Part 1
Nutrition and consumers
2
What consumers eat
A. Trichopoulou and A. Naska, University of Athens
2.1 Introduction
Documenting and monitoring dietary patterns are priorities in nutritional epi-
demiology, in the planning of national food and nutrition policies and in the
evaluation of nutrition education strategies. Early efforts in documenting dietary
patterns were focused on identifying the specific nutrients that may be respon-
sible for effects on people’s health, but recently research has expanded towards
studying patterns of food intake. Food data are often derived from:
? Food Balance Sheets, providing information on food supply at the population
level.
? Household Budget Surveys, which collect data on food availability in the
household, based on nationally representative samples of households.
? specifically designed Individual Dietary Surveys, providing information on
the food intake of free-living individuals.
In section 2.1 of the present chapter, food data sources are presented and com-
mented upon, with emphasis on the dietary information collected. Section 2.2
provides an overview of individual dietary surveys undertaken in Europe, during
the last 20 years, and discusses the factors that need to be taken into considera-
tion before data from varied sources are combined and compared. European
studies (DAFNE, EPIC, MONICA and SENECA) that allow for international
comparisons are also presented and the section concludes with examples of
European studies designed to address specific, nutrition-related research ques-
tions. Based on currently available data, the last section of the chapter describes
dietary patterns in Europe and attempts to identify socio-demographic factors
responsible for the disparities observed.
2.2 Dietary components and health
The availability of food in Europe has never been as good as in recent decades.
Affluent though European countries are, sub-groups of populations experience
the deficiency of minerals and micronutrients that play a vital role in health and
development (Serra-Majem, 2001). A significant proportion of European infants
and children are today experiencing a low dietary intake of iodine and iron
(Trichopoulou and Lagiou, 1997a; WHO, 1998). The iodine deficiency leads to
several disorders collectively referred to as Iodine Deficiency Disorders (IDD),
with goitre (hyperplasia of thyroid cells), cretinism (mental deficiency) and
severe brain damage being the most common. It is estimated that IDD may affect
approximately 16% of the European population. Furthermore, inadequate levels
of folate have been implicated with a rise in the blood homocysteine levels,
leading possibly to increased risk of cardiovascular disease (CVD). European
policies address such deficiencies either by recommending the consumption of
foods rich in the implicated micronutrients or with supplementation policies (e.g.
iodised salt, flour supplemented with folic acid).
The general increase, however, in the quantity and variety of food available
has mostly been accompanied by the emergence of degenerative conditions such
as CVD, various types of cancer, non-insulin dependent diabetes mellitus, obesity,
osteoporosis and hypertension. Documenting and monitoring dietary patterns has
therefore become a priority in the formulation of dietary recommendations and
the planning of national food, nutrition and agricultural policies (Société
Fran?aise de Santé Publique. Health and Human Nutrition, 2000).
However, there are questions that emerge early in the formulation of a nutri-
tion and food policy: these concern the nature of the best diet and the objectives
of an ideal diet. With respect to chronic nutrition-related conditions, most of our
existing knowledge relies on evidence accumulated mainly in relation to the two
most common categories of disease, cardiovascular disease and cancer.
With respect to CVD, there is strong evidence that the intake of vegetables,
fruits and pulses reduces the risk, although there is no agreement to what extent
the apparent protection is conveyed by fibre, homocysteine-reducing folic acid,
antioxidant compounds in vegetables and fruits, the high quantities of olive oil
that usually accompany high intake of vegetables and legumes, or the comple-
mentary reduced consumption of red meat and lipids of animal origin (Willett,
1994,1998).
The mainstream view on the effects of macronutrients on CVD is that dietary
lipids high in saturated fatty acids and especially trans-fatty acids increase the
risk. On the contrary, polyunsaturated fatty acids and some long chain n-3 fatty
acids have beneficial effects. Monounsaturated lipids, overwhelmingly present in
olive oil, also act beneficially by reducing the disadvantageous low density
lipoprotein cholesterol (LDL-C) and increasing the protective high density
lipoprotein cholesterol (HDL-C) (Mattson and Grundy, 1985; Mensink and
Katan, 1987). Complex carbohydrates do not adversely affect the risk for CVD
and their effect on HDL-C is less favourable than that of monounsaturated lipids
8 The nutrition handbook for food processors
(Mensink and Katan, 1987). Refined carbohydrates substantially affect post-
prandial hyperglycemia and they appear to accentuate insulin resistance. With
respect to other nutrients, there is converging, but not yet conclusive, evidence
that moderate alcohol intake, vitamin E and folic acid are inversely associated
with the risk of coronary heart disease (CHD) (Gaziano et al, 1993; Stampfer et
al, 1993; Robinson et al, 1998). Salt intake, on the contrary, contributes to the
elevation of blood pressure levels in susceptible individuals and thus to the
increase of CVD risk (Beilin et al, 1999).
The evidence on the role of specific dietary factors in cancer aetiology has
been critically summarised in recent reviews (Willett and Trichopoulos, 1996;
Willett, 2000). With respect to food groups, vegetable consumption, and perhaps
less definitely fruit consumption, have a beneficial effect on a broad spectrum of
human cancer types. Among macronutrients, animal protein intake has been
reported to increase the risk for colorectal cancer, while intake of saturated fat is
positively associated with endometrial, prostate, colorectal, lung and kidney
cancer. Although the percentage of calories from dietary lipids does not appear
related to colon cancer, greater risks have been seen with higher consumption of
red meat, possibly suggesting that factors other than dietary lipids per se may be
important. Fibre intake, on the contrary, appears to protect against cancer of the
pancreas and the large bowel. There are also indications of a protective role of
monounsaturated lipids against breast cancer (Trichopoulou, 1995). Concerning
micronutrients the evidence is largely insufficient. Recent studies indicate an
inverse association of lycopene (Gann et al, 1999), selenium (Yoshizawa et al,
1998) and vitamin E (Tzonou et al, 1999) with prostate cancer, folic acid in rela-
tion to colon and breast cancers (Giovannucci et al, 1998); while beta-carotene
supplements have been found to be ineffective against lung cancer risk
(Hennekens et al, 1996).
Consumption of large quantities of alcoholic beverages, particularly in con-
junction with tobacco smoking, has been reported to increase the risk of cancer
in the upper respiratory and digestive tract, whereas alcoholic cirrhosis frequently
leads to liver cancer. There are also data suggesting that intake of smaller quan-
tities of alcohol may be linked to the occurrence of breast and colorectal cancer.
Among added substances, only salt appears to be an important contributor to
stomach cancer. Moreover, intake of salty fish very early in life has been linked
to the occurrence of nasopharyngeal cancer in Southern Asia. Finally, in Central
Asia and Southern America the intake of very hot drinks has been found to
increase the risk of esophageal cancer (Kinjo et al, 1998).
Many of the early efforts have been focused on identifying specific dietary
components that may be responsible for effects on people’s health. Evaluating
the effects of specific foods and nutrients, rather than integral dietary patterns, on
disease illustrates how shifting from the empirical evidence may increase uncer-
tainty. Dietary exposures are unusually complex and strongly intercorrelated.
Current data suggest that apparently favourable effects cannot be exclusively
attributed to specific components and in several instances these components may
act synergistically (Gerber et al, 2000). Consequently, instead of focusing only
What consumers eat 9
on nutrients within foods, research has expanded towards studying patterns of
food intake (Trichopoulos et al, 2000).
2.3 Sources of dietary data
As mentioned earlier, food data are often derived from:
? Food Balance Sheets that provide information on food supply at the popula-
tion level.
? Household Budget Surveys that collect data on food availability in the house-
hold, based on nationally representative samples of households.
? specifically designed Individual Dietary Surveys that provide information on
the food intake of free-living individuals, over a specified time period.
2.3.1 Food balance sheets
The food balance sheets (FBSs) assembled by the Food and Agriculture Organ-
isation (FAO) describe the current and developing structure of the national dietary
patterns, in terms of the major food commodities that disappear from the national
markets (www.fao.org). A food balance sheet is completed at national level, on
the basis of the annual food production, imports and exports, changes in stocks
and the agricultural and industrial uses within a country. When these have been
taken into account, the remaining quantities represent the food that can be
assumed to have been available for human consumption in that country (Kelly
et al, 1991).
Since 1949, FBSs are regularly collected on a world-wide basis and, in spite
of their limitations, countries with no routine information on the food consump-
tion of their population and those interested in comparing their national dietary
patterns with those of other populations have traditionally used them (Helsing,
1995).
International comparisons based on the time series FBS data, in conjunction
with information from other sources, can help to indicate trends in the food avail-
able to the overall population of one country in relation to others, and have thus
been used for ecological correlations of food patterns with the morbidity and mor-
tality of nutrition-related diseases. The user of these data, however, should bear
in mind their constraints and interpret comparisons with due caution (Southgate,
1991). The accuracy of recording differs considerably between countries and
commodities. Although data on their own food production are collected in some
countries, these sources of information can be largely under-recorded. Waste and
food given to pets may also be sources of error, since they are considerably depen-
dent on time, cultures and type of commodities. Lastly, the conversion of food-
stuffs into nutrient equivalents by the application of factors derived from various
sources must be prudently treated.
10 The nutrition handbook for food processors
2.3.2 Household budget surveys
The household budget surveys (HBSs) are periodically conducted by the National
Statistical Offices of most European countries in nationally representative
samples of households. By recording the values and quantities of household food
purchases, the HBSs can adequately depict the dietary patterns prevailing in rep-
resentative population samples. Moreover, the concurrent recording of demo-
graphic and socio-economic characteristics of the household members may allow
exploratory analyses on the evaluation of their effects on dietary choices. One
of the main advantages of the multi-purpose HBSs is their periodic undertaking
by Governmental Services, making them a readily available and thus an afford-
able source of dietary information in developed and developing countries
(Trichopoulou, 1992).
The HBSs can be thought of as occupying a position between the FBSs and
the specially designed individual food consumption surveys. Like food balance
sheets, the HBSs allow intercountry comparisons on a regular basis but, moving
from total population to household level, they further allow the calculation of
both the mean and the distribution of food availability within the population and
specific subgroups (Trichopoulou et al, 1999).
Issues of comparability can be raised when using HBS data for international
comparisons. The data collection methodology is uniform enough to allow such
comparisons, but the food information recorded in the various countries may be
of different forms and levels of detail. The methodology, however, for address-
ing these discrepancies has been developed in the context of the DAta Food NEt-
working (DAFNE) project (Lagiou et al, 2001; Friel et al, 2001). However, since
HBSs are not primarily designed to collect nutritional information, the food data
bear limitations, which need to be considered when they are used for nutritional
purposes (van Staveren et al, 1991; Southgate, 1991; Trichopoulou, 1992). The
following points should be borne in mind:
? In most cases, no records are collected on the type and quantity of food items
and beverages consumed outside the home.
? Information on food losses and waste, food given to pets, meals offered to
guests, use of vitamin and mineral supplements and the presence of pregnant
or lactating women is not consistently collected.
? Data are collected at household level and estimation of the individuals’ intake
requires the application of stochastic statistical models.
? Information on nutrient intake is not readily available. Nevertheless, appro-
priate conversion factors based on food composition tables are developed for
converting quantity data into nutrients.
Despite their limitations, the HBSs provide a resource for the conduct of a
wide range of nutritional analyses. They also constitute a reasonable alternative
to specially designed individual-based nutrition surveys for most Mediterranean
and central/eastern European countries. HBS data could help highlight issues
such as differences in dietary patterns (Byrd-Bredbenner et al, 2000), high risk
population groups on account of their nutritional habits, relationships between
What consumers eat 11
diet and morbidity/mortality data (Lagiou et al, 1999) and dietary intakes of addi-
tives and contaminants.
2.3.3 Individual dietary surveys
The specially designed individual dietary surveys (IDSs) primarily aim at the col-
lection of information on the food intake of free-living individuals over a speci-
fied period. The individual surveys, when intakes of the subject are recorded as
adequately as possible, are expected to provide evidence on the food quantities
consumed and to allow the calculation of both the mean and the distribution of
food and nutrient intake among the whole or segments of the population.
The methods used to assess individual intake can be broadly divided into two
generic categories (Willett, 1998):
? Recall methods of sporadic or habitual diet. They can be limited to the pre-
vious 24 hours (24-hour dietary recall), where subjects are asked to recall
everything they consumed the previous day, or to a diet history referring
to a broader and less precisely defined time period using food frequency
methods.
? Record methods of daily intake, where subjects are required to keep records
of everything they eat and drink for one (24-hour food record) or more days.
The 7-day weighed record is the one commonly used.
The quantification of foods consumed and the selection of items to be included
in the food list, in the case of closed lists, are critical components of data col-
lection. Standard, natural and household units, three-dimensional food models,
photographs, drawings of foods and geometric shapes are often used for docu-
menting portion sizes.
Recall methods, in comparison to the record ones, do not require literacy; they
are not expected to cause alterations in the eating behaviour of the subject, since
the information is collected after the fact; and they have minimal respondent
burden. Nevertheless, recall methods are subject to respondents’ memory, a limi-
tation not present in food records. In recent surveys, dietary recalls are collected
using computer software programmes that allow data to be uniformly collected,
by prompting interviewers to ask all the necessary questions, and may further
reduce the cost of data collection and processing.
The food records and the 24-hour recall may be used to estimate the absolute
intake of energy, macronutrients and some vitamins and minerals that are com-
monly found in the food supply. Both methods are frequently used in describing
the mean intake of aggregated food groups and in validating food frequency ques-
tionnaires. These short-term methods are completely open ended, they accom-
modate any food or food combination reported by the subject and they allow
recording information at various levels of detail including the type of food, the
food source, the food processing and preparation methods. They are therefore
particularly useful for estimating intakes of culturally diverse populations. One
single day of intake, however, is highly unlikely to be representative of usual
12 The nutrition handbook for food processors
intake. For this reason the collection of multiple days of intake is required in
order to estimate as adequately as possible the subjects’ usual intake.
Food frequency questionnaires are food lists of differing length and the infor-
mation collected can refer either to the frequency of consuming certain foods and
beverages, or to both the frequency and estimates of the portions consumed. The
underlying principle of the food frequency method is that the average long-term
diet reflects the conceptually important exposure, and therefore makes the food
frequency questionnaires the method of choice for measuring dietary exposures
in epidemiological studies. In constructing a food frequency questionnaire,
careful attention must be given to the format of the food frequency section, the
selection of foods that will be included in the food list and the clarity of the ques-
tions. Food frequency questionnaires can be administered to large population
groups; they can be applied as interviews or in a self-administered form and are
relatively easy and less time consuming to complete when compared to other
dietary assessment methods. It should, however, be borne in mind that food fre-
quency questionnaires including a restricted food list may result in reducing the
true variance of intake.
For most investigations of nutritional epidemiology, the relative ranking of
individuals according to their food and nutrient intakes is adequate for deter-
mining correlations of relative risks. In such cases, food frequency questionnaires
constitute the primarily selected dietary assessment method. In situations,
however, when the aim is to compare the nutrient intakes of various populations
or to evaluate compliance with dietary recommendations, estimates of the
absolute energy and macronutrient intakes may be required. In such instances,
records or 24-hour recalls are generally the methods of choice (Willett, 1998).
2.4 Dietary data in Europe: national surveys
A number of European countries have carried out national dietary surveys. Table
2.1 summarises basic information on the various IDSs that have been undertaken
in 20 European countries during the last 20 years.
The surveys are often designed to document the dietary patterns of the general
population or segments of it and possibly to identify groups at nutritional risk. In
other instances, the primary aim is to address country-specific objectives. The
selection of the dietary survey method depends on a number of different factors
and investigators may frequently have to compromise according to the specific
objectives of the survey and the inherent cost of setting it up.
When the option of running international comparisons using these data is
raised, a number of methodological constraints emerge. It can directly be noted
that a variety of dietary assessment methods are used, making it difficult to
accomplish comparability at the international level (Friedenreich, 1994). The dif-
ferences in the data collection methodology are reflected in the type and accu-
racy of the data collected. Some dietary surveys, usually those conducted with
food frequency questionnaires, collect data on the intake of particular foods,
What consumers eat 13
14
The nutrition handbook for food processors
Table 2.1 Specially designed dietary surveys undertaken in the general population of 20 European countries during the last 20 years.
Sample size Survey Population Dietary
Country Name of the survey Years of data collection (number of
Gender Age (yrs)
assessment
individuals) method
Austria Austrian Study on 1991–1994 2 173 F + M 6–18 7 day record
Nutritional Status 1993–1997 2 065 F + M 19–65 24 hour recall,
(ASNS) diet history
1995, 1998 78 F + M Elderly 7 day record
Belgium Belgian Interuniversity 1980–1985 10 971 F + M 25–74 1 day record
Research on Nutrition
and Health
(BIRNH)
Croatia Croatian Study on 1997–1998 348 F + M 12–14 24 hour recall and
Schoolchildren’s food frequency
Nutrition questionnaire
Denmark Dietary Habits in Denmark 1985 2 242 F + M 15–80 diet history
National Dietary Survey 1995 3 098 F + M 1–80 7 day record
National Continuous 2000–2002 1 500 (2000) F + M 4–75 7 day record
Dietary Survey
Finland Dietary Survey of Finnish 1992 1 861 F + M 25–64 3 day record
Adults 1997 2 862 F + M 25–64 24 hour recall
(FINDIET) 290 F + M 65–74
France National Food 1985–1995 1 778 F + M 18–62 diet history
Consumption Survey 1993–1994 1 229 F + M18+ 7 day record
(ASPCC) 1993–1994 1500 F + M 2–85 7 day record
Individual National Food 1998–1999 1 018 F + M 3–14 7 day record
Consumption Surveys 1 985 F + M15+
(INCA)
What consumers eat
15
Germany National Nutrition Survey 1985–1989 24 632 F + M 4–70+ 7 day record
in former West Germany
National Health Survey in 1991–1992 1 897 F + M 18–79 diet history
former East Germany
German Nutrition Survey 1998 4 030 F + M 18–79 diet history
Hungary First Hungarian 1985–1988 16 641 F + M 15–60+ Two 24 hour recalls
Representative Nutrition and food frequency
Survey questionnaire
Hungarian Randomised 1992–1994 2 559 F + M 18–60+ Three 24 hour recalls
Nutrition Survey and food frequency
questionnaire
Iceland Icelandic National 1990 1 240 F + M 15–80 diet history
Nutrition Survey
Ireland Irish National Nutrition 1990 1 214 F + M 8–18+ diet history
Survey
North-South Food 1998 1 379 F + M 18–64 7 day record
Consumption Survey
Italy INN-CA 1994–1996 3 600 F + M 0–94 7 day record
Lithuania Baltic Nutrition and Health 1997 2 183 F + M 20–65 24 hour recall and
Survey food frequency
questionnaire
Netherlands Dutch National Food 1987–1988 5 898 F + M 1–79 2 day record
Consumption Survey 1992 6 218 F + M 1–92 2 day record
1997–1998 6250 F + M 1–97 2 day record
Norway National Dietary Survey 1993–1994 3 144 F + M 16–79 food frequency
among Adults questionnaire
(NORKOST) 1997 2 672 F + M 16–79 food frequency
questionnaire
National Dietary Survey 1993 1 705 F + M 13 food frequency
1 564 18 questionnaire
1999 2400 F + M 6 and 12 food frequency
months questionnaire
1999 2010 F + M 2 food frequency
questionnaire
Table 2.1 Continued
Sample size Survey Population Dietary
Country Name of the survey Years of data collection (number of
Gender Age (yrs)
assessment
individuals) method
16
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Table 2.1 Continued
Sample size Survey Population Dietary
Country Name of the survey Years of data collection (number of
Gender Age (yrs)
assessment
individuals) method
Poland Dietary Habits and 1991–1994 1 126 F + M 11–14 24 hour recall
Nutritional Status of 2 193 18
selected populations 4 945 20–65
Portugal National Dietary Survey 1980 13 080 F + M 1–65+ 24 hour record
Slovak Assessment of food habits 1991–1999 3 337 F + M 11–14 24 hour recall and
Republic and nutritional status 4 556 15–18 food frequency
4 807 19–88 questionnaire
Sweden HULK 1989 2 036 F + M 1–74 7 day record
Riksmaten 1997–1998 1215 F + M 18–74 7 day record
Switzerland Swiss Health Survey 1992–1993 26 000 F + M 15–74 food frequency
questionnaire
United The Dietary and Nutritional 1986–1987 2 197 F + M 16–64 7 day record
Kingdom Survey of British Adults
(NDNS)
National Diet and Nutrition 1992–1993 1 675 F + M1
1
/
2
–4
1
/
2
4 day record
Survey: Children aged
1
1
/
2
–4
1
/
2
yrs
National Diet and Nutrition 1994–1995 1 687 F + M65+ 4 day record
Survey: people aged
65 yrs and over
National Diet and Nutrition 1997 1 701 F + M 4–18 7 day record
Survey: young people
aged 4–18 yrs
Adapted from Verger et al, 2002.
selected for their relevance to the objectives of the survey. Therefore, the results’
efficacy for calculating the energy and nutrient intake is limited. Methods such
as 24-hour recalls and food records, on the other hand, do not necessarily reflect
habitual intake. In highly demanding surveys, such as those requiring weighed
diaries of multiple days, a significant proportion of subjects may drop out, intro-
ducing bias in the sample.
The representativeness of the survey population, the potential of the data (e.g.
suitability for energy and nutrient calculations), the elements that may affect the
reliability of the collected data and the accuracy of the results (e.g. participation
rate), are all factors affecting the suitability of a dietary survey to be used for
international comparisons (Haraldsdóttir, 1991). The error possibly introduced by
the application of various food composition databases for estimating nutrient
intakes should also be considered. The documented lack of compatibility of food
composition data from various countries (Deharveng et al, 1999) may compro-
mise the validity of the observed relationships.
It is generally acknowledged that dietary intake cannot be estimated without
error and each method has its strengths and weaknesses. The knowledge of the
method’s limitations and of the nature and the magnitude of the errors will lead
to a more scientific and sensible interpretation of the results. Although dietary
surveys differ widely in the accuracy of their estimates of quantities of food eaten,
these differences are usually not listed when the results are presented. These dif-
ferences are seldom obvious and must be borne in mind when various surveys
are compared.
The often prohibitive cost of special dietary surveys may limit the European
coverage of data collection. Being expensive and labour intensive, such surveys
are regularly undertaken only in a limited number of countries, usually those with
robust economies and years of experience in the field. In the modern world of
rapid changes, however, nutrition surveillance and intervention programmes
should make use of dietary surveys that have built-in mechanisms of continuity
over time and extensive coverage.
2.5 Dietary data in Europe: European surveys
In Europe, there is a need for sources of dietary data that would provide a regular
and comparable flow of information. A limited number of studies on document-
ing and monitoring the dietary intake in Europe have been conducted. The EPIC
and SENECA projects are examples of studies that developed procedures to allow
the collection of harmonised data across countries. DAFNE is an example of a
European project that aimed at achieving post-harmonisation of data already
collected.
2.5.1 The DAta Food NEtworking (DAFNE) initiative
The DAFNE initiative aims at exploiting the HBS-derived data for nutritional
purposes and developing a cost-effective food databank, based on data collected
What consumers eat 17
in the European HBSs. The project has been successful in developing the method-
ology for harmonising food, demographic and socio-economic data collected in
the HBSs of fourteen European countries (Belgium, Croatia, France, Germany,
Greece, Hungary, Italy, Luxembourg, Norway, Poland, Portugal, the Republic of
Ireland, Spain and the United Kingdom). The project is coordinated by the
Department of Hygiene and Epidemiology of the Medical School, University of
Athens, Greece.
The initial objective of the DAFNE project was the creation of comparable
categories of food and socio-demographic information, allowing intra- and inter-
country comparisons of nutritional habits and the identification of socio-
demographic variables affecting them. Although several socio-demographic char-
acteristics are recorded in the HBSs and many of them are included in the final
roster of variables to be studied, the DAFNE team is currently focusing on local-
ity (degree of urbanisation of the area where the household was situated), edu-
cation and occupation of household head, as well as on household composition.
These variables are used for the characterisation of the socio-demographic status
of the household.
The development of a food classification system that would allow international
comparisons of dietary patterns was a central element in the development of an
HBS-based European food databank One of the intermediate results of the
harmonisation procedure is the development of the DAFNE food classification
system, which allows the categorisation of HBS-collected food data into 56
detailed subgroups. These subgroups can be aggregated at various levels ending
up at 15 main food groups (Lagiou et al, 2001). The feasibility studies under-
taken in the context of the DAFNE project demonstrated that the prospect of using
HBSs for the assessment of dietary information is realistic and the potential con-
siderable, assuming political will, administrative support and a minimal adjust-
ment in infrastructure (Trichopoulou and Lagiou, 1997b, 1998).
In order to evaluate the nutritional information available in the DAFNE data-
bank, a comparison of individualised HBS data with food consumption values
derived from specially designed IDSs has recently been undertaken (Naska et al,
2001a, 2001b; Vasdekis et al, 2001). Preliminary results of this analysis show that
there is considerable scope in using the DAFNE databank to achieve an average
estimate of the populations’ food habits, to run international comparisons and to
complement with regular information the data collected in the specially designed
individual dietary surveys.
2.5.2 The European Prospective Investigation into Cancer and Nutrition
(the EPIC study)
The EPIC is a multi-centre prospective cohort study with the aim of investigat-
ing the complex relation between nutrition and other lifestyle and environmental
factors in relation to the incidence of and mortality from cancer and other dis-
eases (Riboli, 1992). The study is being undertaken in ten European countries
(Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain,
18 The nutrition handbook for food processors
Sweden and the United Kingdom) and is co-ordinated by the International
Agency for Research on Cancer (IARC) in Lyon, France.
EPIC was initiated in 1990 with pilot and methodological studies to test the
validity and feasibility of drawing, determining representative portions and
storing biological samples, of taking anthropometric measurements and of col-
lecting data through different types of questionnaires and from variable European
populations (Riboli and Kaaks, 1997). Upon the finalisation and the standardi-
sation of the study protocol, the fieldwork was undertaken from 1993 to 1998
and more than 480 000 subjects were included in the cohort.
Eligible subjects were generally drawn from the general population, residing
in a given geographical area. In some countries different sampling frames were
used in order to ensure a good participation rate and complete follow-up; this did
not seriously violate the sampling scheme of a cohort study. According to the
study protocol, men over 40 years and women over 35 years of age were recruited.
The lower age limit for women was selected to ensure a sufficient number of sub-
jects for investigating risk factors for premenopausal cancers. The upper age limit
of the cohort is less precisely defined and varies between 60 and 74 years, depend-
ing on the study centre.
Standardised protocols have been developed to collect data on the subjects’
medical history, current medication, several lifestyle factors, anthropometry, diet
and collection of blood samples. Sections of optional questions were added in
some cases to address country-specific objectives. The questionnaire on physical
activity was the same in the majority of the countries. A standard common pro-
tocol was used for the anthropometric measurements, allowing for tests of within-
and between-observer variability.
For the dietary assessment, study subjects were requested to complete a centre-
specific dietary questionnaire on their habitual food habits. In most countries a
semi-quantitative, interviewer- or self-administered food frequency questionnaire
was used. Preliminary analyses of the data colleted through the baseline ques-
tionnaire were undertaken in the coordinating center and included the estimation
of the energy and selected nutrient intake and the daily consumption of major
food groups.
Additionally, a random sample from each cohort selected on the basis of the
number and age-gender distribution of expected cancer cases was interviewed by
trained interviewers using a computerised software programme (the EPIC-SOFT)
specially designed to collect standardised 24-hour recalls of foods consumed
during the preceding day (Slimani et al, 1999).
In the field of collecting dietary data at a European level, the EPIC project
contributed by developing methods for collecting comparable individual dietary
intake data in culturally diverse populations. Although EPIC was not primarily
aiming at documenting dietary patterns in Europe, the central database includes
information on the habitual (using the food frequency method) and the sporadic
(using one 24-hour recall) diet of more than 480 000 Europeans with heteroge-
neous dietary habits, covering the diet of Mediterranean regions, the central
European food patterns and the dietary habits of the Nordic populations.
What consumers eat 19
2.5.3 MONItor trends in CArdiovascular diseases
(the WHO-MONICA study)
The WHO-MONICA (The WHO MONICA Project, 1989; Tunstall-Pedoe et al,
2000) is a collaborative project designed to study the relationship between trends:
1. In the main cardiovascular risk factors and CVD morbidity and mortality.
2. In the acute medical care for CHD and the lethality of the disease.
3. In the incidence of CHD and stroke.
To address the above research questions, data were collected in thirty nine
centres in twenty six countries of four continents. Although the MONICA study
was not solely undertaken in Europe, the majority of the MONICA populations
were Europeans. Two types of databases were set up in each population, within
a time period of ten years:
? One, including cross-sectional data on the prevalence of cardiovascular risk
factors in the general adult population, aged 35–64 years. The data collection
was undertaken at least twice (one at the beginning and one at the end of the
period) and preferably three times within the ten-year period.
? The second, including longitudinal data on the incidence of CVD through a
continuous registration of fatal and non-fatal coronary and/or stroke events.
The project started in the early 1980s and was concluded in the mid-1990s.
The most essential criteria and procedures for recruitment and the standardisa-
tion of measurements, fieldwork, quality control and data storage are thoroughly
described in the MONICA Manual (The WHO-MONICA Project, 1989–1999).
A number of quality assessment reports and MONICA-related publications are
available at the MONICA website (www.ktl.fi/monica).
The fieldwork for the core study included standardised questionnaires, anthro-
pometric and biological measurements and study of medical records. Quality
assurance in MONICA was based on several procedures described in the
MONICA Manual, such as international training sessions, continuous internal and
external quality control procedures, regular communication with the quality
control and reference centres, and the elaboration and publication of several
retrospective quality assessment reports. The core data were centralised in the
MONICA Data Centre in Helsinki, Finland.
2.5.4 Nutrition and the elderly in Europe – the Euronut-SENECA study
In 1986 the Management Group of the Concerted Action on Nutrition and Health
in the European Community (Euronut), decided to embark on a study of nutri-
tion in the elderly. An international longitudinal study was thus initiated to study
the effective use of food and food resources to enhance the quality of life in older
persons, both in social and biological terms (de Groot et al, 1991). The first phase
of the study was carried out in 19 centres of 12 European countries in 1988 and
1989. The follow-up study took place in 1993 in 9 out of the 19 centres. The first
part was a cross-sectional study aiming at exploring the dietary patterns of elderly
20 The nutrition handbook for food processors
populations living in different European communities and at running international
comparisons. The follow-up study provided the opportunity to analyse the effect
of ageing and the relation of nutrition and health parameters with age.
Approximately 2600 individuals born between 1913 and 1918 were studied
using strictly standardised methodology. The basic protocol was standardised and
common to all participating groups. Data were collected on the dietary intake of
the subjects, on their nutritional status (by collecting and analysing blood
samples), on their anthropometric characteristics, physical activity, life-style,
health and performance.
Food consumption data were collected during a personal interview, using a
modified version of the dietary history method consisting of two parts: first, an
estimated 3-day record including two weekdays and one weekend day, and sec-
ondly a checklist of foods. The food record was collected to assist the interviewer
in having an idea of the subjects’ eating pattern. In order to assess the habitual
pattern of intake, subjects were questioned about their usual intake using the pre-
ceding month as the reference period. Portion sizes were recorded either by
weighing, or were based on standardised household measures. Food consump-
tion data were converted into energy and nutrients by using country-specific food
composition tables (Euronut SENECA investigators, 1991).
2.5.5 International studies to address specific objectives
Apart from the four international projects described above, there are numerous
other studies with European coverage, designed to address specific, nutrition-
related research questions. Although some dietary information is recorded in
these surveys, the data collected cannot be informative on the dietary patterns of
the populations. Two European studies, with specific nutrition-related objectives,
are indicatively presented below.
The calcium intake and peak bone mass (CALEUR) study is a European multi-
centre study undertaken from 1994 to 1997 in six European countries (Denmark,
Finland, France, Italy, the Netherlands and Poland) and coordinated by the TNO-
Nutrition and Food Research Institute (Zeist, the Netherlands). CALEUR was a
cross-sectional study aiming at evaluating the association between the dietary
calcium intake and the radial bone density in two age groups: adolescent
girls aged 11–15 years and young women of 20–23 years of age (Kardinaal et al,
1999).
Another international study with specific objectives was the TRANSFAIR
study, also coordinated by the TNO-Nutrition and Food Research Institute in the
Netherlands. The TRANSFAIR study aimed at determining the trans-fatty acid
content of 1299 food samples in fourteen European countries (Belgium,
Denmark, Finland, France, Germany, Greece, Iceland, Italy, the Netherlands,
Norway, Portugal, Spain, Sweden and the United Kingdom) (Van Poppel et al,
1998), at calculating the trans-fatty acid intake of the fourteen European
populations, using data from representative food consumption surveys (Hulshof
et al, 1999) and at studying in a cross-sectional design the relationship of
What consumers eat 21
CVD risk factors and trans-fatty acid intake in eight of the above European
populations.
2.6 Dietary patterns in Europe
During the second half of the twentieth century, there have been significant
changes in the foods Europeans choose to eat, their eating occasions and how
much they spend on food. The development of new production methods in the
crop and livestock sectors of agriculture and the advancement of food science
have significantly increased the quantity and variety of food available. Progress
in food technology has facilitated the production of foods preserved in new ways
and the formulation of entirely new or fundamentally modified products. The
rising number of meals eaten outside the home; the shift away from traditional
dishes prepared from raw ingredients; the tendency towards the consumption of
products, which are considered to be ‘healthy’; and the interest in new, foreign
foods are the results of alterations in the Europeans’ perceptions and lifestyle.
Data from the FBSs show that over the last few decades, European eating
patterns have been quite labile and subject to various changes. Bearing in mind
the caveats of using FBSs for nutritional purposes, data for the 15 member states
of the European Union (Fig. 2.1) show a constant increase in the meat supply
from 185 g/person/day in 1970 to 236/g/p/d in the late 1990s. Cereal availability
has been generally static. The trend for the supply of vegetables is unclear, as no
22 The nutrition handbook for food processors
150.0
200.0
250.0
300.0
350.0
400.0
1970 1972 1974 1976 197
8
19
80
19
82
19
84
19
86
1
9
88
199
0
199
2
1994 199
6
Cereals Fruits Vegetables Meat
Fig. 2.1 Supply (g/person/day) of 4 food groups (cereals, meat, fruits and vegetables) in
the 15 EU member states. Data from the 1970–1997 Food Balance Sheets. (www.fao.org)
30.0
35.0
40.0
45.0
50.0
55.0
60.0
1970 1972 1974 1976 197
8
198
0
1982 198
4
198
6
1988 199
0
199
2
1994 199
6
Vegetable oils Animal Fat
Fig. 2.2 Supply (g/person/day) of vegetable oils and animal fat in the 15 EU member
states. Data from the 1970–1997 Food Balance Sheets. (www.fao.org)
31.00–45.99 (5)
46.00–60.99 (4)
61.00–75.00 (3)
Total added lipids
(g/prs/day)
Fig. 2.3 Availability of total added lipids, in 12 DAFNE countries, around 1990
(g/person/day). (Trichopoulou, 2001)
constant pattern can be identified. Fruit supply, on the other hand, is continuously
increasing in the 15 member states since 1978, probably reflecting the docu-
mented consumers’ preference to increase their fruit rather than vegetable intake,
as well as the availability of fruit regardless of season (Naska et al, 2000).
The availability of vegetable oils has always been higher than that of animal
fat (Fig. 2.2). It is worth noting, however, that in the 1970s, the supply of both
vegetable oils and animal fats was estimated to be approximately 37 g/p/d, but
since 1978 a remarkable increase in the vegetable oil availability started, which
was not followed by a similar trend in the availability of animal fat.
Between countries data clearly show that the European region is characterised
by a divergence in eating behaviours. Results from the DAFNE databank col-
lected around 1990 in 12 European countries reveal considerable variations in
food availability of different European populations (Trichopoulou, 2001).
Total added lipids (Fig. 2.3) cover both oils, generally of vegetable origin, and
solid or semi-solid fat, either from animal sources, or following industrial pro-
cessing mainly of vegetable oils (margarine). Total added lipid availability varies
between 75 g/p/d in Italy to 32 g/p/d in the UK. When the type of lipid is exam-
24 The nutrition handbook for food processors
Lipids of animal origin
(g/prs/day)
0.00–13.99 (7)
14.00–27.99 (3)
28.00–41.00 (2)
Fig. 2.4 Availability of added lipids of animal origin, in 12 DAFNE countries, around
1990 (g/person/day). (Trichopoulou, 2001)
ined, however, butter and animal fat (Fig. 2.4) account for less than 10% of the
total added lipid availability in the Mediterranean countries, while they exceed
30% in the majority of northern and central European countries. Margarine is
gradually becoming the lipid of preference in northern Europe, with its avail-
ability rising as high as 75% of total added lipids in Norway. In the Mediter-
ranean countries, vegetable oils (Fig. 2.5) represent the lipid of preference; 62%
of the vegetable oil availability in Italy and 83% in Greece is olive oil.
The north-south dietary pattern may also be noted when the availability of
fresh vegetables (Fig. 2.6) and fruits (Fig. 2.7) is estimated. Two Mediterranean
countries, Greece and Spain, lead in the availability of vegetable and fruit avail-
ability respectively. The proportion of fresh vegetables consumed varies between
countries, from 58% in Germany to 97% in Portugal. Again, fruit is mainly con-
sumed fresh in the Mediterranean countries. In Ireland, availability of fruit barely
exceeds 100 g/p/d; 79% of the total fruit is purchased fresh.
Figure 2.8 presents the meat (red meat, poultry and meat products) availabil-
ity by the educational status of the household head. The mean daily availability
has been estimated to exceed 180 g/p/d in Hungary, Poland and Luxembourg and
What consumers eat 25
1.00–24.99 (8)
25.00–48.90 (0)
48.91–73.35 (4)
Vegetable oils
(ml/prs/day)
Fig. 2.5 Availability of vegetable oils, in 12 DAFNE countries, around 1990
(ml/person/day). (Trichopoulou, 2001)
it is around 130 g/p/d in Norway, Portugal and Greece. Data presented in Fig. 2.8
further reveals a tendency for lower consumption among the more educated
households. It is further worth noting that the Mediterranean countries have
become important meat consumers which is not what they were in the past. The
availability of different meat types varies among the participating countries. For
example, while Greeks seem to prefer beef, Spaniards show a preference towards
poultry and processed meat.
Interesting patterns are also revealed when food availability is studied accord-
ing to the degree of urbanisation of the permanent residence (household local-
ity). A general trend is noticed: the availability of added lipids decreases as one
moves from the rural to the urban areas (the DafneSoft, www.nut.uoa.gr). This is
also true for the availability of vegetable oils. Norway is an exception; here veg-
etable oil availability increases in the urban areas, whereas the opposite is true
for total added lipids. This pattern could be interpreted in terms of easier access
to information on health issues and current nutrition advice among urban popu-
lations; People living in the urban areas have a lower overall consumption of
lipids, and a higher consumption of vegetable oils.
26 The nutrition handbook for food processors
Fresh vegetables
(g/prs/day)
1.00–120.99 (5)
121.00–162.99 (4)
163.00–204.18 (3)
Fig. 2.6 Availability of fresh vegetables, in 12 DAFNE countries, around 1990
(g/person/day). (Trichopoulou, 2001)
1.00–159.99 (7)
160.00–239.99 (2)
240.00–236.00(3)
Fresh Fruits
(g/prs/day)
Fig. 2.7 Availability of fresh fruits, in 12 DAFNE countries, around 1990 (g/person/day).
(Trichopoulou, 2001)
0
50
100
150
200
250
BE GR HU IT LU NO PL PT ES
Illiterate/Elementary education incomplete Elementary education completed Secondary education incomplete
Secondary education completed
University/College
Fig. 2.8 Average availability of meat (red meat, poultry and meat products) by educa-
tional level of household head, around 1990 (g/person/day). (Trichopoulou, 2001)
(BE = Belgium; GR = Greece; HU = Hungary; IT = Italy; LU = Luxembourg;
NO = Norway; PL = Poland; PT = Portugal; ES = Spain)
Data collected in the context of national surveys presented in Table 2.1 have
been included in numerous reports and scientific papers, readily accessible in the
international literature. Information on food consumption patterns of selected
European populations can also be retrieved from publications referring to
country-specific cohorts of the EPIC study (Kesse et al, 2001; Schulze et al, 2001;
Fraser et al, 2000; Agudo and Pera, 1999). The large volume of nutritional data
collected in EPIC is now being analysed and results on the dietary pattern of the
EPIC cohort of ten European countries will soon be published. Furthermore, to
overcome possible inconsistencies among the national food composition tables,
the EPIC investigators are now in the process of developing standardised tables,
which will serve for harmonised estimations of nutrient intake.
Information on the dietary patterns of selected European populations may also
be retrieved from publications of the Euronut-SENECA study on the nutrition of
an elderly population. Examination of the SENECA data reveals considerable
variability in dietary intake within and between countries (De Groot et al, 1992).
The SENECA data further pinpoints groups of elderly with inappropriate meal
frequency, persons not having regular cooked meals, persons eating alone and
those with food-budgeting problems (de Groot and van Staveren, 2000).
2.7 Future trends
The majority of sources of dietary data clearly suggest that there remains con-
siderable room for improvement in the Europeans’ diet. As we enter a new mil-
lennium weighted with much information, priorities could be set to clarify the
objectives of a prudent diet. Are they to prolong life as much as possible, or to
maximise quality-adjusted life expectancy? We must also consider externalities
that should take into account our cultural heritage, protection of the environment
and macroeconomic considerations.
The factors influencing consumer choice are many and varied. It is thus na?ve
to assume that in order to promote healthy eating it is sufficient to tell consumers
what constitutes a healthy diet. An effective strategy to improve nutritional health
must address a wide range of conceptions, misconceptions and perceptions, con-
cerning diet and its effects on health and disease.
The Mediterranean diet has been identified as ‘the most realistic alternative,
open to people long-used to Western type of diet’ (Trichopoulou and Lagiou,
1997a). Furthermore, four studies have been published, evaluating the role of
the Mediterranean diet, as operationally defined through the following eight
components:
? high monounsaturated-to-saturated lipid ratio (mainly olive oil),
? moderate ethanol consumption,
? high consumption of legumes,
? high consumption of cereals (including bread),
? high consumption of fruits,
? high consumption of vegetables,
28 The nutrition handbook for food processors
? low consumption of meat and meat products,
? moderate consumption of milk and dairy products.
The first of these studies was conducted in Greece (Trichopoulou et al, 1995),
the second in Denmark (Osler and Schroll, 1997), the third in Australia (Kouris-
Blazos et al, 1999) and the fourth in Spain (Lasheras et al, 2000). All have shown
that the Mediterranean diet has beneficial, substantial and statistically significant
effects on longevity.
2.8 Sources of further information and advice
Data on dietary patterns of European citizens can be retrieved from:
1. The World Health Organisation, Regional Office for Europe, available at
www.who.dk
2. WHO Regional Office for Europe. Program for Nutrition and Food Security
(2001). Urban and peri-urban food and nutrition action plan. Elements for
community action to promote social cohesion and reduce inequalities through
local production and local consumption.
3. The Food and Agriculture Organisation, available at www.fao.org
4. The DAFNE Software Program (DafneSoft v1.0), which can be freely down-
loaded at www.nut.uoa.gr
5. Dietary Patterns in Europe in 10 Countries Participating in the EPIC Study.
Public Health Nutrition Special Issue (to be published in August 2002)
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