Anna Brzozowska

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.

Hedonic tests in different locations as predictors of apple juice consumption at home in elderly and young subjects

Abstract The objective of this study was to evaluate the predictive value of hedonic tests on apple juice carried out in a sensory laboratory, University common room and at home (post-consumption test) on ad libitum home consumption measured over 5 consecutive days. Thirty-five elderly volunteers (59–88 years old) and 33 young subjects (20–30 years old) assessed the degree of liking five apple juices varying in sweetness (0, 2, 4, 7 and 10% w/w sucrose added) on a nine-point hedonic scale. Both age groups judged similarly the juice with the lowest sugar concentrations, whereas the juice with 2% sugar added received lower scores from the elderly compared to the young participants. Those samples with higher sweetness (4, 7 and 10%) received higher scores from the elderly compared to the young people. The sample with no sugar added had higher mean score (all the subjects) in the home test (6.92±1.78) compared to both laboratory (5.51±2.15) and common room (5.92±2.08). No such differences were observed for the juices with the other sugar contents. In the elderly group, 1-day intake of apple juice remained on a similar level, regardless of sweetness liking, while among young adults the intake varied, and was highest for juices that were liked most (with 0 and 2% sucrose added). The results showed that hedonic ratings have a limited value as predictors of fruit juice consumption at home. The correlation between rated degree of liking and intake was low, especially for the elderly ( r =0.39), indicating that factors other than pleasantness may affect intake. Among three test conditions, the lowest correlation of juice intake was obtained with laboratory test results ( r =0.38), relatively higher—when hedonic tests were conducted in common room setting ( r =0.49), or as the post-consumption test at home ( r =0.73). Further research is required on sensory procedures relevant for the elderly, which together with some other nonsensory factors, would give a better prediction of consumption.

Dietary Calcium and Magnesium Intake and Mortality: A Prospective Study of Men

The authors examined the association of dietary calcium and magnesium intake with all-cause, cardiovascular disease (CVD), and cancer mortality among 23,366 Swedish men, aged 45-79 years, who did not use dietary supplements. Cox proportional hazards regression models were used to estimate the multivariate hazard ratios and 95% confidence intervals of mortality. From baseline 1998 through December 2007, 2,358 deaths from all causes were recorded in the Swedish population registry; through December 2006, 819 CVD and 738 cancer deaths were recorded in the Swedish cause-of-death registry. Dietary calcium was associated with a statistically significant lower rate of all-cause mortality (hazard ratio (HR) = 0.75, 95% confidence interval (CI): 0.63, 0.88; P(trend) < 0.001) and a nonsignificantly lower rate of CVD (HR = 0.77, 95% CI: 0.58, 1.01; P(trend) = 0.064) but not cancer mortality (HR = 0.87, 95% CI: 0.65, 1.17; P(trend) = 0.362) when the highest intake tertile (mean = 1,953 mg/day; standard deviation (SD), 334) was compared with the lowest (990 mg/day; SD, 187). Dietary magnesium intake (means of tertiles ranged from 387 mg/day (SD, 31) to 523 mg/day (SD, 38) was not associated with all-cause, CVD, or cancer mortality. This population-based, prospective study of men with relatively high intakes of dietary calcium and magnesium showed that intake of calcium above that recommended daily may reduce all-cause mortality.

Diet quality and mortality: a population-based prospective study of men.

Background/Objectives:To study quality of diet in relation to all-cause mortality, cardiovascular disease (CVD) and cancer mortality.Subjects/Methods:The population-based prospective Cohort of Swedish Men (COSM) included 40 837 men, 45–79 years of age, who filled in a FFQ (96 food items) and were CVD- and cancer-free at baseline. Quality of diet was assessed by Recommended Food Score (RFS) based on 36 items and Non-Recommended Food Score (Non-RFS) based on 16 items. Coxs proportional hazards regression models were used to estimate the hazard ratios (HRs) of mortality and 95% confidence intervals (CIs). Multivariate HRs for RFS and Non-RFS were adjusted for age, education, physical activity, martial status, self-perceived health status, smoking status, dietary supplements use, WHR, alcohol use, intake of energy and mutually adjusted.Results:Between 1998 and 2005, 4501 deaths from all-causes were registered. Between 1998 and 2003, there were 1394 CVD and 759 cancer deaths. High RFS (⩾28) compared with low (⩽20) was associated with lower risk of all-cause mortality (HR: 0.81; 95% CI: 0.71–0.91; P-value for trend<0.0001) and CVD mortality (HR: 0.71; 95% CI: 0.54–0.93; P-value for trend=0.003). In contrast, men with high Non-RFS (⩾5) had higher risk of all-cause (HR: 1.21; 95% CI: 1.09–1.34; P-value for trend=0.001) and CVD mortality (HR: 1.27; 95% CI: 1.05–1.54; P-value for trend=0.07) compared to those with low Non-RFS (⩽2 items). No significant associations with cancer mortality were observed.Conclusions:Both measures of diet quality, RFS and Non-RFS, showed statistically significant associations with all-cause and CVD mortality (recommended foods inversely while nonrecommended foods positively), but not with cancer mortality.

How we will produce the evidence-based EURRECA toolkit to support nutrition and food policy

BackgroundThere is considerable variation in the recommended micronutrient intakes used by countries within Europe, partly due to different methodologies and concepts used to determine requirements and different approaches used to express the recommendations. As populations become more mobile and multi-national, and more traditional foods become available internationally, harmonised recommendations based on up to date science are needed. This was recognised by the European Commission’s (EC) Directorate-General (DG) Research in their 2005 call for proposals for a Network of Excellence (NoE) on ’nutrient status and requirements of specific vulnerable population groups’. EURopean micronutrient RECommendations Aligned (EURRECA), which has 34 partners representing 17 European countries, started on its 5-year EC-funded programme in January 2007. The programme of work was developed over 2 years prior to submitting an application to the EC. The Network’s first Integrating Meeting (IM) held in Lisbon in April 2007, and subsequent consultations, has allowed further refinement of the programme.AimThis paper presents the rationale for the EURRECA Network’s roadmap, which starts by establishing the status quo for devising micronutrient recommendations. The Network has the opportunity to identify previous barriers and then explore ’evidence-based’ solutions that have not been available before to the traditional panels of experts. The network aims to produce the EURRECA ’toolkit’ to help address and, in some cases, overcome these barriers so that it can be used by those developing recommendations.ResultsThe status quo has been largely determined by two recent initiatives; the Dietary Reference Intake (DRI) reports from the USA and Canada and suggestions for approaches to international harmonisation of nutrient-based dietary standards from the United Nations University (UNU). In Europe, the European Food Safety Authority (EFSA) has been asked by the EC’s Directorate-General for Health and Consumer Protection to produce values for micronutrient recommendations. Therefore, EURRECA will draw on the uniqueness of its consortium to produce the sustainable EURRECA toolkit, which will help make such a task more effective and efficient. Part of this uniqueness is the involvement in EURRECA of small and medium-sized enterprises (SMEs), consumer organisations, nutrition societies and other stakeholders as well as many scientific experts. The EURRECA toolkit will contain harmonised best practice guidance for a more robust science base for setting micronutrient recommendations. Hence, in the future, the evidence base for deriving nutrient recommendations will have greater breadth and depth and will be more transparent.ConclusionsThe EURRECA Network will contribute to the broader field of food and nutrition policy by encouraging and enabling the alignment of nutrient recommendations. It will do this through the development of a scientific toolkit by its partners and other stakeholders across Europe. This will facilitate and improve the formulation of micronutrient recommendations, based on transparently evaluated and quantified scientific evidence. The Network aims to be sustainable beyond its EC funding period.

Vitamin B12, Folate, Homocysteine, and Bone Health in Adults and Elderly People: A Systematic Review with Meta-Analyses

Elevated homocysteine levels and low vitamin B12 and folate levels have been associated with deteriorated bone health. This systematic literature review with dose-response meta-analyses summarizes the available scientific evidence on associations of vitamin B12, folate, and homocysteine status with fractures and bone mineral density (BMD). Twenty-seven eligible cross-sectional (n = 14) and prospective (n = 13) observational studies and one RCT were identified. Meta-analysis on four prospective studies including 7475 people showed a modest decrease in fracture risk of 4% per 50 pmol/L increase in vitamin B12 levels, which was borderline significant (RR = 0.96, 95% CI = 0.92 to 1.00). Meta-analysis of eight studies including 11511 people showed an increased fracture risk of 4% per μmol/L increase in homocysteine concentration (RR = 1.04, 95% CI = 1.02 to 1.07). We could not draw a conclusion regarding folate levels and fracture risk, as too few studies investigated this association. Meta-analyses regarding vitamin B12, folate and homocysteine levels, and BMD were possible in female populations only and showed no associations. Results from studies regarding BMD that could not be included in the meta-analyses were not univocal.

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.

Discriminability and appropriateness of category scaling versus ranking methods to study sensory preferences in elderly

Abstract Two methods: the nine-point hedonic scale and hedonic ranking, have been compared for their discrimination power and appropriateness when studying hedonic responses in elderly. A group of 35 elderly subjects (aged 60–88) and a control group of 35 young adults (aged 20–25) participated in the comparison. Five samples of each of two commercial fruit juices (apple and orange) differing in sensory profiles served as test material. Generally hedonic discriminability in elderly was lower than in young subjects for both methods. Ranking appeared to be more discriminating for apple juice samples, where hedonic differences among samples were smaller ( F sample apple =8.80); for orange juice samples, of more pronounced hedonic differences ( F sample orange =17.24) both methods revealed equal discriminability. From simplicity of the task and “user friendliness” of the tasting procedure, hedonic ranking seems to have some advantages over nine-point hedonic scaling. Results obtained by both methods for both juices were significantly correlated for elderly as well as for young subjects. However, the strength of correlation (Spearman R value) in elderly was much lower ( R apple =0.2217; R orange =0.2213) than in young ( R apple =0.4766; R orange =0.4844). Repeatability of hedonic assessment of orange juice samples performed by elderly ( n =27) 2 weeks after first evaluation for both methods was very good and did not show any advantage of one method over another.

Vitamin B12 Intake and Status and Cognitive Function in Elderly People

Current recommendations on vitamin B12 intake vary from 1.4 to 3.0 μg per day and are based on the amount needed for maintenance of hematologic status or on the amount needed to compensate obligatory losses. This systematic review evaluates whether the relation between vitamin B12 intake and cognitive function should be considered for underpinning vitamin B12 recommendations in the future. The authors summarized dose-response evidence from randomized controlled trials and prospective cohort studies on the relation of vitamin B12 intake and status with cognitive function in adults and elderly people. Two randomized controlled trials and 6 cohort studies showed no association or inconsistent associations between vitamin B12 intake and cognitive function. Random-effects meta-analysis showed that serum/plasma vitamin B12 (50 pmol/L) was not associated with risk of dementia (4 cohort studies), global cognition z scores (4 cohort studies), or memory z scores (4 cohort studies). Although dose-response evidence on sensitive markers of vitamin B12 status (methylmalonic acid and holotranscobalamin) was scarce, 4 of 5 cohort studies reported significant associations with risk of dementia, Alzheimers disease, or global cognition. Current evidence on the relation between vitamin B12 intake or status and cognitive function is not sufficient for consideration in the development of vitamin B12 recommendations. Further studies should consider the selection of sensitive markers of vitamin B12 status.

Supplement use and mortality: the SENECA study

BackgroundIt is hypothesis that in relatively healthy older people supplement usage can be consider as healthy life style habit and as such can positively influence longevity.Aim of the studyTo determine whether supplement use was associated with all-cause mortality in the participants of the SENECA study.MethodsBaseline measurements were carried out in 1988/1989 among 75 to 80-year-old people living in 15 European small towns. All-cause mortality was followed up to April 30, 1999. Data from 920 men and 980 women who were ischemic heart diseases-, stroke- and cancer-free at baseline were included. The multivariate adjusted (for sex, age, years of education, physical activity, BMI, chronic diseases, Mediterranean Diet Score, alcohol use and the place of living) hazard ratio (HRs) and 95% confidence intervals (CIs) of mortality by use of any type of nutrient supplement and by particular nutrient supplement use were estimated by Cox proportional hazards regression models.ResultsAt baseline, 13% of participants used nutritional supplements, 19% of subjects were smokers. During 10 years of follow-up 445 men and 252 women died. Among non-smokers no significant associations between total supplement use and particular nutrient supplement use were observed. Among smokers use of any type of supplements (Multivariate HR: 1.52; 95%CI: 1.02–2.28), use of vitamin B1 (Multivariate HR: 1.57; 95%CI: 1.00–2.48) and vitamin B2 supplements (Multivariate HR: 1.60; 95%CI: 1.00–2.56) were associated with a significantly higher risk of all-cause mortality. The similar tendencies were observed among vitamin B6 and vitamin C supplement users who were smokers.ConclusionsAmong smokers, participants of the SENECA study, supplement use increased all-cause mortality risk.