method. Dietary cholesterol was underestimated by 17% by the FFQ. These differences were however, not statistically significant. Pearson's correlation coefficients (95% confidence intervals (CI)) between intakes assessed by FFQ and reference method varied from 0.58 (0.45, 0.69) for total fat to 0.39 (0.23, 0.53) for polyunsaturated fat. Cross-classification into quintiles resulted in correct classification into the same or adjacent quintiles in 70% of subjects, with only one or two subjects being grossly misclassified. Nitrogen (N) intake from the 24 h recalls did not differ significantly from that estimated from the urinary nitrogen excretion. The mean (± SD) difference was 0.0 ± 0.4 g and the Pearson correlation coefficient (95% CI) was 0.55 (0.31, 0.72). It is concluded that the newly developed FFQ is an adequate tool for classifying individuals' intakes into quintiles for epidemiological studies among Singaporean adults.

Nutritional concerns, health and survival in old age

The ageing process is-apart from chance or good luck-not only influenced by factors intrinsic to the individual, but also by extrinsic factors that include environmental and lifestyle variables. This paper deals with the epidemiological evidence for the role of dietary patterns and key nutritional concerns in relation to survival and ageing related disorders that present themselves in later life. Dietary patterns, such as the Mediterranean diet, characterized by mainly plant foods including protective factors e.g. vegetables, nuts and monounsaturated fatty acids and excluding harmful factors e.g. trans-fatty acids and foods with a high glycemic factor, appear to be relevant even in old age. Specific nutritional concerns focus on general undernutrition, vitamin D and vitamin B(12). Prevalence of nutritional inadequacies, diagnostic criteria, causes and health consequences are described. The paper ends with recommendations for guidance on healthy diets for elderly people. An important challenge should be research to further expand the knowledge base, acknowledging the complexity of the ageing process and integrating different dimensions of research into human healthy ageing in properly designed studies. In the mean time reversing poor adherence to existing guidelines for a healthy diet remains a first challenge in public health nutritional practices.

Dietary intake and status of folate and vitamin B12 and their association with homocysteine and cardiovascular disease in European populations

BACKGROUND/OBJECTIVES

Folate and vitamin B12 have been suggested to play a role in chronic diseases like cardiovascular diseases. The objectives are to give an overview of the actual intake and status of folate and vitamin B12 in general populations in Europe, and to evaluate these in view of the current vitamin recommendations and the homocysteine concentration.

METHODS

Searches in Medline with 'folic acid', 'folate' and 'vitamin B12', 'B12' or 'cobalamin' as key words were combined with the names of the European countries. Populations between 18 and 65 years were included.

RESULTS

Sixty-three articles reporting on studies from 15 European countries were selected. Low folate intakes were observed in Norway, Sweden, Denmark and the Netherlands. Low intakes of vitamin B12 were not common and only seen in one small Greek study. In the countries with a low intake of folate, the recommended levels were generally not achieved, which was also reflected in the folate status. Vitamin B12 intake was not strongly associated with the vitamin B12 status, which can explain why in the Netherlands and Germany the vitamin B12 status was inadequate, despite sufficient intake levels. In countries with a low folate intake in particular, the Hcy concentration was higher than ideal.

CONCLUSIONS

Populations from the Nordic countries, the Netherlands, Germany and Greece may need to improve their intakes of folic acid, B12 or both to either meet the recommendations or to optimize their statuses. This could be achieved via a food-based approach, food fortification or supplements.

Changes in markers of cobalamin status after cessation of oral B-vitamin supplements in elderly people with mild cobalamin deficiency

Mildly cobalamin-deficient elderly were supplemented with 1000 microg cobalamin (group C, n=34), 1000 microg cobalamin with 400 microg folic acid (group CF, n=31) or a placebo (n=30) for 6 months. Participants provided one single blood sample 3, 5 or 7 months after cessation of supplementation to monitor early changes in plasma concentrations of cobalamin, holotranscobalamin (holoTC) and methylmalonic acid (MMA). At the end of supplementation (groups C+CF), one participant met our criteria for mild cobalamin deficiency, as did 13, 14 and 43% of the participants assessed at respectively 3, 5 and 7 months post-supplementation. Cobalamin and holoTC declined on average with 47 and 56% relative to concentrations at the end of supplementation for the group assessed at 7 months post-supplementation. Essentially similar declines were observed for those participants assessed at 3 and 5 months post-supplementation. Mean MMA concentrations increased by 15% (P=0.07) in those participants assessed at 3 and 5 months post-supplementation, and increased by 50% (P=0.002) in those participants assessed at 7 months post-supplementation. Considering MMA as a sensitive tissue marker for cobalamin status, oral supplementation may afford adequate cobalamin status for a period of up to 5 months after cessation in the majority of participants.

Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review

BACKGROUND

Guidelines for lifestyle and dietary modification in patients with coronary artery disease (CAD) are mainly supported by evidence from general population studies. CAD patients, however, differ from the general population in age (older) and treatment with preventive drugs. This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients.

METHODS AND RESULTS

A literature search was performed on the effect of lifestyle and dietary changes on mortality in CAD patients. Prospective cohort studies and randomized controlled trials of patients with established CAD were included if they reported all-causes mortality and had at least 6 months of follow-up. The effect estimates of smoking cessation (relative risk [RR], 0.64; 95% CI, 0.58 to 0.71), increased physical activity (RR, 0.76; 95% CI, 0.59 to 0.98), and moderate alcohol use (RR, 0.80; 95% CI, 0.78 to 0.83) were studied most extensively. For the 6 dietary goals, data were too limited to provide reliable effect size estimates. Combinations of dietary changes were associated with reduced mortality (RR, 0.56; 95% CI, 0.42 to 0.74).

CONCLUSIONS

Available studies show convincingly the health benefits of lifestyle changes in CAD patients. Effect estimates of combined dietary changes look promising. Future studies should confirm these findings and assess the contribution of the individual dietary factors.

Comparison of three different dietary scores in relation to 10-year mortality in elderly European subjects: the HALE project

OBJECTIVE

To investigate and compare the associations between dietary patterns and mortality using different European indexes of overall dietary quality.

DESIGN, SETTING AND PARTICIPANTS

The HALE (Healthy Ageing: a Longitudinal study in Europe) population includes 2,068 men and 1,049 women, aged between 70 and 90 years of 10 European countries. Subjects were followed for 10 years. This cohort study was conducted between 1988 and 2000.

RESULTS

During the follow-up period, 1,382 people died. The Mediterranean Diet Score (MDS) (HR: 0.82 with 95% CI: 0.75-0.91), the Mediterranean Adequacy Index (MDI) (HR: 0.83 with 95% CI: 0.75-0.92) and the Healthy Diet Indicator (HDI)(HR: 0.89 with 95% CI: 0.81-0.98) were inversely associated with all-causes mortality. Adjustments were made for age, gender, alcohol consumption, physical activity, smoking, number of years of education, body mass index, chronic diseases at baseline and study centre.

CONCLUSIONS

The MDS, the MDI and the HDI were significantly inversely related with mortality.

SPONSORSHIP

This study is based on data of the HALE project and supported by a grant from the European Union (QLK6-CT-2000-00211) to D Kromhout.

Nutritional deficiency in general practice: a systematic review

OBJECTIVE

Nutritional deficiency is an independent risk factor for mortality. Despite its clinical relevance, the prevalence in a primary care setting is poorly documented. We performed a systematic review of reported prevalence and clinical assessment of nutritional deficiency in general practice.

METHODS

From MEDLINE, Current Contents and EMBASE, we derived articles and checked the initially included ones for references on prevalence data. Of the eligible articles, we assessed the quality of research and results.

RESULTS

We finally included eight studies. The prevalence ranged from 0 to 13%. However, the study populations were heterogeneous and all studies contained methodological flaws, especially selection bias. In addition, the clinical assessment differed between studies.

CONCLUSION

Literature on the prevalence of nutritional deficiency within general practice is rare and provides disputable prevalence assessments.

Nutritional deficiency in Dutch primary care: data from general practice research and registration networks

OBJECTIVE

To explore incidence and prevalence rates of nutritional deficiency in adults in general practice.

METHODS

Six Dutch general practice research and registration networks supplied incidence and prevalence rates of nutritional deficiency by the International Classification of Primary Care (ICPC) or 'E-list' labels ('loss of appetite, feeding problem adult, iron, pernicious/folate deficiency anaemia, vitamin deficiencies and other nutritional disorders, weight loss'). In case of disease-related nutritional deficiency, we asked whether this was labelled separately ('co-registered') or included in the registration of the underlying disease.

RESULTS

'Iron deficiency anaemia' had highest incidence (0.3-8.5/1000 person years), and prevalence rates (2.8-8.9/1000 person years). Nutritional deficiency was mostly documented in the elderly. In two networks 'co-registration' was additional, two only documented the underlying disease and two did not specify 'co-registration'. No clear difference was found between networks considering the difference in 'co-registration'.

CONCLUSION

Nutritional deficiency is little documented in general practice, and generally is not registered separately from the underlying disease.

Homocysteine and cognitive function in institutionalised elderly A cross-sectional analysis

BACKGROUND

Several cross-sectional, case-control and prospective studies revealed a relation between homocysteine and cognitive function or dementia. These studies included either patient populations or healthy, community- dwelling elderly people.

AIM OF THE STUDY

In this study we tested the hypothesis that homocysteine was inversely associated with cognitive function in a population of institutionalised elderly (aged >/= 60 y; n = 157).

METHODS

For testing this hypothesis baseline data of a recently conducted intervention study in institutionalised elderly (median age 83 years) were used. Cognitive function was evaluated by the cognitive subscale of the Alzheimer's disease Assessment Scale (ADAS-cog). The association between fasting plasma homocysteine level and cognitive function was investigated by multiple linear regression analysis.

RESULTS

In the crude model homocysteine concentration was not significantly related to ADAS-cog score (beta = 0.061; p = 0.45). Age was found to be related to ADAS-cog score (beta = 0.161; p < 0.05). Adjusting for age did however not result in a relation between homocysteine and cognitive function.

CONCLUSIONS

In our study no association was found between homocysteine and cognitive function in a population of very old institutionalised subjects.

Role of social support in lifestyle-focused weight management interventions

Social support is important to achieve beneficial changes in risk factors for disease, such as overweight and obesity. This paper presents the theoretical and practical framework for social support, and the mechanisms by which social support affects body weight. The theoretical and practical framework is supported with a literature review addressing studies involving a social support intervention for weight loss and weight loss maintenance. A major aspect in social support research and practice is the distinction between structural and functional support. Structural support refers to the availability of potential support-givers, while functional support refers to the perception of support. Interventions often affect structural support, for example, through peer groups, yet functional support shows a stronger correlation with health. Although positive correlations between social support and health have been shown, social support may also counteract health behaviour change. Most interventions discussed in this review showed positive health outcomes. Surprisingly, social support was clearly defined on a practical level in hardly any studies, and social support was assessed as an outcome variable in even fewer studies. Future social support intervention research would benefit from clear definitions of social support, a clear description of the intended mechanism of action and the actual intervention, and the inclusion of perceived social support as a study outcome.

Inactivity and weight loss: effective criteria to identify frailty

The effectiveness was examined of inactivity and weight loss as criteria to identify a frail subgroup within independently living elderly persons participating in the SENECA study (Survey in Europe on Nutrition and the Elderly, a Concerted Action). Eight-hundred-forty-nine participants (aged 75 to 80) from nine countries were classified in four subgroups: 1) inactive elderly (lowest tertile activity score: n = 204); 2) weight losing elderly (lowest quintile: * 6.3% weight loss over 4-5 years: n = 108); 3) both inactive and weight losing (n = 54); 4) neither inactive nor weight losing: reference (n = 483). Differences in health, physical functioning and nutritional characteristics between groups 1, 2 and 3 respectively, and the reference group were evaluated. Compared to the weight-stable, active reference group, both inactive, weight losing (group 3) and inactive subjects (group 1) reported significantly more chronic diseases (2.2 and 1.8 vs. 1.1), disabilities (81 and 80 vs. 43%), use of medications (both 2.3 vs. 1.1) and care services (26 and 21 vs. 6%), and a lower self-rated health (2.8 and 3.1 vs. 3.8), relative health (1.9 and 2.1 vs. 2.6), and physical performance score (17 and 18 vs. 22). In addition, inadequate micronutrient intake and biochemical deficiencies were more prevalent. Weight-losing elderly were not significantly different from the reference group with respect to these characteristics. Therefore, physical inactivity alone or in combination with weight loss seems to be a practical and inexpensive screening criterion for identifying a subgroup of elderly with less favourable health and nutritional characteristics and poorer physical functioning among non-institutionalised elderly.

[Nutrition and health--vitamin supplementation and the vitality of the elderly]

The increasing number of elderly people above 65 years of age is extremely heterogeneous with regard to sickness and health. As a result, the nutritional needs and food consumption also vary. 'Anorexia of aging', leading to nutritional deficiencies, is a common syndrome in the elderly people and may be either caused by or result in loss of functions and accelerated aging. Early detection of malnutrition and intervention with supplements or an adequate diet should stop the negative health spiral. A limited number of intervention trials, including Dutch ones, have demonstrated a positive effect on the nutritional and immune status. However, the improvement in physical and mental functions as a result of supplementation is less clear. The results of larger current trials on the effect of supplementation with, for example, vitamin D, folic acid, vitamin B12 and complete enriched products will provide more clarity in the future on the necessity of supplementation for elderly people.

Screening of nutritional status in The Netherlands

BACKGROUND AND AIMS

In 2001, the Dutch Dietetic Association conducted a national screening on malnutrition. The goal of this screening was to determine the prevalence of disease-related malnutrition in The Netherlands in all fields of medical care and to investigate the involvement of the dietitian in the treatment of malnutrition.

METHODS

Eight thousand five hundred and twenty nine patients were screened of which data of 7606 patients could be analysed. Eighty one per cent (6150) of the patients were hospital patients. Eleven per cent (808) of the patients lived in a nursing home. Seven per cent (533) of the patients were home-care patients, who were measured at home or at the general practitioner's office. The origin of 115 patients (2%) was not registered. Age, height, weight, unintentional weight loss, kind of illness and intervention by a dietitian were registered. Malnutrition was defined as >10% unintentional weight loss during the past 6 months and risk of malnutrition was defined as 5-10% unintentional weight loss during the past 6 months.

RESULTS

Twelve per cent (884) of all patients appeared to be malnourished. Thirteen per cent (962) were at risk of malnutrition and 75% (5760) were well nourished. Fifty four per cent of the malnourished patients were referred to a dietitian. Oncological disease was more associated with malnutrition than non-oncological disease (in particular in the head and neck, lung and intestinal areas). Also, non-oncological gastro-intestinal and lung disease patients were often categorised as malnourished. Elderly patients (>75 years) were more at risk of malnutrition. BMI and unintentional weight loss did not correlate well.

CONCLUSION

In this national survey conducted by dietitians, including a convenience sample of mainly institutionalised patients, approximately 25% of patients in all medical fields were categorised as moderately or severely malnourished. About half of these patients were seen by a dietitian.

Undernutrition in the European SENECA studies

The SENECA study, which sampled a cohort of community-dwelling persons born between 1913 and 1918 in 12 European countries in baseline (1988), follow up (1993), and final (1999) surveys, found a relatively high risk of malnutrition despite a low prevalence of actual malnourishment. The results point out the importance of monitoring nutritional status in healthy elderly adults.

[The multidisciplinary guidelines on nutrition for patients indicated for nursing home care, 2001]

This article describes the most important aspects of these guidelines. The guidelines are composed of two complementary lines of care. The first line focusses on the basic nutritional care in nursing homes and the second specifically on the patient with nutritional problems. The purpose is to help nursing homes in formulating a sensible and patient-centred nutritional policy; and to realize alertness on nutritional problems in patients, so that necessary interventions can be undertaken in time. Attention is also paid to the importance of an adequate implementation of the guidelines.

Life style characteristics associated with nutritional risk in elderly subjects aged 80-85 years

A logistic regression model was applied to 627 elderly men and women, who participated in all three data collections of the SENECA study in 1989, 1993, and 1999, to test the hypothesis that nutritional status in 80-85 year old persons was related to functional and cognitive status, but not significantly affected by living arrangement. Additionally, the authors hypothesized that relationships between cognitive status and self-care ability, between self-care ability and living situation, and between cognitive status and living situation would be stronger with increasing age. Nutritional status was categorized as being well nourished (> or = 24) or at nutritional risk (<24) using the 18-item mini-nutritional assessment questionnaire (MNA). Diminished self-care ability was defined as inability to perform all 7 self-care items on the ADL instrument. Respondents were deemed to have possible cognitive impairment if they scored <24 on the MMSE test. Residence situation was categorized as either living alone, with spouse/partner, or with others. Nutritional risk was found to be associated with diminished cognitive status and diminished self-care ability, but not associated with living alone. Elderly people with diminished cognitive function and diminished self-care ability had a more than two times higher risk of being at nutritional risk. In addition, the strength of relationships between cognitive status and self-care ability, self-care ability and living situation, and cognitive ability and living situation all increased over time. In the oldest old lifestyle characteristics and functional ability appeared to be stronger predictors of risk for malnutrition than in younger adults.

Physical exercise or micronutrient supplementation for the wellbeing of the frail elderly? A randomised controlled trial

OBJECTIVE

To examine the effects of 17 weeks of physical exercise and micronutrient supplementation on the psychological wellbeing of 139 independently living, frail, elderly subjects (inactive, body mass index < or =25 or experiencing weight loss).

METHODS

Participants (mean (SD) age 78.5 (5.7)) were randomly assigned to: (a) comprehensive, moderate intensity, group exercise; (b) daily micronutrient enriched foods (25-100% recommended daily amount); (c) both; (d) neither. A social programme and identical regular foods were offered as attention control and placebo.

RESULTS

At baseline, moderate to low but significant correlations were found between general wellbeing scores and physical fitness (r = 0.28), functional performance (r = 0.37), and blood concentrations of pyridoxine (r = 0.20), folate (r = 0.25), and vitamin D (r = 0.23) (all p values < or =0.02), but not with physical activity levels and other blood vitamin concentrations. General wellbeing score and self rated health were not responsive to 17 weeks of exercise or nutritional intervention.

CONCLUSION

Psychological wellbeing in frail elderly people was not responsive to 17 weeks of intervention with exercise and/or micronutrient enriched foods. The moderate but significant correlations between wellbeing and physical fitness and several blood vitamin concentrations at baseline suggest that changes in wellbeing may occur after long term interventions.

Can dietary factors explain differences in serum cholesterol profiles among different ethnic groups (Chinese, Malays and Indians) in Singapore?

In Singapore. there exists differences in risk factors for coronary heart disease among the three main ethnic groups: Chinese, Malays and Indians. This study aimed to investigate if differences in dietary intakes of fat, types of fat, cholesterol, fruits, vegetables and grain foods could explain the differences in serum cholesterol levels between the ethnic groups. A total of 2408 adult subjects (61.0% Chinese, 21.4% Malays and 17.6% Indians) were selected systematically from the subjects who took part in the National Health Survey in 1998. The design of the study was based on a cross-sectional study. A food frequency questionnaire was used to assess intakes of energy, total fat, saturated fat, polyunsaturated fat, monounsaturated fat, cholesterol, fruits, vegetables and cereal-based foods. The Hegsted score was calculated. Serum total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol were analysed and the ratio of total cholesterol to high density lipoprotein cholesterol was computed. The results showed that on a group level (six sex-ethnic groups), Hegsted score, dietary intakes of fat, satutrated fat, cholesterol, vegetables and grain foods were found to be correlated to serum cholesterol levels. However, selected dietary factors did not explain the differences in serum cholesterol levels between ethnic groups when multivariate regression analysis was performed, with adjustment for age, body mass index, waist-hip ratio, cigarette smoking, occupation, education level and physical activity level. This cross-sectional study shows that while selected dietary factors are correlated to serum cholesterol at a group level, they do not explain the differences in serum cholesterol levels between ethnic groups independently of age, obesity, occupation, educational level and other lifestyle risk factors.

Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients

OBJECTIVES

To evaluate the acceptance of a multinutrient liquid nutrition supplement in psycho-geriatric nursing home patients and the effect on weight, plasma nutrients and activities of daily life.

DESIGN

Double-blind, placebo-controlled 12-week intervention study.

SETTING

Two nursing homes in Boxtel, The Netherlands.

SUBJECTS

Forty-two (body mass index (BMI) <23 kg/m2 for men or <25 kg/m2 for women) psycho-geriatric nursing home patients aged 60 y or over.

INTERVENTIONS

Provision with a complete micronutrient-enriched liquid nutrition supplement of 125 ml and 0.6 MJ (135 kcal) or placebo twice daily during daytime between main meals. Study parameters were assessed at 0, 6 and 12 weeks. MAIN OUTCOME FOR MEASURES: Weight, Barthel index of daily activities, several plasma values (albumin, C-reactive protein (CRP), homocysteine, thiamine, thiamine diphosphate (TDF), vitamin B6, vitamin B12, folic acid, vitamin D), bowel function.

RESULTS

The supplement was well accepted. Thirty-five patients completed the intervention period (16 control group; 19 supplement group). Baseline daily nutrient intake was low. A statistically significant improvement was observed for body weight (difference between groups 2.2 kg, P=0.03), and homocysteine, vitamin B1, TDF, vitamin B6, vitamin B12, folate and vitamin D in the supplement group compared to the placebo group. No significant difference was observed in the Barthel index (mean difference -0.3+/-1.1 for both groups). No difference in occurrence of diarrhoea was observed.

CONCLUSIONS

The study shows that nutritional supplementation is well accepted and can improve the nutritional status of psycho-geriatric nursing home patients.

SPONSORSHIP

Numico Research BV.

Body weight recovery, eating difficulties and compliance with dietary advice in the first year after stem cell transplantation: a prospective study

Among healthcare professionals there is no consensus about the best policy to increase oral intake and promote recovery in the post-hospital phase after bone marrow or blood stem cell transplantation. In order to evaluate body weight recovery and compliance with dietary advice among these patients, we performed a prospective longitudinal study in the first year post transplant. At five time intervals (days 50, 75, 125, 200 and 350) patients received a nutritional questionnaire with items on nutrition-related symptoms, physical condition, body weight recovery and compliance with dietary advice. From the initial cohort of 135 patients 69 completed the study. Prevalence of eating difficulties was high (66% at day 50). Anorexia, dry mouth, altered taste, nausea and tiredness were the symptoms most strongly associated with eating difficulties. Compliance with dietary advice was poor. Conditioning regimen was found to be a prognostic factor for body weight status at day 350. In more than 50% of the TBI-treated patients body weight was not restored to 95% of the pretreatment value within 1 year after transplant. Future studies should focus on increasing energy and protein intake in the TBI-treated subgroup.

Evaluation of dietary quality in relationship to nutritional and lifestyle factors in elderly people of the US Framingham Heart Study and the European SENECA study

OBJECTIVE

To evaluate dietary quality of European and American elderly subjects using different derivatives of dietary patterns (dietary scores and clusters) and to investigate the relationship of these approaches to nutritional and lifestyle factors.

DESIGN

Data from the cross-sectional SENECA baseline study and Framingham Heart Study (original cohort and offspring) were used for data analysis. Food intake data were summarised into dietary clusters and into dietary scores (Healthy Diet Indicator and Mediterranean Diet Score). These measures of dietary quality were then tested for associations with lifestyle factors and measures of nutritional status.

SUBJECTS/SETTING

The study population, aged 70-77 y, consisted of 828 subjects from Framingham, MA (USA) and 1282 subjects from the following European centres: Hamme, Belgium; Roskilde, Denmark; Padua, Italy; Culemborg, The Netherlands; Vila Franca de Xira, Portugal; Betanzos, Spain; and Yverdon, Burgdorf and Bellinzona, Switzerland.

RESULTS

Dietary intake varied widely across the European and American research centres. In general, Southern European centres and Framingham had higher mean diet scores, indicating a higher dietary quality, than Northern European centres (MD-scores: 4.2-4.4 vs 2.7-3.5). Cluster analysis identified the following five dietary patterns characterised by: (1) sugar and sugar products; (2) fish and grain; (3) meat, eggs and fat; (4) milk and fruit; and (5) alcohol intake. The meat, eggs and fat pattern had significantly lower average dietary quality, as measured with all three diet scores than all other groups except the alcohol group. The fish and grain group had significantly better Mediterranean diet scores than all other groups.

CONCLUSIONS

Dietary scores and dietary clusters are complementary measures to classify dietary quality. The associations with nutritional and lifestyle factors indicate the adequate categorisation into dietary quality groups.

SPONSORSHIP

European Union, US Department of Agriculture, Agriculture Research Service, under agreement (58-1950-9-001), Haak Bastiaanse-Kuneman Foundation.

Relationships between indices of obesity and its co-morbidities in multi-ethnic Singapore

OBJECTIVE

To investigate the effect of body mass index (BMI) and body fat distribution as measured by waist-to-hip ratio (WHR) on the cardiovascular risk factor profile of the three major ethnic groups in Singapore (Chinese, Malay and Indian people) and to determine if WHO recommended cut-off values for BMI and WHR are appropriate for the different sub-populations in Singapore.

DESIGN

Cross-sectional population study.

SUBJECTS

A total of 4723 adult subjects (64% Chinese individuals, 21% Malay individuals and 15% Indian individuals) were selected through a multi-staged sampling technique to take part in the National Health Survey in 1998.

MEASUREMENTS

Data on socio-economic status (education level, occupation, housing type) and lifestyle habits (smoking and physical activity), body weight, body height, waist and hip circumferences and blood pressure measured using standardised protocols. Fasting venous blood samples were obtained for determination of serum total cholesterol (TC), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides (TG). Venous blood samples were taken for 2 h oral glucose tolerance test (2 h glu).

RESULTS

Absolute and relative risks for at least one cardiovascular risk factor (elevated TC, elevated TC/HDL ratio, elevated TG, hypertension and diabetes mellitus) were determined for various categories of BMI and WHR. At low categories of BMI (BMI between 22 and 24 kg/m(2)) and WHR (WHR between 0.80 and 0.85 for women, and between 0.90 and 0.95 for men), the absolute risks are high, ranging from 41 to 81%. At these same categories the relative risks are significantly higher compared to the reference category, ranging from odds ratio of 1.97 to 4.38. These categories of BMI and WHR are all below the cut-off values of BMI and WHR recommended by WHO.

CONCLUSIONS

The results show that, at relatively low BMI and WHR, Singaporean adults experience elevated levels of risks (absolute and relative) for cardiovascular risk factors. These findings, in addition to earlier reported high percentage body fat among Singaporeans at low levels of BMI, confirm the need to revise the WHO cut-off values for the various indices of obesity and fat distribution, viz BMI and WHR, in Singapore.

Are levels of bone turnover related to lower bone mass of adolescents previously fed a macrobiotic diet?

Dutch adolescents who consumed a macrobiotic (vegan-type) diet in early life, demonstrate a lower relative bone mass than their omnivorous counterparts. We investigated whether subjects from the macrobiotic group showed signs of catching up with controls in terms of relative bone mass, reflected by higher levels of serum osteocalcin and alkaline phosphatase and lower levels of urinary cross-links. Group differences in calciotropic hormones and mineral excretion were also investigated. Bone measurements, blood, and urine samples were obtained from 69 macrobiotic (34 girls, 35 boys) and 99 control (57 girls, 42 boys) subjects, aged 9-15. Bone turnover markers and 1,25(OH)2D reached maximal levels at pubertal stages 3-4, and decreased thereafter. After adjusting for puberty, age, and lean body mass, no group differences were found in markers of bone turnover, 1,25(OH)2D, PTH, or calcium excretion, but phosphate excretion was 23% lower in macrobiotic girls. After adjustment for puberty, 1,25(OH)2D was positively related to osteocalcin. In summary, we found no evidence for group differences in bone turnover, or catch up in relative bone mass, which might be due to the fact that 60% of subjects were still in early stages of puberty.

Basal metabolic rate in children with a solid tumour

OBJECTIVE

To study the level of and changes in basal metabolic rate (BMR) in children with a solid tumour at diagnosis and during treatment in order to provide a more accurate estimate of energy requirements for nutritional support.

DESIGN

An observational study.

SETTING

Tertiary care at the Centre for Paediatric Oncology, University Hospital Nijmegen.

SUBJECTS

Thirteen patients were recruited from a population of patients visiting the University Hospital Nijmegen for treatment. All patients asked to participate took part in and completed the study.

INTERVENTION

BMR was measured by indirect calorimetry, under stringent, standardised conditions, for 20 min and on three different occasions in all patients. Continuous breath gas analysis using a mouthpiece was performed. Weight, height and skinfold measurements were performed before each measurement.

MAIN OUTCOME MEASURES

BMR was expressed as percentage of the estimated reference value, according to the Schofield formulas based on age, weight and sex, and in kJ (kcal) per kg of fat-free mass.

RESULTS

At diagnosis, the BMR was higher than the estimated reference BMR in all patients and 44% of the patients were considered hypermetabolic. Mean BMR (as percentage of reference) was significantly increased (11.6% (s.d. 6.7%); P=0.001), but decreased during treatment in 12 of the 13 patients (mean decrease 12.7% (s.d. 3.9%); P<0.0001). Furthermore, a significant negative correlation (P=-0.67; P=0.01) was found between the change in BMR and tumour response.

CONCLUSIONS

These data suggest that the BMR of children with a solid tumour is increased at diagnosis and possibly during the first phase of oncologic treatment. This may be important when determining energy requirements for nutritional support.

The role of street foods in the dietary pattern of two low-income groups in Nairobi

OBJECTIVES

To examine the frequency of street food consumption of people living in low-income settlements in Nairobi and the role of street foods in their daily diet and to reveal why people consume street foods rather than home-prepared foods. SETTING, SUBJECTS AND METHODS: A cross-sectional descriptive study was done with 1011 households and in-depth interviews with a subsample of 73 households in two selected areas in Nairobi: Korogocho, a low-income slum area and Dandora, a low-middle-income area.

RESULTS

The frequency of street food consumption was higher in Korogocho than in Dandora (3.6 vs 2.0 days per week; P<0.001). Street food consumption did not differ between different types of households, with the exception of household size. Employment status of the household head and street food consumption were related (P<0.001): consumption frequency of 3.7 days per week when irregularly or unemployed, 2.9 days/week when self-employed and 2.1 days/week when regularly employed. Furthermore, where an adult woman with primarily a domestic role was present, street food consumption was less (2.55 days per week when present vs 2.95 when not present; P<0.05).

CONCLUSIONS

Street foods play an important role in the diet of poor households in Nairobi, in particular for breakfast and snacks, because they are cheap and convenient. The frequency of street food consumption is determined by a combination of at least four factors: level of household income; regularity of income; household size; and time available to prepare meals.

SPONSORSHIP

The project is financed by the Netherlands Foundation for the Advancement of Tropical Research (WOTRO), filenumber WV 96-153.

Body fat measurement among Singaporean Chinese, Malays and Indians: a comparative study using a four-compartment model and different two-compartment models

This cross-sectional study compared body fat percentage (BF%) obtained from a four-compartment (4C) model with BF% from hydrometry (using 2H2O), dual-energy X-ray absorptiometry (DXA) and densitometry among the three main ethnic groups (Chinese, Malays and Indians) in Singapore, and determined the suitability of two-compartment (2C) models as surrogate methods for assessing BF% among different ethnic groups. A total of 291 subjects (108 Chinese, seventy-six Malays, 107 Indians) were selected to ensure an adequate representation of age range (18-75 years) and BMI range (16-40 kg/m2) of the general adult population, with almost equal numbers from each gender group. Body weight was measured, together with body height, total body water by 2H2O dilution, densitometry with Bodpod and bone mineral content with Hologic QDR-4500. BF% measurements with a 4C model for the subgroups were: Chinese females 33.5 (sd 7.5), Chinese males 24.4 (sd 6.1), Malay females 37.8 (sd 6.3), Malay males 26.0 (sd 7.6), Indian females 38.2 (sd 7.0), Indian males 28.1 (sd 5.5). Differences between BF% measured by the 4C and 2C models (hydrometry, DXA and densitometry) were found, with underestimation of BF% in all the ethnic-gender groups by DXA of 2.1-4.2 BF% and by densitometry of 0.5-3.2 BF%). On a group level, the differences in BF% between the 4C model and 2H2O were the lowest (0.0-1.4 BF% in the different groups), while differences between the 4C model and DXA were the highest. Differences between the 4C model and 2H2O and between the 4C model and DXA were positively correlated with the 4C model, water fraction (f(water)) of fat-free mass (FFM) and the mineral fraction (f(mineral)) of FFM, and negatively correlated with density of the FFM (D(FFM)), while the difference between 4C model and densitometry correlated with these variables negatively and positively respectively (i.e. the correlations were opposite). The largest contributors to the observed differences were f(water) and D(FFM). When validated against the reference 4C model, 2C models were found to be unsuitable for accurate measurements of BF% at the individual level, owing to the high errors and violation of assumptions of constant hydration of FFM and D(FFM) among the ethnic groups. On a group level, the best 2C model for measuring BF% among Singaporeans was found to be 2H2O.

Health effect of improved meal ambiance in a Dutch nursing home: a 1-year intervention study

BACKGROUND

The aim of this study was to determine the effect of an improved ambiance of food consumption on health and nutritional status of Dutch nursing home elderly residents (n = 38) in a 1-year intervention study.

METHODS

A parallel group intervention study was performed. Improvement of ambiance focused on three points: (1) physical environment and atmosphere of the dining room, (2) food service, (3) organization of the nursing staff assistance. Dietary intake, biochemical indicators of nutritional and health status and quality of life (Sickness Impact Profile and Philadelphia Geriatric Center Moral Scale) were assessed at baseline and after 1 year of intervention. Body weight, used as an indicator of compliance and nutritional status, was assessed every 4 months.

RESULTS

Twenty-two subjects completed the 1-year intervention trial. Mean body weight significantly increased (+3.3 kg, P < 0.05) in the experimental group (n = 12), not in the control group (-0.4 kg, P = 0.78; n = 10). Health status biochemical indicators and the SIP score remained stable in the experimental group, indicating relatively stable health conditions. On the contrary, negative changes in the control group suggested a decline in health status. Dietary intake, which was insufficient at baseline, increased in both groups.

CONCLUSIONS

This study showed that improving the ambiance of food consumption is a non-negligible issue for improving nutritional status and stabilizing health of nursing home residents.

Appraisal of 4 months' consumption of nutrient-dense foods within the daily feeding pattern of frail elderly

OBJECTIVES

The appraisal and acceptance of micronutrient-dense versus identical regular foods among frail elderly are described.

METHODS

Four types of dairy and four types of fruit products, either enriched with multiple micronutrients or not, were consumed by 150 frail elders for 4 months. In the first 2 and last 2 weeks of the intervention, hedonic aspects were assessed. Afterward, evaluation forms were completed.

RESULTS

At the start, small but consistent differences existed between the enriched and the regular foods concerning the scores on pleasantness, desire to eat the product, and attitude toward the product. At the end, those ratings dropped slightly or stayed equal. Significant differences between groups emerged from the overall evaluation score: 6.4 plus or minus 1.6 and 7.7 plus or minus 1.7 respectively (p <.001).

DISCUSSION

Optimization of the hedonic parameters of nutrient-dense foods and major long-term attention for application in the daily elderly feeding pattern is of essential importance.

Meeting nutrient and energy requirements in old age

In old age, the complex relation of food consumption with energy and nutrient requirements finds expression in both single and multiple nutritional problems. Addressing conditions affecting intake -- either from foods or from supplements -- endogenous production, bioefficacy and/or requirements can benefit nutritional health in old age through balancing requirements and supply.

Nutrient-dense foods and exercise in frail elderly: effects on B vitamins, homocysteine, methylmalonic acid, and neuropsychological functioning

BACKGROUND

Frail elders are at risk of suboptimal micronutrient status, functional decline, and neurologic disorders. The influence of oral multimicronutrients in physiologic doses and of moderately intense physical exercise on homocysteine (Hcy), methylmalonic acid (MMA), and neurologic functioning have not yet been investigated.

OBJECTIVE

Our goal was to determine the effects of enriched foods and exercise on blood vitamins, Hcy, MMA, and neuropsychological functioning in the frail.

DESIGN

A 17-wk randomized controlled intervention trial was used to study 1) enriched foods plus a social program, 2) regular foods plus exercise, 3) enriched foods plus exercise, and 4) regular foods plus a social program. Enriched foods contained multiple micronutrients (25-100% of the Dutch recommended dietary allowances); exercises focused on strength, coordination, flexibility, and endurance. Vitamin (cobalamin, red blood cell folate, and pyridoxal 5'-phosphate), Hcy, and MMA concentrations were measured and 2 neuropsychological tests were conducted.

RESULTS

Vitamin concentrations were higher in the supplemented groups than in the unsupplemented groups (P < 0.001; total n = 130). Compared with baseline, cobalamin in the supplemented groups was increased by 22%, plasma folate by 101%, red blood cell folate by 87%, and pyridoxal 5'-phosphate by 68%. Concentrations in the unsupplemented groups changed by -2%, -6%, 1%, and -13%, respectively. Hcy decreased by 25% and MMA by 30% in the supplemented groups, compared with a small increase in Hcy (2%) and decrease in MMA (9%) in the unsupplemented groups. Exercise did not significantly affect vitamin, Hcy, or MMA concentrations. No significant effect of either intervention was observed on the neuropsychological tests.

CONCLUSIONS

The decrease in Hcy and MMA in frail elders confirms a subclinical metabolic deficiency state. Enriched foods containing physiologic amounts of micronutrients have a beneficial effect on these metabolites. No effects of B vitamins on mental health were identified.

Nasogastric tube feeding in children with cancer: the effect of two different formulas on weight, body composition, and serum protein concentrations

BACKGROUND

Treatment of cancer cachexia partly involves the administration of adequate amounts of energy. The aim of this study was to assess the tolerance and efficacy of two equal volumes of tube feeding, one with a standard (1 kcal/mL) and one with a high energy density (1.5 kcal/mL), during the intensive phase of treatment.

METHODS

Nutritional status was assessed weekly, in 27 children with a solid tumor, by measuring weight, height, midupper arm circumference, biceps and triceps skinfold, and serum proteins. Tolerance was assessed by recording the occurrence of vomiting and by expressing the administered volume as a percentage of the required volume.

RESULTS

Both formulas were equally well tolerated, leading to a significantly higher energy intake in the energy-enriched formula group. In both formula groups, all anthropometric variables increased significantly (range of mean increase, 5.2% to 25.5%; p < .05) during the first 4 weeks of intervention. Between 4 and 10 weeks, variables continued to increase significantly in the energy-enriched group, resulting in adequate repletion, in contrast to the standard formula group. The concentration of serum proteins, low at initiation of tube feeding, returned to the normal range within 2 to 4 weeks with no significant differences between the two groups.

CONCLUSIONS

The energy-enriched formula was more effective in improving the nutritional status of children with cancer during the intensive phase of treatment than the standard formula. Intensive, protocolized administration of an energy-enriched formula should therefore be initiated as soon as one of the criteria for initiation of tube feeding is met.

Association between the change in nutritional status in response to tube feeding and the occurrence of infections in children with a solid tumor

In 32 children with a solid tumor, the association between the change in weight for height, in response to 4 weeks of tube feeding during the intensive phase of treatment, and the occurrence of leukopenia, leukopenic infections, and nonleukopenic infections in a period thereafter (4-10 weeks) was studied. Factors possibly influencing the change in weight for height during the first 4 weeks of tube feeding were also assessed. A statistically significant negative correlation (rho = -0.59; p < .001) was found between the change in z-score of weight for height in response to the first 4 weeks of tube feeding, and the occurrence of nonleukopenic infections between 4 and 10 weeks. A reduced occurrence of nonleukopenic infections resulted in a significant reduction of the number of days of infection-related hospital admission (rho = .45; p = .009), which, besides providing advantages for the patient, also had economical benefits. The change in weight for height in response to tube feeding was mainly influenced by the incidence of therapy-induced vomiting (r = -.45; p = .02) and by the amount of energy provided by tube feeding (r = .47; p = .007). Based on these findings, it is recommended that naso-gastric tube feeding be used in children with a solid tumor during the early intensive phase of treatment, and that one should aim for a considerable increase in weight for height during the first 4 weeks of administration, since this has been shown to reduce the number of nonleukopenic infections in a subsequent period. The increase in weight for height may be improved by providing an optimal antiemetic protocol, which will increase energy uptake, and an energy-enriched formula, which will increase energy intake.

Signs of impaired cognitive function in adolescents with marginal cobalamin status

BACKGROUND

Lack of cobalamin may lead to neurologic disorders, which have been reported in strict vegetarians.

OBJECTIVE

The objective of this study was to investigate whether cognitive functioning is affected in adolescents (aged 10-16 y) with marginal cobalamin status as a result of being fed a macrobiotic diet up to an average age of 6 y.

DESIGN

Data on dietary intake, psychological test performance, and biochemical variables of cobalamin status were collected from 48 adolescents who consumed macrobiotic (vegan type) diets up to the age of 6 y, subsequently followed by lactovegetarian or omnivorous diets, and from 24 subjects (aged 10-18 y) who were fed omnivorous diets from birth onward. Thirty-one subjects from the previously macrobiotic group were cobalamin deficient according to their plasma methylmalonic acid concentrations. Seventeen previously macrobiotic subjects and all control subjects had normal cobalamin status.

RESULTS

The control subjects performed better on most psychological tests than did macrobiotic subjects with low or normal cobalamin status. A significant relation between test score and cobalamin deficiency (P: = 0.01) was observed for a test measuring fluid intelligence (correlation coefficient: -0.28; 95% CI: -0.48, -0.08). This effect became more pronounced (P: = 0.003) within the subgroup of macrobiotic subjects (correlation coefficient: -0.38; 95% CI: -0.62, - 0.14).

CONCLUSION

Our data suggest that cobalamin deficiency, in the absence of hematologic signs, may lead to impaired cognitive performance in adolescents.

The paradox of low body mass index and high body fat percentage among Chinese, Malays and Indians in Singapore

OBJECTIVE

To study the relationship between body fat percentage and body mass index (BMI) in three different ethnic groups in Singapore (Chinese, Malays and Indians) in order to evaluate the validity of the BMI cut-off points for obesity.

DESIGN

Cross-sectional study.

SUBJECTS

Two-hundred and ninety-one subjects, purposively selected to ensure adequate representation of range of age and BMI of the general adult population, with almost equal numbers from each ethnic and gender group.

MEASUREMENTS

Body weight, body height, sitting height, wrist and femoral widths, skinfold thicknesses, total body water by deuterium oxide dilution, densitometry with Bodpod(R) and bone mineral content with Hologic(R) QDR-4500. Body fat percentage was calculated using a four-compartment model.

RESULTS

Compared with body fat percentage (BF%) obtained using the reference method, BF% for the Singaporean Chinese, Malays and Indians were under-predicted by BMI, sex and age when an equation developed in a Caucasian population was used. The mean prediction error ranged from 2.7% to 5.6% body fat. The BMI/BF% relationship was also different among the three Singaporean groups, with Indians having the highest BF% and Chinese the lowest for the same BMI. These differences could be ascribed to differences in body build. It was also found that for the same amount of body fat as Caucasians who have a body mass index (BMI) of 30 kg/m2 (cut-off for obesity as defined by WHO), the BMI cut-off points for obesity would have to be about 27 kg/m2 for Chinese and Malays and 26 kg/m2 for Indians.

CONCLUSIONS

The results show that the relationship between BF% and BMI is different between Singaporeans and Caucasians and also among the three ethnic groups in Singapore. If obesity is regarded as an excess of body fat and not as an excess of weight (increased BMI), the cut-off points for obesity in Singapore based on the BMI would need to be lowered. This would have immense public health implications in terms of policy related to obesity prevention and management.

Determinants of macronutrient intake in elderly people

An understanding of the determinants of nutritional intake may be helpful in the early detection and prevention of malnutrition. A vast amount of literature exists on factors influencing daily energy or food intake. Although far less is known about population and subject characteristics influencing the macronutrient composition of the diet, associations appear to exist with cultural factors, snacking and disease. The literature does not provide sufficient evidence in support of relationships with other factors such as living situation, dentition, disability, depression and drug use, partly because information on determinants of macronutrient intake is scarce.

Dietary supplements and physical exercise affecting bone and body composition in frail elderly persons

OBJECTIVES

This study determined the effect of enriched foods and all-around physical exercise on bone and body composition in frail elderly persons.

METHODS

A 17-week randomized, controlled intervention trial, following a 2 x 2 factorial design--(1) enriched foods, (2) exercise, (3) both, or (4) neither--was performed in 143 frail elderly persons (aged 78.6 +/- 5.6 years). Foods were enriched with multiple micronutrients; exercises focused on skill training, including strength, endurance, coordination, and flexibility. Main outcome parameters were bone and body composition.

RESULTS

Exercise preserved lean mass (mean difference between exercisers and non-exercisers: 0.5 kg +/- 1.2 kg; P < .02). Groups receiving enriched food had slightly increased bone mineral density (+0.4%), bone mass (+0.6%), and bone calcium (+0.6%) compared with groups receiving non-enriched foods, in whom small decreases of 0.1%, 0.2%, and 0.4%, respectively, were found. These groups differed in bone mineral density (0.006 +/- 0.020 g/cm2; P = .08), total bone mass (19 +/- g; P = .04), and bone calcium (8 +/- 21 g; P = .03).

CONCLUSIONS

Foods containing a physiologic dose of micronutrients slightly increased bone density, mass, and calcium, whereas moderately intense exercise preserved lean body mass in frail elderly persons.

Effect of dietary supplements and physical exercise on sensory perception, appetite, dietary intake and body weight in frail elderly subjects

This present study investigated the effect of a 17-week intervention programme with nutrient-dense foods (enriched with vitamins and minerals at 25-100% of the Dutch recommended dietary allowance) and/or physical exercise in 159 frail elderly subjects (forty-six men, 113 women, mean age 78.7 (SD 5.6) years). Subjects were randomized into four groups: (1) control, (2) nutrition intervention, (3) exercise or (4) both nutrition intervention and exercise. Main outcome variables were sensory perception (smell test and questionnaire), appetite (questionnaire), energy intake (3 d food record) and body weight (on a weighing scale and with dual energy X-ray absorptiometry measurements). At baseline, moderate but significant correlations were found between appetite and energy intake (r 0.30, P < 0.0001), between smell test and smell perception assessed by questionnaire (r 0.40, P < 0.0001) and between lean body weight and energy intake (r 0.50, P < 0.0001). Results after 17-weeks intervention revealed neither change in smell test scores (P = 0.19) nor in appetite (P = 0.17). A slight positive effect of exercise compared with non-exercising groups on energy intake (difference 0.5 MJ, P = 0.05) was shown next to a preserving effect of exercise on lean body mass (+0.08 kg) compared with a decrease (-0.4 kg) in non-exercisers (P < 0.02). The correlation between the change in lean body mass and change in energy intake was 0.18 (P = 0.05). In conclusion, an interesting preserving effect on lean body mass in frail elderly subjects due to 17 weeks of exercise was shown. Since a decline in lean body mass was observed in the non-exercisers, effects may be attributable to change in activity pattern. Changes in lean mass were also slightly, but significantly, correlated with changes in energy intake. In turn, energy intake was not related to a change in reported appetite or sensory perception. Nutrient-dense foods were not able to improve any of the outcome variables in this study.

Short-term regulation of food intake in children, young adults and the elderly

OBJECTIVE

The present study investigated the effects of consuming preloads with different macronutrient and energy contents on subsequent intake and subjective feelings of hunger and satiety in children, young adults and the elderly.

SUBJECTS

30 Children (4-6 y), 33 young adults (18-26 y) and 24 elderly (61-86 y).

DESIGN

A 'preload test meal' design was applied. Subjects were given four different strawberry yoghurt preloads that varied in energy and macronutrient content, or no yoghurt. Children, young adults and elderly consumed 200, 340 and 300 g of the preload, respectively. One yoghurt was low-fat, low-carbohydrate and low in energy (the control; 0.7 MJ/500 g serving), one yoghurt was high-fat and medium in energy (71% of energy (en%) of fat; 2 MJ/500 g serving), one yoghurt was high-carbohydrate and medium in energy (87 en% of carbohydrate; 2 MJ/500 g serving) and the fourth yoghurt was high-fat and high-carbohydrate and high in energy (42 en% of fat and 53 en% of carbohydrate; 3 MJ/500 g serving). Ninety minutes after preload consumption, subjects had an attractive ad libitum lunch-buffet. Energy intake at lunch and subjective feelings of hunger and satiety were analysed.

RESULTS

The ability to compensate at lunch did not differ among the three age groups. Compared to the no-preload condition, all children, young adults and elderly ate significantly less after the high-fat and high-carbohydrate yoghurt. The energy compensation observed in the children ranged between -21% and 34%, in the young adults between 15% and 44% and in the elderly between 17% and 23%. Hunger responses were clearly different between young adults and the elderly. Compared to the no-preload condition, the young adults showed larger differences in their appetite ratings than the elderly, indicating that the elderly were less sensitive to the energy content of the preload than the young adults.

CONCLUSION

We conclude that the ability to regulate the food intake within a preload 90 min test meal paradigm did not differ among children, young adults and the elderly.

SPONSORSHIP

This study was funded by the European Commission as part of project FAIR-CT95-0574.

Severe linear growth retardation in rural Zambian children: the influence of biological variables

BACKGROUND

The prevalence of stunting in preschool children in Zambia is high; stunting has detrimental effects on concurrent psychomotor development and later working capacity.

OBJECTIVE

Our objective was to investigate biological variables that may contribute to linear growth retardation in preschool children in Samfya District, Zambia.

DESIGN

Children aged 6-9 mo (n = 108) and 14-20 mo (n = 102) attending mother-and-child health clinics were included. With a mixed-longitudinal design, they were followed up 9 and 21 mo later. Height and weight of children and their mothers were measured. Biochemical measures (eg, serum zinc, retinol, thyrotropin, iron, and acute phase protein concentrations), malaria parasitemia, and intestinal parasitosis were assessed.

RESULTS

Height-for-age z scores (HAZ) were low, indicating a high prevalence of stunting (36-79%). Ninety percent of the children were anemic, 53-71% had elevated acute phase proteins, and 80% had malaria parasitemia. Regression analyses showed that maternal height predicted the children's height at 6-9 mo (regression coefficient = 0.05; 95% CI: 0.02, 0.08). The children's height at an early age (6-9 and 14-20 mo) showed a strong relation with their height at later ages (22-30 and 34-41 mo). Serum micronutrient status did not show a significant relation with later HAZ.

CONCLUSION

Unlike other studies, we did not identify specific biological factors, such as health and micronutrient status, which contribute to the retardation of linear growth. The normal zinc and iodine statuses of the children suggest that at least these factors are not causal.

Nutritional status of breastfed infants in rural Zambia: comparison of the National Center for Health Statistics growth reference versus the WHO 12-month breastfed pooled data set

Cross-sectional data for breastfed infants in rural Zambia were used to evaluate the effect of applying two different data sets as a reference, i.e. the WHO 12-month breastfed pooled data set and the National Center for Health Statistics (NCHS) growth reference in terms of prevalence of malnutrition (stunting, underweight, and wasting). A total of 518 infants who were attending mother-and-child health clinics were included. Age, weight and length were recorded. Anthropometric Z-scores were calculated in two ways: by applying the NCHS growth reference and by using the WHO breastfed data set. Anthropometric Z-scores calculated using the breastfed data set were lower during the first 6-7 months of life compared with those calculated by applying the NCHS growth reference. This resulted in a higher proportion of children aged 0-6 months being classified as stunted and underweight using the breastfed data set versus the NCHS growth reference. After the age of 7 months, similar prevalences of stunting or underweight were observed. Relatively few infants were classified as wasted. In order to adequately assess the prevalence of stunting and underweight in breastfed infants, it is recommended that a new growth reference be developed, as has been initiated by WHO.

Functional biochemical and nutrient indices in frail elderly people are partly affected by dietary supplements but not by exercise

A decline in dietary intake due to inactivity and, consequently, development of a suboptimal nutritional status is a major problem in frail elderly people. However, benefits of micronutrient supplementation, all-round physical exercise or a combination of both on functional biochemical and hematologic indicators of nutritional and health status in frail elderly subjects have not been tested thoroughly. A 17-wk randomized controlled trial was performed in 145 free-living frail elderly people (43 men, 102 women, mean age, 78 +/- 5.7 y). Based on a 2 x 2 factorial design, subjects were assigned to one of the following: 1) nutrient-dense foods, 2) exercise, 3) both (1) and (2) or 4) a control group. Foods were enriched with micronutrients, frequently characterized as deficient [25-100% of the recommended daily allowance (RDA)] in elderly people. Exercises focused on skill training, including strength, endurance, coordination and flexibility. Dietary intake, blood vitamin levels and nutritional and health indicators, including (pre)albumin, ferritin, transferrin, C-reactive protein, hemoglobin and lymphocytes were measured. At baseline, 28% of the total population had an energy intake below 6.3 MJ, up to a maximum of 93% having vitamin intakes below two thirds of the Dutch RDA. Individual deficiencies in blood at baseline ranged from 3% for erythrocyte glutathione reductase-alpha to 39% for 25-hydroxy vitamin D and 42% for vitamin B-12. These were corrected after 17 wk in the two groups receiving the nutrient-dense foods, whereas no significant changes were observed in the control or exercise group. Biochemical and hematologic indicators at baseline were within the reference ranges (mean albumin, 46 g/L; prealbumin, 0.25 g/L; hemoglobin, 8.6 mmol/L) and were not affected by any of the interventions. The long-term protective effects of nutrient supplementation and exercise, by maintaining optimal nutrient levels and thereby reducing the initial chance of developing critical biochemical values, require further investigation. Other indicative functional variables for suboptimal nutritional status, in addition to those currently selected, should also be explored.

Impaired sensory functioning in elders: the relation with its potential determinants and nutritional intake

This study assessed the relation of an impaired taste and smell perception with (a) potential determinants and (b) nutritional intake and status in elderly people. Determinants examined were age, gender, functional category (institutionalized vs independently living), dental state, illnesses, smoking behavior, drug usage, and saliva excretion and composition. Nutritional intake and status were measured by an "appetite and hunger" questionnaire, a food frequency questionnaire, and body mass index (BMI). In order to have access to a large heterogeneous group, two different categories of elderly people were studied. We enrolled independently living elders (n=89) assumed to have a relatively good taste and smell perception, and institutionalized elders (n=67) with a potential poorer taste and smell perception. Scores at the smell identification (range: 0-10) and taste perception (range: 0-4) test were, respectively, 5.7 (independently living) versus 3.5 (institutionalized); p < .0001 and 3.3 versus 3.0; p < .05. Correlation between smell test scores and outcomes of the "appetite and hunger" questionnaire ranged from r: .19 to .50; p values < .05. There was, however, no clear correlation of any sensory outcome with energy and food intake, nor with BMI. Regression analyses revealed that age and the functional category were the most important determinants of the scores on the taste perception and smell identification tests. It is concluded that a poor performance on sensory tests is related to a poor appetite but not necessarily to low energy intake or low BMI. Age-related factors and smoking are important determinants of impaired sensory functioning.

Alcohol intake assessment: the sober facts

Recent recommendations in regard to the level of alcohol intake have mainly been based on epidemiologic studies which relied on self-reported amounts of alcohol consumed. Therefore, it is important to be aware of the quality of self-reported measures of alcohol intake. Alcohol intake assessment methods were reviewed with respect to their capacity to rank individuals according to alcohol intake and their ability to explain the variation in the level of intake in population samples. In 33 methodological papers published after 1984, alcohol intake was assessed by five main methods: quantity frequency, extended quantity frequency, retrospective diary, prospective diary, and 24-hour recalls. The mean level of alcohol intake differed by 20% between these methods. It was also found that when researchers asked specifically about intake of beer, wine, and liquor, this resulted in 20% higher estimates of intake. These percentages were similar among populations with low and high mean alcohol consumption (4 vs. 10 drinks per week). It was found that ranking of individuals according to intake was satisfactory, with weighted correlation coefficients between methods ranging from 0.63 to 0.73. The authors conclude that, when there is sufficient evidence that alcohol intake is underestimated in a population, methods that enquire about both the frequency and amount consumed, for beer, wine, and liquor, separately, will yield the most realistic levels of intake.

[Nutrition assessment of the elderly based on results of the SENECA Study "Nutrition and the elderly in Europe"]

The SENECA Study "Nutrition and the elderly in Europe" investigates men and women born 1913-1918 in 20 small traditional towns in Europe. At the age of 74-79 years subjective health was satisfactory or good in 95% of 399 men and 93% of 414 women in 6 study towns. In these subjects suboptimal nutritional blood values were virtually nonexistent. Food intake was low in energy and rich in protein and fat. Lowest European recommended dietary allowances were not reached by all subjects. The even higher values recommended as potentially protective factors were not met by a substantial part of subjects with energy intakes below 6.3 MJ/d. Regularity of food intake was high and had increased over 4 years. Living alone did not adversely affect food intake while low economic situation did.