Kerstin Klipstein-Grobusch

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

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.

A dietary pattern protective against type 2 diabetes in the European Prospective Investigation into Cancer and Nutrition (EPIC)--Potsdam Study cohort.

Aims/hypothesisThe aim of this study was to identify a dietary pattern associated with diabetes-related biomarkers and to investigate whether this pattern is associated with the incidence of type 2 diabetes.MethodsA nested case–control study of 192 cases of incident type 2 diabetes and 382 control subjects matched for sex and age was conducted. All subjects were participants in the population-based European Prospective Investigation into Cancer and Nutrition (EPIC)—Potsdam Study. Dietary pattern score was derived using intake data on 48 food groups as exposure variables and the biomarkers HbA1c, HDL cholesterol, C-reactive protein and adiponectin as response variables in reduced rank regression. The association of the score with diabetes risk was estimated by conditional logistic regression analysis.ResultsA high score for the identified dietary pattern was characterised by a high intake of fresh fruit and a low intake of high-caloric soft drinks, beer, red meat, poultry, processed meat, legumes and bread (excluding wholegrain bread). Subjects with high scores had high plasma concentrations of HDL cholesterol and adiponectin and low plasma concentrations of HbA1c and C-reactive protein. After multivariate adjustment, the odds ratios for type 2 diabetes across increasing quintiles of the dietary pattern score were 1.0, 0.59, 0.51, 0.26 and 0.27, respectively (p=0.0006 for trend).Conclusions/interpretationA high score for the identified dietary pattern is associated with a more favourable biomarker profile and a substantially reduced incidence of type 2 diabetes.

Patterns of alcohol consumption in 10 European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) project

OBJECTIVE The aim of this study was to compare the quantities of alcohol and types of alcoholic beverages consumed, and the timing of consumption, in centres participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). These centres, in 10 European countries, are characterised by widely differing drinking habits and frequencies of alcohol-related diseases. METHODS We collected a single standardised 24-hour dietary recall per subject from a random sample of the EPIC cohort (36 900 persons initially and 35 955 after exclusion of subjects under 35 and over 74 years of age). This provided detailed information on the distribution of alcohol consumption during the day in relation to main meals, and was used to determine weekly consumption patterns. The crude and adjusted (by age, day of week and season) means of total ethanol consumption and consumption according to type of beverage were stratified by centre and sex. RESULTS Sex was a strong determinant of drinking patterns in all 10 countries. The highest total alcohol consumption was observed in the Spanish centres (San Sebastian, 41.4 g day-1) for men and in Danish centres (Copenhagen, 20.9 g day-1) for women. The lowest total alcohol intake was in the Swedish centres (Umeå, 10.2 g day-1) in men and in Greek women (3.4 g day-1). Among men, the main contributor to total alcohol intake was wine in Mediterranean countries and beer in the Dutch, German, Swedish and Danish centres. In most centres, the main source of alcohol for women was wine except for Murcia (Spain), where it was beer. Alcohol consumption, particularly by women, increased markedly during the weekend in nearly all centres. The German, Dutch, UK (general population) and Danish centres were characterised by the highest percentages of alcohol consumption outside mealtimes. CONCLUSIONS The large variation in drinking patterns among the EPIC centres provides an opportunity to better understand the relationship between alcohol and alcohol-related diseases.

Prevalence of HIV among those 15 and older in rural South Africa

A greater knowledge of the burden of HIV in rural areas of Southern Africa is needed, especially among older adults. We conducted a cross-sectional biomarker survey in the rural South African Agincourt Health and Socio-demographic Surveillance site in 2010–2011 and estimated HIV prevalence and risk factors. Using an age–sex stratified random sample of ages 15+, a total of 5037 (65.7%) of a possible 7662 individuals were located and 4362 (86.6%) consented to HIV testing. HIV prevalence was high (19.4%) and characterized by a large gender gap (10.6% for men and 23.9% for women). Rates peaked at 45.3% among men and 46.1% among women – both at ages 35–39. Compared with a similar study in the rural KwaZulu-Natal Province, South Africa, peak prevalence occurred at later ages, and HIV prevalence was higher among older adults – with rates above 15% for men and 10% for women through to age 70. High prevalence continues to characterize Southern Africa, and recent evidence confirms that older adults cannot be excluded from policy considerations. The high prevalence among older adults suggests likely HIV infection at older ages. Prevention activities need to expand to older adults to reduce new infections. Treatment will be complicated by increased risk of noncommunicable diseases and by increasing numbers of older people living with HIV.

The association of pattern of lifetime alcohol use and cause of death in the European Prospective Investigation into Cancer and Nutrition (EPIC) study

BACKGROUND There is limited evidence for an association between the pattern of lifetime alcohol use and cause-specific risk of death. METHODS Multivariable hazard ratios were estimated for different causes of death according to patterns of lifetime alcohol consumption using a competing risks approach: 111 953 men and 268 442 women from eight countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study were included. Self-reported alcohol consumption at ages 20, 30, 40 or 50 years and at enrollment were used for the analysis; 26 411 deaths were observed during an average of 12.6 years of follow-up. RESULTS The association between lifetime alcohol use and death from cardiovascular diseases was different from the association seen for alcohol-related cancers, digestive, respiratory, external and other causes. Heavy users (>5 drinks/day for men and >2.5 drinks/day for women), regardless of time of cessation, had a 2- to 5-times higher risk of dying due to alcohol-related cancers, compared with subjects with lifetime light use (≤1 and ≤0.5 drink/week for men and women, respectively). Compared with lifetime light users, men who used <5 drinks/day throughout their lifetime had a 24% lower cardiovascular disease mortality (95% confidence interval 2-41). The risk of death from coronary heart disease was also found to be 34-46% lower among women who were moderate to occasionally heavy alcohol users compared with light users. However, this relationship was only evident among men and women who had no chronic disease at enrollment. CONCLUSIONS Limiting alcohol use throughout life is associated with a lower risk of death, largely due to cardiovascular disease but also other causes. However, the potential health benefits of alcohol use are difficult to establish due to the possibility of selection bias and competing risks related to diseases occurring later in life.

Plasma folate as marker of folate status in epidemiological studies: the European Investigation into Cancer and Nutrition (EPIC)-Potsdam study

Folate deficiency is often discussed as a potential risk factor for CVD and some cancers. Reliable assessment of folate status in large-scale epidemiological studies is therefore of major importance. The present study assessed the value of plasma folate (PF) compared with erythrocyte folate (EF) as a marker of folate status in 363 participants in the European Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort. EF and PF, total homocysteine (tHcy), pyridoxine, cobalamin, creatinine, total protein and packed cell volume were determined; glutamate carboxypeptidase (GCP) C1561T, reduced folate carrier (RFC) G80A and methylenetetrahydrofolate (MTHFR) C677T polymorphisms were analysed. Anthropometric measurements were taken and dietary intake was assessed with the EPIC-Potsdam food-frequency questionnaire. Comparison of EF and PF with factors that may modulate their concentrations was performed. Cross-classification of blood folates in quintile categories resulted in correct classification into the same or adjacent category of 75.5 % of all subjects. Age, BMI, pyridoxine and cobalamin, fruit and vegetable intake, and vitamin supplementation 24 h before blood draw were positively associated with EF and with PF. For tHcy an inverse association was found. Participants with the MTHFR 677TT genotype showed significantly elevated EF concentrations compared with those with 677CT genotype; EF and PF were more strongly correlated (r 0.78, P<0.0001) for participants with MTHFR 677TT genotype than for those with the 677CC or 677CT genotype. In summary, our present results indicate that plasma folate seems to be a suitable marker for assessment of folate status for use in large-scale epidemiological studies.

Obesity as a major determinant of underreporting in a self-administered food frequency questionnaire : Results from the EPIC-Potsdam study

SummaryThe phenomenon of underreporting of dietary intake has been observed previously in many epidemiologic studies. In this study it was investigated whether dependencies exist between energy intake obtained by a semi-quantitative, self-administered food frequency questionnaire and lifestyle or anthropometric factors, particularly obesity.The study population consisted of 2 531 subjects, men aged 40 to 64 years and women aged 35 to 64 years from the general population of Potsdam and the surrounding areas. First, subjects were allocated into quintiles of the ratio ‘reported energy intake (EI)’ to ‘calculated basal metabolic rate (BMR)’ as a measure of age and weight adjusted energy intake. No apparent dependencies between socio-economic variables and the ratio EI/BMR were observed. Among anthropometric variables, BMI and related measures of obesity were inversely related to the ratio EI/BMR in men and women. While dietary intake was directly related to the ratio EI/BMR in absolute quantities, energy adjusted intake of fat, protein, carbohydrate, and alcohol was found to be independent of this ratio. Energy adjusted food group consumption was also found to be independent of the ratio EI/BMR, showing only slightly increasing trends across quintiles of EI/BMR for cereals and fats, and a slightly decreasing trend for sweet foods in women. When subjects were classified into three categories of BMI, reported energy intake decreased across categories. Estimated energy expenditure based on BMR was increasing with BMI categories. A close direct relationship was observed between BMI categories and the difference between reported energy intake and estimated energy expenditure.It is concluded that obesity is a major determinant of underreporting. Energy adjusted dietary variables were found to be largely independent of such methodological influences.ZusammenfassungDie Angaben zur Energie- und Nährstoffaufnahme aus einem semi-quantitativen Verzehrshäufigkeits-Fragebogen wurden auf eine mögliche Unterschätzung in Abhängigkeit vom relativen Körpergewicht untersucht. Die Studienpopulation bildeten 2 531 Personen aus Potsdam und den umliegenden Gemeinden, Männer im Alter von 40 bis 64 Jahren und Frauen im Alter von 35 bis 64 Jahren.Das Verhältnis von Energieaufnahme (EI) zu Grundumsatz (BMR) diente als Maß für die alters- und gewichtsunabhängige relative Energieaufnahme. Die Studienteilnehmer wurden auf Basis des Parameters EI/BMR in Quintile eingeteilt. Zwischen dem body mass index (BMI) und dem Parameter EI/BMR konnte, bei Männern und Frauen, ein inverses Verhältnis beobachtet werden. Zwischen verschiedenen sozio-ökonomischen Variablen und EI/BMR zeigte sich dagegen kein Zusammenhang. Während die absolute Nährstoffaufnahme mit steigendem EI/BMR zunahm, war der energieadjustierte Verzehr von Fett, Protein, Kohlenhydraten und Alkohol unabhängig von der relativen Energieaufnahme. Der Verzehr aus Lebensmittelgruppen, ebenfalls energieadjustiert, zeigte bei Frauen einen leicht ansteigenden Trend über die EI/BMR-Quintile für die Gruppen, ‚Getreide‘ und ‘Fette’ sowie einen leicht abfallenden Trend für ‚Süßigkeiten‘. Nach Zuordnung der Meßwerte in drei BMI-Kategorien, zeigte sich, daß die angegebene Energieaufnahme mit zunehmendem BMI abnahm. Der auf Basis des BMR geschätzte Energieverbrauch stieg dagegen über die BMI-Kategorien an. Es konnte ein direkter Zusammenhang zwischen der Differenz von angegebener Energieaufnahme und geschätztem Energieverbrauch und dem relativen Körpergewicht beobachtet werden.Die Ergebnisse zeigen, daß Übergewicht als ein wesentlicher Prädiktor für die Unterschätzung der Energieaufnahme gelten kann. Energieadjustierte Werte der Nährstoffaufnahme erscheinen unabhängig von dem methodischen Einfluß der Unterschätzung.

Predictors of adolescent weight status and central obesity in rural South Africa.

OBJECTIVE To investigate predictors of adolescent obesity in rural South Africa. DESIGN Cross-sectional study. Height, weight and waist circumference were measured using standard procedures. Overweight and obesity in adolescents aged 10-17 years were assessed using the International Obesity Taskforce cut-offs, while the WHO adult cut-offs were used for participants aged 18-20 years. Waist-to-height ratio of >0.5 defined central obesity in those at Tanner stages 3-5. Linear and logistic regression analysis was used to evaluate risk factors. SETTING Agincourt sub-district, rural South Africa. SUBJECTS Participants (n 1848) were aged 10-20 years. RESULTS Combined overweight and obesity was higher in girls (15 %) than boys (4 %), as was central obesity (15 % and 2 %, respectively). With regard to overweight/obesity, fourfold higher odds were observed for girls and twofold higher odds were observed for participants from households with the highest socio-economic status (SES). The odds for overweight/obesity were 40 % lower if the household head had not completed secondary level education. For central obesity, the odds increased 10 % for each unit increase in age; girls had sevenfold higher odds v. boys; post-pubertal participants had threefold higher odds v. pubertal participants; those with older mothers aged 50+ years had twofold higher odds v. those whose mothers were aged 35-49 years; those in highest SES households had twofold higher odds v. those in lowest SES households. CONCLUSIONS In rural South Africa, adolescent females are most at risk of obesity which increases with age and appears to be associated with higher SES. To intervene effectively, it is essential to understand how household factors influence food choice, diet and exercise.

Nutritional status and HIV in rural South African children

BackgroundAchieving the Millennium Development Goals that aim to reduce malnutrition and child mortality depends in part on the ability of governments/policymakers to address nutritional status of children in general and those infected or affected by HIV/AIDS in particular. This study describes HIV prevalence in children, patterns of malnutrition by HIV status and determinants of nutritional status.MethodsThe study involved 671 children aged 12-59 months living in the Agincourt sub-district, rural South Africa in 2007. Anthropometric measurements were taken and HIV testing with disclosure was done using two rapid tests. Z-scores were generated using WHO 2006 standards as indicators of nutritional status. Linear and logistic regression analyses were conducted to establish the determinants of child nutritonal status.ResultsPrevalence of malnutrition, particularly stunting (18%), was high in the overall sample of children. HIV prevalence in this age group was 4.4% (95% CI: 2.79 to 5.97). HIV positive children had significantly poorer nutritional outcomes than their HIV negative counterparts. Besides HIV status, other significant determinants of nutritional outcomes included age of the child, birth weight, maternal age, age of household head, and area of residence.ConclusionsThis study documents poor nutritional status among children aged 12-59 months in rural South Africa. HIV is an independent modifiable risk factor for poor nutritional outcomes and makes a significant contribution to nutritional outcomes at the individual level. Early paediatric HIV testing of exposed or at risk children, followed by appropriate health care for infected children, may improve their nutritional status and survival.

Joint effects of risk factors for stroke and transient ischemic attack in a German population: the EPIC Potsdam Study.

BackgroundSingle, modifiable risk factors for stroke have extensively been studied. In contrast, differences of their combined effects among stroke and transitoy ischemic attack (TIA) have been rarely investigated. The aim of the present study was to assess single and joint effects of risk factors on the incidence of stroke and TIA and to compare their magnitudes in a large population-based German cohort.MethodsIncident cases of stroke and TIA were identified among 25538 participants (aged 35–65 at baseline) of the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Relative risks for stroke and TIA related to modifiable risk factors were estimated using Cox proportional hazard models.ResultsDuring 4.3 years of follow-up 100 stroke cases and 112 TIA cases occurred. Incidences of stroke and TIA were 91.7 and 102.7 per 100 000 person-years, respectively. Relative risks for ischemic stroke (RR 5.12, 95% CI 1.49–17.6, p for trend <0.0001) and for TIA (RR 3.08, 95% CI 1.00–9.44, p for trend <0.024) were highest among participants having 4 or 5 modifiable risk factors. 58.5% of ischemic strokes and 26.2% of TIA cases were attributable to the 5 risk factors hypertension, diabetes mellitus, high alcohol consumption, hyperlipidemia, and smoking.ConclusionOur data indicate that classical risk factors may explain almost 60% of ischemic stroke but only one in four TIA cases. Analysing potential differences of known risk factors between ischemic stroke and TIAs and the identification of other determinants of ischemic attacks are important steps to better explain the burden of stroke.