Adriënne Cavelaars

Projected Prevalence of Inadequate Nutrient Intakes in Europe

Background: The purpose of this study was to analyze the prevalence of nutrient intake inadequacy in Europe, applying the Nordic Nutritional Recommendations in the context of the EURRECA Network of Excellence. Methods: Nutrient data was obtained from the European Nutrition and Health Report II. Those nutritional surveys using a validated food frequency questionnaire or diet history and a food diary/ register with at least 7 days of registers or with an adjustment for intraindividual variability were included. The nutrients analyzed were: vitamin C, vitamin D, vitamin B12, folic acid, calcium, iron, zinc, selenium, copper, and iodine. The estimated average requirement cut point was applied to estimate inadequacy. The Nordic and Institute of Medicine nutrient recommendations were used as references. Results: The mean prevalence of inadequacy was below 11% for zinc, iron, and vitamin B12 (only in the elderly), and it was 11–20% for copper in adults and the elderly and for vitamin B12 in adults and vitamin C in the elderly. The prevalence was above 20% for vitamin D, folic acid, calcium, selenium, and iodine in adults and the elderly and for vitamin C in adults. Conclusions: Vitamin C, vitamin D, folic acid, calcium, selenium, and iodine were the nutrients showing a higher prevalence of inadequate intakes in Europe.

Current micronutrient recommendations in Europe: towards understanding their differences and similarities

BackgroundNowadays most countries in Europe have established their own nutrient recommendations to assess the adequacy of dietary intakes and to plan desirable dietary intakes. As yet there is no standard approach for deriving nutrient recommendations, they may vary from country to country. This results in different national recommendations causing confusion for policy-makers, health professionals, industry, and consumers within Europe. EURRECA (EURopean micronutrient RECommendations Aligned) is a network of excellence funded by the European Commission (EC), and established to identify and address the problem of differences between countries in micronutrient recommendations. The objective of this paper is to give an overview of the available micronutrient recommendations in Europe, and to provide information on their origin, concepts and definitions. Furthermore this paper aims to illustrate the diversity in European recommendations on vitamin A and vitamin D, and to explore differences and commonalities in approaches that could possibly explain variations observed.MethodsA questionnaire was developed to get information on the process of establishing micronutrient recommendations. These questionnaires were sent to key informants in the field of micronutrient recommendations to cover all European countries/regions. Also the latest reports on nutrient recommendations in Europe were collected. Standardisation procedures were defined to enable comparison of the recommendations. Recommendations for vitamin A and vitamin D were compared per sex at the ages 3, 9 months and 5, 10, 15, 25, 50 and 70 years. Information extracted from the questionnaires and reports was compared focusing on: (1) The concept of recommendation (recommended daily allowance (RDA), adequate intake (AI) or acceptable range), (2) The year of publication of the report (proxy for available evidence), (3) Population groups defined, (4) Other methodological issues such as selected criteria of adequacy, the type of evidence used, and assumptions made.ResultsTwenty-two countries, the World Health Organization (WHO)/the Food and Agriculture Organization of the United Nations (FAO) and the EC have their own reports on nutrient recommendations. Thirteen countries based their micronutrient recommendations on those from other countries or organisations. Five countries, WHO/FAO and the EC defined their own recommendations. The DACH-countries (Germany, Austria and Switzerland) as well as the Nordic countries (Norway, Sweden, Finland, Denmark and Iceland) cooperated in setting recommendations. Greece and Portugal use the EC and the WHO/FAO recommendations, respectively and Slovenia adopted the recommendations from the DACH-countries. Rather than by concepts, definitions, and defined population groups, variability appears to emerge from differences in criteria for adequacy, assumptions made and type of evidence used to establish micronutrient recommendations.DiscussionThe large variation in current micronutrient recommendations for population groups as illustrated for vitamin A and vitamin D strengthens the need for guidance on setting evidence based, up-to-date European recommendations. Differences in endpoints, type of evidence used to set recommendations, experts’ opinions and assumptions are all likely to contribute to the identified variation. So far, background information was not sufficient transparent to disentangle the relative contribution of these different aspects.ConclusionEURRECA has an excellent opportunity to develop tools to improve transparency on the approaches used in setting micronutrient recommendations, including the selection of criteria for adequacy, weighing of evidence, and interpretation of data.

Socio-economic determinants of micronutrient intake and status in Europe: a systematic review

OBJECTIVE To provide the evidence base for targeted nutrition policies to reduce the risk of micronutrient/diet-related diseases among disadvantaged populations in Europe, by focusing on: folate, vitamin B12, Fe, Zn and iodine for intake and status; and vitamin C, vitamin D, Ca, Se and Cu for intake. DESIGN MEDLINE and Embase databases were searched to collect original studies that: (i) were published from 1990 to 2011; (ii) involved >100 subjects; (iii) had assessed dietary intake at the individual level; and/or (iv) included best practice biomarkers reflecting micronutrient status. We estimated relative differences in mean micronutrient intake and/or status between the lowest and highest socio-economic groups to: (i) evaluate variation in intake and status between socio-economic groups; and (ii) report on data availability. SETTING Europe. SUBJECTS Children, adults and elderly. RESULTS Data from eighteen publications originating primarily from Western Europe showed that there is a positive association between indicators of socio-economic status and micronutrient intake and/or status. The largest differences were observed for intake of vitamin C in eleven out of twelve studies (5-47 %) and for vitamin D in total of four studies (4-31 %). CONCLUSIONS The positive association observed between micronutrient intake and socio-economic status should complement existing evidence on socio-economic inequalities in diet-related diseases among disadvantaged populations in Europe. These findings could provide clues for further research and have implications for public health policy aimed at improving the intake of micronutrients and diet-related diseases.

EURRECA's Approach for Estimating Micronutrient Requirements

In Europe, micronutrient dietary reference values have been established by (inter)national committees of experts and are used by public health policy decision-makers to monitor and assess the adequacy of diets within population groups. The approaches used to derive dietary reference values (including average requirements) vary considerably across countries, and so far no evidence-based reason has been identified for this variation. Nutrient requirements are traditionally based on the minimum amount of a nutrient needed by an individual to avoid deficiency, and is defined by the bodys physiological needs. Alternatively the requirement can be defined as the intake at which health is optimal, including the prevention of chronic diet-related diseases. Both approaches are confronted with many challenges (e. g., bioavailability, inter and intra-individual variability). EURRECA has derived a transparent approach for the quantitative integration of evidence on Intake-Status-Health associations and/or Factorial approach (including bioavailability) estimates. To facilitate the derivation of dietary reference values, EURopean micronutrient RECommendations Aligned (EURRECA) is developing a process flow chart to guide nutrient requirement-setting bodies through the process of setting dietary reference values, which aims to facilitate the scientific alignment of deriving these values.

Folate Intake and Markers of Folate Status in Women of Reproductive Age, Pregnant and Lactating Women: A Meta-Analysis

Background. Pregnant and breastfeeding women are at risk for folate deficiency. Folate supplementation has been shown to be associated with enhanced markers of folate status. However, dose-response analyses for adult women are still lacking. Objective. To assess the dose-response relationship between total folate intake (folic acid plus dietary folate) and markers of folate status (plasma/serum folate, red blood cell folate, and plasma homocysteine); to evaluate potential differences between women in childbearing age, pregnant and lactating women. Methods. Electronic literature searches were carried out on three databases until February 2010. The overall pooled regression coefficient (β) and SE(β) were calculated using meta-analysis on a double-log scale. Results. The majority of data was based on nonpregnant, nonlactating women in childbearingage. The pooled estimate of the relationship between folate intake and serum/plasma folate was 0.56 (95% CI = 0.40–0.72, P < 0.00001); that is, the doubling of folate intake increases the folate level in serum/plasma by 47%. For red blood cell folate, the pooled-effect estimate was 0.30 (95% CI = 0.22–0.38, P < 0.00001), that is, +23% for doubling intake. For plasma-homocysteine it was –0.10 (95% = –0.17 to –0.04, P = 0.001), that is, –7% for doubling the intake. Associations tended to be weaker in pregnant and lactating women. Conclusion. Significant relationships between folate intake and serum/plasma folate, red blood cell folate, and plasma homocysteine were quantified. This dose-response methodology may be applied for setting requirements for women in childbearing age, as well as for pregnant and lactating women.

Micronutrient intake and status in Central and Eastern Europe compared with other European countries, results from the EURRECA network

OBJECTIVE To compare micronutrient intakes and status in Central and Eastern Europe (CEE) with those in other European countries and with reference values. DESIGN Review of the micronutrient intake/status data from open access and grey literature sources from CEE. SETTING Micronutrients studied were folate, iodine, Fe, vitamin B12 and Zn (for intake and status) and Ca, Cu, Se, vitamin C and vitamin D (for intake). Intake data were based on validated dietary assessment methods; mean intakes were compared with average nutrient requirements set by the Nordic countries or the US Institute of Medicine. Nutritional status was assessed using the status biomarkers and cut-off levels recommended primarily by the WHO. SUBJECTS For all population groups in CEE, the mean intake and mean/median status levels were compared between countries and regions: CEE, Scandinavia, Western Europe and Mediterranean. RESULTS Mean micronutrient intakes of adults in the CEE region were in the same range as those from other European regions, with exception of Ca (lower in CEE). CEE children and adolescents had poorer iodine status, and intakes of Ca, folate and vitamin D were below the reference values. CONCLUSIONS CEE countries are lacking comparable studies on micronutrient intake/status across all age ranges, especially in children. Available evidence showed no differences in micronutrient intake/status in CEE populations in comparison with other European regions, except for Ca intake in adults and iodine and Fe status in children. The identified knowledge gaps urge further research on micronutrient intake/status of CEE populations to make a basis for evidence-based nutrition policy.

Physiological and public health basis for assessing micronutrient requirements in children and adolescents. The EURRECA network

This paper provides an overview of the current knowledge relating to the nutritional requirements and corresponding recommended nutrient intake values of children and adolescents for micronutrients and specificities related to these requirements in the course of childhood and adolescence in Europe. Aspects that can influence micronutrient requirements, such as physiological requirements and bioavailability of the nutrients in the organism, are discussed. The methodology used to obtain the data and also the main knowledge gaps regarding these concepts are emphasized. Methodological critical points in achieving the data and physiological aspects of children and adolescents are important in order to standardize the reference values for micronutrients among Europe for these stages of life.

Socioeconomic factors are associated with folate and vitamin B12 intakes and related biomarkers concentrations in European adolescents: the Healthy Lifestyle in Europe by Nutrition in Adolescence study

Because socioeconomic factors (SEFs) may influence dietary quality and vitamin intakes, this study aimed to examine associations between socioeconomic factors and folate and vitamin B12 intakes as well as their related biomarkers in the Healthy Lifestyle in Europe by Nutrition in Adolescence study. Vitamin intakes were obtained from two 24-hour recalls in 2253 participants (47% males). Vitamin B biomarkers were assessed in a subsample of 977 participants (46% males). Socioeconomic factors were assessed by questionnaire, and 1-way analysis of covariance and linear regression analysis were applied. For males and females, mean intakes of folate were 211.19 and 177.18 μg/d, and for vitamin B12, 5.98 and 4.54 μg/d, respectively. Levels of plasma folate, red blood cell folate, serum B12, and holotranscobalamin were 18.74, 807.19, 330.64, and 63.04 nmol/L in males, respectively, and 19.13, 770.16, 377.9, and 65.63 nmol/L in females, respectively. Lower folate intakes were associated with several SEFs, including maternal and paternal education in both sexes. Regarding folate biomarkers, lower plasma folate intakes were associated with single/shared care in males and with lower paternal occupation in females. Lower vitamin B12 intakes were associated with almost all the studied SEFs, except paternal occupation in both sexes. In females, when considering vitamin B12 biomarkers, lower plasma vitamin B12 was associated with lower maternal education and occupation, and lower holotranscobalamin was associated with lower maternal education and lower paternal occupation. In conclusion, from the set of socioeconomic determinants studied in a sample of European adolescents, maternal education and paternal occupation were more consistently associated with folate and vitamin B12 intakes and biomarkers concentrations.

Contents Vol. 59, 2011

A. Astrup, Copenhagen A. Berg, Freiburg Z.A. Bhutta, Karachi S.C. Bischoff , Stuttgart F. Branca, Rome R. Brigelius-Flohé, Nuthetal P.C. Calder, Southampton S. Carlson, Kansas City, Kan. I. Cetin, Milan R.J. Deckelbaum, New York, N.Y. T. Decsi, Pécs C.J. Field, Edmonton K. Godfrey, Southampton R. Hakkak, Little Rock, Ark. W.S. Harris, Sioux Falls, S. Dak. H. Hauner, Munich M. Hernández-Triana, Havana H. Heseker, Paderborn J. Kopecky, Prague M. Krawinkel, Giessen M. Lamprecht, Graz W. Langhans, Zurich J. Linseisen, Heidelberg O. Ljungqvist, Örebro J.A. Martinez, Pamplona H.J. McArdle, Aberdeen Y. Naito, Kyoto P.W. Nathanielsz, San Antonio, Tex. H. Oberritter, Bonn R. Saff ery, Parkville, Vic. W.H.M. Saris, Maastricht L. Serra-Majem, Las Palmas de Gran Canaria C. Sieber, Nürnberg A.P. Simopoulos, Washington, D.C. P. Singer, Petah Tikva N.W. Solomons, Guatemala City P. Stehle, Bonn I. Th orsdottir, Reykjavik K. Tontisirin, Nakhon Pathom R. Uauy, Santiago S. Villalpando, Cuernavaca Morelos T. Yoshikawa, Kyoto A. Zittermann, Bad Oeynhausen Founded 1959 as ‘Nutritio et Dieta’ by E. Azerad, H. Kapp and J. Trémolières. Continued by A. Wretlind (1961–1969). Continued by N. Zöllner (1970–1990) as ‘Nutrition and Metabolism’ (1970–1980), since 1980 integrating ‘Annales de la Nutrition et de l’Alimentation’, continued as ‘Annals of Nutrition and Metabolism’. Continued by G. Wolfram (1991–1999), Continued by I. Elmadfa (2000–2010) An Official Journal of International Union of Nutritional Sciences (IUNS) Federation of European Nutrition Societies (FENS) European Neutraceutical Association (ENA) Deutsche Gesellschaft für Ernährung (DGE)