Showing papers in "Public Health Nutrition in 2002"

European prospective investigation into cancer and nutrition (EPIC): study populations and data collection

Abstract: The European Prospective Investigation into Cancer and Nutrition (EPIC) is an ongoing multi-centre prospective cohort study designed to investigate the relationship between nutrition and cancer, with the potential for studying other diseases as well. The study currently includes 519 978 participants (366 521 women and 153 457 men, mostly aged 35-70 years) in 23 centres located in 10 European countries, to be followed for cancer incidence and cause-specific mortality for several decades. At enrollment, which took place between 1992 and 2000 at each of the different centres, information was collected through a non-dietary questionnaire on lifestyle variables and through a dietary questionnaire addressing usual diet. Anthropometric measurements were performed and blood samples taken, from which plasma, serum, red cells and buffy coat fractions were separated and aliquoted for long-term storage, mostly in liquid nitrogen. To calibrate dietary measurements, a standardised, computer-assisted 24-hour dietary recall was implemented at each centre on stratified random samples of the participants, for a total of 36 900 subjects. EPIC represents the largest single resource available today world-wide for prospective investigations on the aetiology of cancers (and other diseases) that can integrate questionnaire data on lifestyle and diet, biomarkers of diet and of endogenous metabolism (e.g. hormones and growth factors) and genetic polymorphisms. First results of case-control studies nested within the cohort are expected early in 2003. The present paper provides a description of the EPIC study, with the aim of simplifying reference to it in future papers reporting substantive or methodological studies carried out in the EPIC cohort.

Development, validation and utilisation of food-frequency questionnaires - a review.

Abstract: Objective: The purpose of this review is to provide guidance on the development, validation and use of food-frequency questionnaires (FFQs) for different study designs. It does not include any recommendations about the most appropriate method for dietary assessment (e.g. food-frequency questionnaire versus weighed record). Methods: A comprehensive search of electronic databases was carried out for publications from 1980 to 1999. Findings from the review were then commented upon and added to by a group of international experts. Results: Recommendations have been developed to aid in the design, validation and use of FFQs. Specific details of each of these areas are discussed in the text. Conclusions: FFQs are being used in a variety of ways and different study designs. There is no gold standard for directly assessing the validity of FFQs. Nevertheless, the outcome of this review should help those wishing to develop or adapt an FFQ to validate it for its intended use.

Validity of self-reported height and weight in 4808 EPIC-Oxford participants.

Abstract: Objective: To assess the validity of self-reported height and weight by comparison with measured height and weight in a sample of middle-aged men and women, and to determine the extent of misclassification of body mass index (BMI) arising from differences between self-reported and measured values. Design: Analysis of self-reported and measured height and weight data from participants in the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford). Subjects: Four thousand eight hundred and eight British men and women aged 35-76 years. Results: Spearman rank correlations between self-reported and measured height, weight and BMI were high (r > 0.9, P < 0.0001). Height was overestimated by a mean of 1.23 (95% confidence interval (CI) 1.11-1.34) cm in men and 0.60 (0.51-0.70) cm in women; the extent of overestimation was greater in older men and women, shorter men and heavier women. Weight was underestimated by a mean of 1.85 (1.72-1.99) kg in men and 1.40 (1.31-1.49) kg in women; the extent of underestimation was greater in heavier men and women, but did not vary with age or height. Using standard categories of BMI, 22.4% of men and 18.0% of women were classified incorrectly based on self-reported height and weight. After correcting the self-reported values using predictive equations derived from a 10% sample of subjects, misclassification decreased to 15.2% in men and 13.8% in women. Conclusions: Self-reported height and weight data are valid for identifying relationships in epidemiological studies. In analyses where anthropometric factors are the primary variables of interest, measurements in a representative sample of the study population can be used to improve the accuracy of estimates of height, weight and BMI.

An overview on the nutrition transition and its health implications: the Bellagio meeting.

Abstract: This supplement is based on papers presented at the Bellagio Conference on the Nutrition Transition. The meeting was organised to allow us to assess current lowand moderate-income industrialising countries’ experience related to the nutrition transition and provide ideas for pushing forth a broader public health agenda in this area. More specifically, the meeting focused on changes in patterns of behaviour (diet, smoking, drinking, activity) that lead to rapid increases in obesity, cardiovascular disease (CVD) and cancer. The nutrition-related noncommunicable diseases (NR-NCDs) were once referred to as diseases of affluence. For decades this has not been true among higher-income countries, and as we now show, this is increasingly not the case in the lowerand middleincome countries. Two historic processes of change occur simultaneous to or precede the nutrition transition. One is the demographic transition – the shift from a pattern of high fertility and high mortality to one of low fertility and low mortality (typical of modern industrialised countries). Even more directly relevant is the epidemiological transition, first described by Omran: the shift from a pattern of high prevalence of infectious diseases associated with malnutrition, and periodic famine and poor environmental sanitation, to a pattern of high prevalence of chronic and degenerative diseases associated with urban–industrial lifestyles. A third pattern of delayed degenerative diseases has been formulated more recently (e.g. Olshansky and Ault). Accompanying this progression is a major shift in age-specific mortality patterns and a consequent increase in life expectancy. Interpretations of the demographic and epidemiological transitions share a focus with the nutrition transition on the ways in which populations move from one pattern to the next. Similarly, large shifts have occurred in dietary and physical activity and inactivity patterns. These changes are reflected in nutritional outcomes, such as changes in average stature and body composition. Modern societies seem to be converging on a pattern of diet high in saturated fat, sugar and refined foods and low in fibre – often termed the ‘Western diet’. Many see this dietary pattern to be associated with high levels of chronic and degenerative diseases and with reduced disability-free time. These three relationships are presented in Fig. 1. Human diet and activity patterns and nutritional status have undergone a sequence of major shifts, defined as broad patterns of food use and their corresponding nutrition-related diseases. Over the last three centuries, the pace of dietary and activity change appears to have accelerated, to varying degrees in different regions of the world. Further, dietary and activity changes are paralleled by major changes in health status, as well as by major demographic and socio-economic changes. Obesity emerges early in these shifting conditions as does the level and age composition of morbidity and mortality. We can think of five broad nutrition patterns. They are not restricted to particular periods of human history. For convenience, the patterns are outlined as historical developments; however, ‘earlier’ patterns are not restricted to the periods in which they first arose but continue to characterise certain geographic and socioeconomic sub-populations.

The shift in stages of the nutrition transition in the developing world differs from past experiences

Abstract: Objective: This paper explores the unique nutrition transition shifts in diet and activity patterns from the period termed the receding famine pattern to the one dominated by nutrition-related non-communicable diseases (NR-NCDs). The paper examines the speed and timing of these changes; unique components, such as the issue of finding both under- and overnutrition in the same household; potential exacerbating biological relationships that contribute to differences in the rates of change; and political issues. Setting: The focus is on lower- and middle-income countries of Asia, Africa, the Middle East and Latin America. Results: These changes are occurring at great speed and at earlier stages of these countries’ economic and social development. There are some unique issues that relate to body composition and potential genetic factors. The significance of the high number of persons exposed to heavy insults during pregnancy and infancy (foetal origins hypothesis) and the subsequent rapid shifts in energy imbalance remains to be understood. Countries that are still addressing major concerns of undernutrition are not ready to address these NR-NCDs. Conclusions: The developing world needs to give far greater emphasis to addressing the prevention of the adverse health consequences of this shift to the nutrition transition stage of degenerative diseases.

An accelerated nutrition transition in Iran.

Abstract: Objective: To describe the emergence of the nutrition transition, and associated morbidity shifts, in the Islamic Republic of Iran. Design: Review and analysis of secondary data relating to the socio-political and nutritional context, demographic trends, food utilisation and consumption patterns, obesity, and diet-related morbidity. Results and conclusions: The nutrition transition in Iran is occurring rapidly, secondary to the rapid change in fertility and mortality patterns and to urbanisation. The transition is occurring against the backdrop of lack of sustained economic growth. There is considerable imbalance in food consumption with low nutrient density characterising diets at all income levels, over-consumption evident among more than a third of households, and food insecurity among 20% of the population. Obesity is an emerging problem, particularly in urban areas and for women, and both diabetes and other risk factors for heart disease are becoming significant problems.

Nutrition transition in India

Abstract: OBJECTIVE: The primary objective of this review is to examine the demographic and nutrition transition in India in relation to its contribution to the emerging epidemic of chronic non-communicable diseases in this country. SETTING: India, the country as a whole and its different states with a population exceeding 1 billion in 2001. SUBJECTS: The review examines demographic changes in the population with consequent effects on the population pyramid, the rapidity and rates of urbanisation with striking variations in chronic disease patterns and the trends in obesity between rural and urban communities, attempting to relate their prevalence with the diet and lifestyle changes accompanying them. DESIGN: The review is based largely on representative large-scale surveys in the country and other reliable documented data on population characteristics. It also includes a review of the published literature. RESULTS: The results indicate that the demographic changes, rates of urbanisation and changes in dietary patterns are contributing to the changing trends in chronic disease in India. CONCLUSIONS: There is clear evidence of a demographic, epidemiological and nutrition transition in India that is fuelling the epidemic of chronic diseases and obesity, particularly in the urban areas.

Epidemiological and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity.

Abstract: Objective: The objective of this paper is to characterise the epidemiological and nutritional transition and their determinants in Mexico. Design: Age-adjusted standardised mortality rates (SMRs) due to acute myocardial infarction (AMI), diabetes mellitus and hypertension were calculated for 1980‐1998. Changes in the prevalences of overweight and obesity in women and children and of dietary intake from 1988 to 1999 were also used in the analysis. Quantities of food groups purchased by adult equivalent (AE) and food expenditures away from home between 1984 and 1989 were used to assess trends. All information was analysed at the national and regional levels, and by urban and rural areas. Results: SMR for diabetes, AMI and hypertension increased dramatically parallel to obesity at the national and regional levels. Fat intake in women and the purchase of refined carbohydrates, including soda, also increased. Discussion: The results suggest that obesity is playing a role in the increased SMRs of diabetes, AMI and hypertension in Mexico. Total energy dietary intake and food purchase data could not explain the rise in the prevalence of obesity. The increases in fat intake and the purchase of refined carbohydrates may be risk factors for increased mortality. Information on physical activity was not available. Conclusion: SMRs due to diabetes, hypertension and AMI have increased dramatically in parallel with the prevalence of obesity; therefore actions should be taken for the prevention of obesity. Reliable information about food consumption and physical activity is required to assess their specific roles in the aetiology of obesity.

A new stage of the nutrition transition in China

Abstract: Objective: To fully explore the long-term shifts in the nutrition transition and the full implications of these changes in the Chinese diet. Design: A descriptive, population-based study. Setting: Data come from nationally representative surveys: the China Health and Nutrition Survey (1989‐1997), the China National Nutrition Survey (1982 and 1992), the annual household consumption surveys of the State Statistical Bureau, and the Annual Death Report of China. Results: During the first part of the major economic transformation in China (before 1985), cereal intake increased but decreased thereafter. There was also a long-term reduction of vegetable consumption that has now stabilised. Intake of animal foods increased slowly before 1979 and more quickly after the economic reforms occurred. While the total energy intake of residents has decreased, as has energy expenditure, large changes in the composition of energy have occurred. The overall proportion of energy from fat increased quickly, reaching an overall average of 27.3% and 32.8% for urban residents in 1997. Over a third of all Chinese adults and 60.1% of those in urban areas consumed over 30% of their energy from fat in 1997. Large shifts towards increased inactivity at work and leisure occurred. These changes are linked with rapid increases of overweight, obesity and diet-related non-communicable diseases (DRNCDs) as well as total mortality for urban residents. Conclusions: The long-term trend is a shift towards a high-fat, high-energy-density and low-fibre diet. The Chinese have entered a new stage of the nutrition transition.

European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study: rationale, design and population characteristics

Abstract: The European Prospective Investigation into Cancer and Nutrition (EPIC), which covers a large cohort of half a million men and women from 23 European centres in 10 Western European countries, was designed to study the relationship between diet and the risk of chronic diseases, particularly cancer Information on usual individual dietary intake was assessed using different validated dietary assessment methods across participating countries In order to adjust for possible systematic over- or underestimation in dietary intake measurements and correct for attenuation bias in relative risk estimates, a calibration approach was developed This approach involved an additional dietary assessment common across study populations to re-express individual dietary intakes according to the same reference scale A single 24-hour diet recall was therefore collected, as the EPIC reference calibration method, from a stratified random sample of 36 900 subjects from the entire EPIC cohort, using a software program (EPIC-SOFT) specifically designed to standardise the dietary measurements across study populations This paper describes the design and populations of the calibration sub-studies set up in the EPIC centres In addition, to assess whether the calibration sub-samples were representative of the entire group of EPIC cohorts, a series of subjects' characteristics known possibly to influence dietary intakes was compared in both population groups This was the first time that calibration sub-studies had been set up in a large multi-centre European study These studies showed that, despite certain inherent methodological and logistic constraints, a study design such as this one works relatively well in practice The average response in the calibration study was 783% and ranged from 465% to 925% The calibration population differed slightly from the overall cohort but the differences were small for most characteristics and centres The overall results suggest that, after adjustment for age, dietary intakes estimated from calibration samples can reasonably be interpreted as representative of the main cohorts in most of the EPIC centres

Bias in dietary-report instruments and its implications for nutritional epidemiology.

Abstract: Objective To evaluate measurement error structure in dietary assessment instruments and to investigate its implications for nutritional studies, using urinary nitrogen excretion as a reference biomarker for protein intake. Design The dietary assessment methods included different food-frequency questionnaires (FFQs) and such conventional dietary-report reference instruments as a series of 24-hour recalls, 4-day weighed food records or 7-day diaries. Setting Six original pilot validation studies within the European Prospective Investigation of Cancer (EPIC), and two validation studies conducted by the British Medical Research Council (MRC) within the Norfolk cohort that later joined as a collaborative component cohort of EPIC. Subjects A sample of approximately 100 to 200 women and men, aged 35-74 years, from each of eight validation studies. Results In assessing protein intake, all conventional dietary-report reference methods violated the critical requirements for a valid reference instrument for evaluating, and adjusting for, dietary measurement error in an FFQ. They displayed systematic bias that depended partly on true intake and partly was person-specific, correlated with person-specific bias in the FFQ. Using the dietary-report methods as reference instruments produced substantial overestimation (up to 230%) of the FFQ correlation with true usual intake and serious underestimation (up to 240%) of the degree of attenuation of FFQ-based log relative risks. Conclusion The impact of measurement error in dietary assessment instruments on the design, analysis and interpretation of nutritional studies may be much greater than has been previously estimated, at least regarding protein intake.

Where does the black population of South Africa stand on the nutrition transition

Abstract: Objective: To review data on selected risk factors related to the emergence of noncommunicable diseases (NCDs) in the black population of South Africa. Methods: Data from existing literature on South African blacks were reviewed with an emphasis placed on changes in diet and the emergence of obesity and related NCDs. Design: Review and analysis of secondary data over time relating to diet, physical activity and obesity and relevant to nutrition-related NCDs. Settings: Urban, peri-urban and rural areas of South Africa. National prevalence data are also included. Subjects: Black adults over the age of 15 years were examined. Results: Shifts in dietary intake, to a less prudent pattern, are occurring with apparent increasing momentum, particularly among blacks, who constitute three-quarters of the population. Data have shown that among urban blacks, fat intakes have increased from 16.4% to 26.2% of total energy (a relative increase of 59.7%), while carbohydrate intakes have decreased from 69.3% to 61.7% of total energy (a relative decrease of 10.9%) in the past 50 years. Shifts towards the Western diet are apparent among rural African dwellers as well. The South African Demographic and Health Survey conducted in 1998 revealed that 31.8% of African women (over the age of 15 years) were obese (body mass index (BMI) $ 30 kg m 22 ) and that a further 26.7% were overweight (BMI $ 25 to ,30 kg m 22 ). The obesity prevalence among men of the same age was 6.0%, with 19.4% being overweight. The national prevalence of hypertension in blacks was 24.4%, using the cut-off point of 140/90 mmHg. There are limited data on the population’s physical activity patterns. However, the effects of the HIV/AIDS epidemic will become increasingly important. Conclusions: The increasing emergence of NCDs in black South Africans, compounded by the HIV/AIDS pandemic, presents a complex picture for health workers and policy makers. Increasing emphasis needs to be placed on healthy lifestyles.

Validation and calibration of food-frequency questionnaire measurements in the Northern Sweden Health and Disease cohort

Abstract: OBJECTIVES: To evaluate the reproducibility of, and to compare and calibrate, diet measures by the Northern Sweden 84-item food-frequency questionnaire (FFQ) with measures from 24-hour diet recalls ...

Cardiovascular diseases in the developing countries: dimensions, determinants, dynamics and directions for public health action.

Abstract: The global burden of disease due to cardiovascular diseases (CVDs) is escalating, principally due to a sharp rise in the developing countries which are experiencing rapid health transition. Contributory causes include: demographic shifts with altered population age profiles; lifestyle changes due to recent urbanisation, delayed industrialisation and overpowering globalisation; probable effects of foetal undernutrition on adult susceptibility to vascular disease and possible gene-environment interactions influencing ethnic diversity. Altered diets and diminished physical activity are critical factors contributing to the acceleration of CVD epidemics, along with tobacco use. The pace of health transition, however, varies across developing regions with consequent variations in the relative burdens of the dominant CVDs. A comprehensive public health response must integrate policies and programmes that effectively impact on the multiple determinants of these diseases and provide protection over the life span through primordial, primary and secondary prevention. Populations as well as individuals at risk must be protected through initiatives that espouse and enable nutrition-based preventive strategies to protect and promote cardiovascular health. An empowered community, an enlightened policy and an energetic coalition of health professionals must ensure that development is not accompanied by distorted nutrition and disordered health.

The emergence of cardiovascular disease during urbanisation of Africans.

Abstract: Objective To review the available data on risk factors for cardiovascular disease (CVD), the influence of urbanisation of Africans on these risk factors, and to examine why stroke emerges as a higher risk than ischaemic heart disease (IHD) in the health transition of black South Africans. Design A review of published data on mortality from and risk factors of CVD in South Africans. Setting South Africa. Subjects South African population groups and communities. Methods The available data on the contribution of stroke and IHD to CVD mortality in South Africa are briefly reviewed, followed by a comparison of published data on the prevalence and/or levels of CVD risk factors in the different South African population groups. The impact of urbanisation of black South Africans on these risk factors is assessed by comparing rural and urban Africans who participated in the Transition and Health during Urbanisation of South Africans (THUSA) study. Results and conclusions The mortality rates from CVD confirmed that stroke is a major public health problem amongst black South Africans, possibly because of an increase in hypertension, obesity, smoking habit and hyperfibrinogenaemia during various stages of urbanisation. The available data further suggest that black South Africans may be protected against IHD because of favourable serum lipid profiles (low cholesterol and high ratios of high-density lipoprotein cholesterol) and low homocysteine values. However, increases in total fat and animal protein intake of affluent black South Africans, who can afford Western diets, are associated with increases in body mass indices of men and women and in total serum cholesterol. These exposures may increase IHD risk in the future.

Nutrition transition in Chile: determinants and consequences

Abstract: Objectives: The purpose of this study was to analyse the determinants and consequences of the nutrition transition in Chile and describe the related health promotion policies. Design and setting: This is a descriptive, population-based study including data on demographic, diet, nutrition and biomedical related variables. Data came from the Food and Agriculture Organization (FAO), the National Institute of Statistics (INE), the Ministries of Planning, Health and Education surveillance systems, and national surveys. Results: As malnutrition decreased during the 1980s, obesity increased rapidly in all age groups. In adults, currently about 25% of women are obese (body mass index .30 kg m 22 ); particularly those from low socio-economic levels. Among preschoolers, obesity is now 10% while in 6-year-old children it is 17.5% (weight/height greater than two standard deviations (.2SD) of the World Health Organization reference). Nutritional risk factors are prevalent, diet is changing to a ‘Western diet’ with an increasing fat consumption, and sedentarianism is constant in all groups. High blood pressure (.140/90) is greater than 10% in adults. Diabetes is increasing in urban areas, including in the indigenous population, and more than 40% of adults have a cholesterol level of more than 200 mg ml 21 . Conclusions: Promotion of healthy lifestyles is the main strategy to cope with this situation, particularly changing behaviour in food habits, physical activity and psychosocial factors. Changes in lifestyles will not only allow the prolonged life expectancy to be of better quality, but also will favour a decrease in the morbidity and mortality from chronic diseases, mainly cardiovascular diseases.

Variability of fish consumption within the 10 European countries participating in the European Investigation into Cancer and Nutrition (EPIC) study

Abstract: OBJECTIVE: To describe and compare the consumption of total fish (marine foods) and the fish sub-groups - white fish, fatty fish, very fatty fish, fish products and crustacea, in participants from the European Investigation into Cancer and Nutrition (EPIC) study. DESIGN: Cross-sectional analysis of dietary intake using a computerised standardised 24-hour recall interview. Crude means, means and standard errors adjusted by age, season and day of the week were calculated, stratified by centre and gender. SETTING: Twenty-seven redefined centres in the 10 European countries participating in the EPIC study. SUBJECTS: In total, 35 955 subjects (13 031 men and 22 924 women), aged 35-74 years, selected from the main EPIC cohort. RESULTS: A six- to sevenfold variation in total fish consumption exists in women and men, between the lowest consumption in Germany and the highest in Spain. Overall, white fish represented 49% and 45% of the intake of total fish in women and men, respectively, with the greatest consumption in centres in Spain and Greece and the least in the German and Dutch centres. Consumption of fatty fish reflected that of total fish. However, the greatest intake of very fatty fish was in the coastal areas of northern Europe (Denmark, Sweden and Norway) and in Germany. Consumption of fish products was greater in northern than in southern Europe, with white fish products predominating in centres in France, Italy, Spain, The Netherlands and Norway. Intake of roe and roe products was low. The highest consumption of crustacea was found in the French, Spanish and Italian centres. The number of fish types consumed was greater in southern than in northern Europe. The greatest variability in consumption by day of the week was found in the countries with the lowest fish intake. CONCLUSIONS: Throughout Europe, substantial geographic variation exists in total fish intake, fish sub-groups and the number of types consumed. Day-to-day variability in consumption is also high.

Part I. What has happened in terms of some of the unique elements of shift in diet, activity, obesity, and other measures of morbidity and mortality within different regions of the world?: Is obesity replacing or adding to undernutrition? Evidence from different social classes in Brazil

Abstract: Objective: To describe time trends in under- and overnutrition in different regional and income strata of the child and adult population of Brazil. Design: Nation-wide surveys conducted in 1975, 1989 and 1996/7 in probabilistic samples of 1‐4-year-old children and adults 20 years and over. Time trends refer to stunting, wasting and overweight prevalences among children and age-adjusted underweight and obesity prevalences among adults (95% confidence intervals included). Subjects: Individuals examined by each survey in each age group ranged from 1796 young children in 1996 to 78 031 adults in 1975. Setting: North-eastern and south-eastern regions of Brazil. Results: Undernutrition indicators declined intensively and continuously among children and adults in all region and income strata. Obesity remained low and relatively stable among children, but increased intensively and continuously in all regions and income strata among adult males. Obesity also increased intensively and continuously among adult women from the less economically developed region of Brazil (the north-eastern region) and among lower-income women from the more developed region (the south-eastern region). Higher-income women from the more developed region had a significant increase in obesity from 1975 to 1989, followed by a significant decline from 1989 to 1997. Conclusions: Undernutrition in young children is being controlled in Brazil without evidence of increasing obesity. However, obesity is rapidly replacing undernutrition in most gender, region and income strata of the adult population. Adult obesity is already more frequent than adult undernutrition in the more economically developed region, among all higher-income groups, and also among lower-income women living in the more developed region. These lower-income women are significantly more exposed than their higher-income counterparts to both undernutrition and obesity.

Socio-economic differences in fruit and vegetable consumption among Australian adolescents and adults

Abstract: Objectives: To determine whether socio-economic groups differ in their fruit and vegetable consumption, and the variety eaten, and whether socio-economic differences are similar for adolescents and adults. The study also examined whether socio-economic groups vary in their reported desire to increase the amount of fruit and vegetables consumed, and the perceived barriers to achieving this. Design, setting and subjects: The 1995 Australian National Nutrition Survey collected fruit and vegetable intake data from adolescents aged 13–17 years (n = 654) and adults 18–64 years (n = 7695) using a 24-hour dietary recall. Gross annual household income was used to measure socio-economic position. Results: Approximately 44% of males and 34% of females did not consume fruit in the 24 hours preceding the survey, and 20% of males and 17% of females did not consume vegetables. Among adolescents and adults, fruit and vegetable consumption was positively related to income. The only exception was vegetable consumption among adolescent males, which did not vary by income Lower-income adults consumed a smaller variety of fruits and vegetables than their higher-income counterparts. Fruit and vegetable variety did not vary by income among adolescents. Lower-income adults expressed less desire to increase their fruit and vegetable consumption, and were more likely to report that price and storage were barriers to doing so. Socio-economic differences in consumption and variety were more apparent for adults than for adolescents. Conclusions: In addition to increasing the consumption of fruits and vegetables among the general population, nutrition interventions, programmes and policy aiming to improve diet should target adolescents and adults from low socio-economic groups. Strategies should address price and storage barriers.

Overweight, obesity and fat distribution in 50- to 64 year old participants in the European prospective investigation into Cancer and Nutrition (EPIC)

Abstract: Objective: To describe anthropometric characteristics of participants of the European Prospective Investigation into Cancer and Nutrition (EPIC). Design: A cross-sectional analysis of baseline data of a European prospective cohort study. Subjects: This analysis includes study populations from 25 centres in nine European countries. The British populations comprised both a population-based and a 'health-conscious' group. The analysis was restricted to 83 178 men and 163 851 women aged 50-64 years, this group being represented in all centres. Methods: Anthropometric examinations were undertaken by trained observers using standardised methods and included measurements of weight, height, and waist and hip circumferences. In the 'health-conscious' group (UK), anthropometric measures were predicted from self-reports. Results: Except in the 'health-conscious' group (UK) and in the French centres, mean body mass index (BMI) exceeded 25.0 kg m(-2). The prevalence of obesity (BMI greater than or equal to 30 kg m(-2)) varied from 8% to 40% in men, and from 5% to 53% in women, with high prevalences (> 25%) in the centres from Spain, Greece, Ragusa and Naples (Italy) and the lowest prevalences (< 10%) in the French centres and the 'health-conscious' group (UK). The prevalence of a large waist circumference or a high waist-to-hip ratio was high in centres from Spain, Greece, Ragusa and Naples (Italy) and among women from centres in Germany and Bilthoven (The Netherlands). Conclusions: Anthropometric measures varied considerably within the EPIC population. These data provide a strong base for further investigation of anthropometric measures in relation to the risk of chronic diseases, especially cancer.

Evaluation of under- and overreporting of energy intake in the 24-hour diet recalls in the European Prospective Investigation into Cancer and Nutrition (EPIC)

Abstract: Objective: To evaluate under- and overreporting and their determinants in the EPIC :24-hour diet recall (24-HDR) measurements collected in the European Prospective Investigation into Cancer and Nutrition (EPIC). Design: Cross-sectional analysis. 24-HDR measurements were obtained by means of a standardised computerised interview program (EPIC-SOFT). The ratio of reported energy intake (EI) to estimated basal metabolic rate (BMR) was used-to ascertain the magnitude, impact and determinants of misreporting. Goldberg's cut-off points were used to identify participants with physiologically extreme low or high energy intake. At the aggregate level the value of 1.55 for physical activity level (PAL) was chosen as reference. At the individual level we used multivariate statistical techniques to identify factors that could explain EI/BMR variability. Analyses were performed by adjusting for weight, height, age at recall, special diet, smoking status, day of recall (weekday vs. weekend day) and physical activity. Setting: Twenty-seven redefined centres in the 10 countries participating in the EPIC project. Subjects: in total, 35955 men and women, aged 35-74 years, participating in the nested EPIC calibration sub-studies. Results: While overreporting has only a minor impact, the percentage of subjects identified as extreme underreporters was 13.8% and 10.3% in women and men, respectively. Mean EI/BMR values in men and women were 1.44 and 1.36 including all subjects, and 1.50 and 1.44 after exclusion of misreporters. After exclusion of misreporters, adjusted EI/BMR means were consistently less than 10% different from the expected value of 1.55 for PAL (except for women in Greece and in the UK), with overall differences equal to 4.0% and 7.4% for men and women, respectively. We modelled the probability of being an underreporter in association with several individual characteristics. After adjustment for age, height, special diet,- smoking status, day of recall and physical activity at work logistic regression analyses resulted in an odds ratio (OR) of being an underreporter for the highest vs. the lowest quartile of body mass index (BMI) of 3.52 (95% confidence interval (CI) 2.91-4.26) in men and 4.80 (95% CI 4.11-5.61) in women, indicating that overweight subjects are significantly more likely to underestimate energy intake than subjects in the bottom BMI category. Older people were less likely to underestimate energy intake: ORs were 0.58 (95% CI 0.45-0.77) and 0.74 (95% CI 0.63-0.88) for age (greater than or equal to 65 years vs. < 50 years). Special diet and day of the week showed strong effects. Conclusion: EI tends to be underestimated in the vast majority of the EPIC centres, although to varying degrees; at the aggregate level most centres were below the expected reference value of 1.55. Underreporting seems to be more prevalent among women than men in the EPIC calibration sample. The hypothesis that BMI (or weight) and age are causally related to underreporting seems to be confirmed in the present work. This introduces further complexity in the within-group (centre or country) and between-group calibration of dietary questionnaire measurements to deattenuate the diet-disease relationship. (Less)

Diversity of dietary patterns observed in the European Prospective Investigation into Cancer and Nutrition (EPIC) project.

Abstract: Objective: To describe the diversity in dietary patterns existing across centres/regions participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). Design and setting: Single 24-hour dietary recall measurements were obtained by means of standardised face-to-face interviews using the EPIC-SOFT software. These have been used to present a graphic multi-dimensional comparison of the adjusted mean consumption of 22 food groups. Subjects: In total, 35 955 men and women, aged 35–74 years, participating in the EPIC nested calibration study. Results: Although wide differences were observed across centres, the countries participating in EPIC are characterised by specific dietary patterns. Overall, Italy and Greece have a dietary pattern characterised by plant foods (except potatoes) and a lower consumption of animal and processed foods, compared with the other EPIC countries. France and particularly Spain have more heterogeneous dietary patterns, with a relatively high consumption of both plant foods and animal products. Apart from characteristics specific to vegetarian groups, the UK ‘health-conscious’ group shares with the UK general population a relatively high consumption of tea, sauces, cakes, soft drinks (women), margarine and butter. In contrast, the diet in the Nordic countries, The Netherlands, Germany and the UK general population is relatively high in potatoes and animal, processed and sweetened/refined foods, with proportions varying across countries/centres. In these countries, consumption of vegetables and fruit is similar to, or below, the overall EPIC means, and is low for legumes and vegetable oils. Overall, dietary patterns were similar for men and women, although there were large gender differences for certain food groups. Conclusions: There are considerable differences in food group consumption and dietary patterns among the EPIC study populations. This large heterogeneity should be an advantage when investigating the relationship between diet and cancer and formulating new aetiological hypotheses related to dietary patterns and disease.

The unique aspects of the nutrition transition in South Korea: the retention of healthful elements in their traditional diet.

Abstract: Objective: The purposes of this paper are to describe the unique aspects of the nutrition transition in South Korea, including trends in food consumption and obesity, patterns of morbidity and mortality; to focus on efforts to maintain the traditional diet in the midst of rapid economic growth and the introduction of Western culture; and to provide insights for other countries. Design: We analysed secondary dietary intake, anthropometric, morbidity and mortality data from published reports and articles. Results: In South Korea, the level and rate of increase in fat intake have remained very low, whereas vegetable intake has been high and fruit intake has increased greatly. South Korea also has a relatively low prevalence of obesity compared with other Asian countries. The traditional Korean diet is a low-fat and high-vegetable diet. Therefore, the government and nutrition specialists have been initiating numerous efforts to advertise and teach the public that the traditional diet is a healthy diet. They are also working on revival of the traditional diet using an approach that is acceptable to contemporary Koreans. Conclusions: The nutrition transition in South Korea is unique. A range of government, nutrition specialists and some private organisation efforts has worked to retain healthful elements of the traditional diet in South Korea. The continued low level of total fat in the overall diet and the high intake of fruits and vegetables bode well for South Korea.

Biomarkers in nutritional epidemiology.

Abstract: Objective To illustrate biomarkers of diet that can be used to validate estimates of dietary intake in the study of gene-environment interactions in complex diseases. Design Prospective cohort studies, studies of biomarkers where diet is carefully controlled. Setting Free-living individuals, volunteers in metabolic suites. Subjects Male and female human volunteers. Results Recent studies using biomarkers have demonstrated substantial differences in the extent of measurement error from those derived by comparison with other methods of dietary assessment. The interaction between nutritional and genetic factors has so far largely gone uninvestigated, but can be studied in epidemiological trials that include collections of biological material. Large sample sizes are required to study interactions, and these are made larger in the presence of measurement errors. Conclusions Diet is of key importance in affecting the risk of most chronic diseases in man. Nutritional epidemiology provides the only direct approach to the quantification of risks. The introduction of biomarkers to calibrate the measurement error in dietary reports, and as additional measures of exposure, is a significant development in the effort to improve estimates of the magnitude of the contribution of diet in affecting individual disease risk within populations. The extent of measurement error has important implications for correction for regression dilution and for sample size. The collection of biological samples to improve and validate estimates of exposure, enhance the pursuit of scientific hypotheses, and enable gene-nutrient interactions to be studied, should become the routine in nutritional epidemiology.

The nutrition transition in Egypt: obesity, undernutrition and the food consumption context.

Abstract: Objectives: To describe changing food consumption patterns in Egypt over the last several decades, current levels of overweight and obesity, and current data on obesity-related morbidity. Design: Secondary analysis and synthesis of existing data from national-level food consumption surveys, large recent surveys of hypertension and diabetes, and documentation of historical and policy context. Setting: Arab Republic of Egypt. Subjects: As selected and described in primary data sources. Results and conclusions: The nutrition transition in Egypt has occured in the context of abundant dietary energy availability, urbanisation and moderate fat intakes. The prevalence of obesity in adults is very high, particularly among women. The prevalences of diabetes mellitus and of hypertension parallel that of obesity, and both are very high. Little information is available on physical activity, but it is likely that a large proportion of the population is quite sedentary, particularly in the cities. At the same time, rates of early childhood malnutrition remain stubbornly stable and relatively high. Public awareness of the increasing prevalence of obesity and of diet-related chronic disease is increasing, and attention has turned to documenting the problem(s).

Measurement of household food security in the USA and other industrialised countries.

Abstract: Objective: To describe the history and current status of household food security measurement.Conclusions:In the 1980s evidence of rising levels of hunger was a concern for many, but disputed by some, Americans. Acknowledgement and quantification of hunger was hindered by the lack of an accepted definition and measure of hunger. Qualitative research at Cornell provided a conceptual framework, description, definition and survey items for hunger. The Community Childhood Hunger Identification Project developed an instrument used in numerous communities. Based upon these initiatives, widely accepted definitions of hunger and food insecurity, and the US Household Food Security Module for its measurement, now exist. The module classifies households as food-secure, or food-insecure without hunger or with moderate or severe hunger, and contains household-, adult- and child-referent items. Its inclusion in the Current Population Survey (CPS) since 1995 has yielded annual estimates of food insecurity. A six-item short form of the module, for surveys with severe time constraints, classifies households only as food-secure or food-insecure without or with hunger and contains no child-specific items. Surveys using the 18-item or short-form module can compare results with published national data from the CPS. Information about the module is available at http://www.ers.usda.gov/briefing/foodsecurity and http://www.fns.usda/fsec. Current research on food security measurement includes measurement of individual food insecurity and hunger, module performance regarding hunger duration and frequency, performance of the module in population subgroups, and the effect of translations on module meaning and performance. National surveys in Canada, New Zealand and Australia also have measured food security.

Consumption of vegetables, fruit and other plant foods in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohorts from 10 European countries.

Abstract: Objective: To describe and compare the consumption of the main groups and subgroups of vegetables and fruits (V&F) in men and women from the centres participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). Design: Cross-sectional analysis. Dietary intake was assessed by means of a 24-hour dietary recall using computerised interview software and standardised procedures. Crude and adjusted means were computed for the main groups and sub-groups of V&F by centre, separately for men and women. Adjusted means by season, day of the week and age were estimated using weights and covariance analysis. Setting: Twenty-seven centres in 10 European countries participating in the EPIC project. Subjects: In total, 35 955 subjects (13 031 men and 22 924 women), aged 35–74 years, randomly selected from each EPIC cohort. Results: The centres from southern countries had the highest consumption of V&F, while the lowest intake was seen in The Netherlands and Scandinavia for both genders. These differences were more evident for fruits, particularly citrus. However, slightly different patterns arose for some sub-groups of vegetables, such as root vegetables and cabbage. Adjustment for body mass index, physical activity, smoking habits and education did not substantially modify the mean intakes of vegetables and fruits. Conclusions: Total vegetable and fruit intake follows a south–north gradient in both genders, whereas for several sub-groups of vegetables a different geographic distribution exists. Differences in mean intake of V&F by centre were not explained by lifestyle factors associated with V&F intake.

The nutrition and health transition in Thailand

Abstract: Objective: To explore and describe the nutrition and health transition in Thailand in relation to social and economic changes, shifts in food consumption patterns and nutritional problems, as well as morbidity and mortality trends. Design: This report reviews the nutrition and health situation and other related issues by compiling information from various reports and publications from several sources. Yearly statistics and reports from the National Statistical Office were used as well as data from the Food and Agriculture Organization (FAO) and national surveys on the nutrition and health situation of the Thai population. Results: Thailand has undergone social and economic transitions during the past three decades and is approaching the post-demographic transitional period. These are evidenced by an increase in life expectancy at birth of the population, and declines in the total fertility and infant mortality rates. The economic structure has also moved from agricultural to industrial. Industrial growth has surpassed that of the agricultural sector as indicated by a steady rise in the share of the industrial sector in the gross domestic product, which is greater than that of other sectors. At the same time, results from several nation-wide surveys indicate that the food consumption pattern of the population has changed considerably; Thai staples and side dishes are being replaced by diets containing a higher proportion of fats and animal meat. A shift in the proportion of expenditure on food prepared at home and that expended on purchased, ready-to-eat food, in both rural and urban settings, gives another reflection of the change in food consumption of the Thai population. The prevalence of overweight and obesity among children and adolescents has increased dramatically during the past 20 years and is more pronounced in children from private schools and urban communities than in those from public schools or rural areas. Among adults, results from two national surveys in 1991 and 1996 indicated that the problem of overweight and other risk factors for cardiovascular disease have increased significantly. In considering the overall causes of death among the Thai population, the leading causes are diet-related chronic degenerative diseases. Diseases of the circulatory system have become the number one cause of death in Thailand and cancer has ranked as the number three cause of death since the late 1980s. Conclusions: The rapid changes in food intake and lifestyle patterns in Thailand clearly demonstrate a significant impact on the shifting pattern of disease burden of the population. These changes should be monitored carefully and must be reversed through appropriate behaviour modification and the promotion of appropriate eating practices and physical activities.

Fish consumption and self-reported physical and mental health status

Abstract: Objective: The aim of this study was to assess whether self-reported mental health status, measured using the SF-36 questionnaire, was associated with fish consumption, assessed using a food-frequency questionnaire. Design: The cross-national data were collected in the 1996/97 New Zealand Health Survey and 1997 Nutrition Survey, which were conducted using the same sampling frame. Survey respondents were categorised into those who consumed no fish of any kind and those who consumed some kind of fish, at any frequency. Data were adjusted for age, household income, eating patterns, alcohol use and smoking. Other demographic variables and potential confounding nutrients were included in the preliminary analyses but were not found to have a significant relationship with fish consumption. Subjects: Data from a nationally representative sample of 4644 New Zealand adults aged 15 years and over were used in this analysis. Results: Fish consumption was significantly associated with higher self-reported mental health status, even after adjustment for possible confounders. Differences between the mean scores for fish eaters and those who never eat fish were 8.2 for the Mental Health scale ( P = 0.005) and 7.5 for the Mental Component score ( P = 0.001). Conversely, the association between fish consumption and physical functioning was in the opposite direction ( P = 0.045). Conclusions: This is the first cross-sectional survey to demonstrate a significant relationship between fish intake and higher self-reported mental health status, therefore offering indirect support for the hypothesis that ω-3 polyunsaturated fatty acids may act as mood stabilisers.

Procedures for screening out inaccurate reports of dietary energy intake.

Abstract: Objective To review existing methods and illustrate the use of a new, simple method for identifying inaccurate reports of dietary energy intake (rEI). Design Comparison of rEI with energy requirements estimated by using total energy expenditure predicted (pTEE) from age, weight, height and sex using a previously published equation. Propagation of error calculations was performed and cut-offs for excluding rEI at plus or minus two standard deviations (+/-2 SD) and +/-1 SD for the agreement between rEI and pTEE were established. Setting Dietary survey in a US national cohort: the Continuing Survey of Food Intakes by Individuals (CSFII), 1994-96. Subjects Men and non-pregnant, non-lactating women aged 21-45 years in the CSFII who provided two multiple-pass 24-hour recalls, height and weight (n = 3755). Results Average rEI was 77% of pTEE in men, and 64% of pTEE in women. Calculated cut-offs were rEI 160% of pTEE (+/-2 SD) and 130% of pTEE (+/-1 SD), respectively. Use of only the +/-1 SD cut-offs, not the +/-2 SD cut-offs, resulted in a relationship between rEI and body weight similar to what was expected (based on an independently calculated relationship between rEI and measured TEE). Exclusion of rEI outside either the +/-2 SD (11% of subjects) or +/-1 SD (57% of subjects) cut-offs did not affect mean reported macronutrient intakes, but did markedly affect relationships between dietary composition and body mass index. Conclusions When examining relationships between diet and health, use of +/-1 SD cut-offs may be preferable to +/-2 SD cut-offs for excluding inaccurate dietary reports.