Margit Velsing Groth

A systematic review of socio-economic differences in food habits in Europe: consumption of fruit and vegetables

Objective: To evaluate the differences in the consumption of fruit and vegetables between groups with different socio-economic status (SES) in the adult population of European countries.Design: A systematic review of published and unpublished surveys of food habits conducted between 1985 and 1999 in 15 European countries. Educational level and occupational status were used as indicators of SES. A pooled estimate of the mean difference between the highest and the lowest level of education and occupation was calculated separately for men and women, using DerSimonian and Lairds random effects model.Setting: The inclusion criteria of studies were: use of a validated method for assessing intake at the individual level; selection of a nationwide sample or a representative sample of a region; and providing the mean and standard deviation of overall fruit and vegetable consumption for each level of education or occupation, and separately for men and women.Subjects: Participants in the individual surveys had to be adults (18–85 y).Results: Eleven studies from seven countries met the criteria for being included in the meta-analysis. A higher SES was associated with a greater consumption of both fruit and vegetables. The pooled estimate of the difference in the intake of fruit was 24.3 g/person/day (95% confidence interval (CI) 14.0–34.7) between men in the highest level of education and those in the lowest level of education. Similarly, this difference was 33.6 g/person/day for women (95% CI 22.5–44.8). The differences regarding vegetables were 17.0 g/person/day (95% CI 8.6–25.5) for men and 13.4 g/person/day (95% CI 7.1–19.7) for women. The results were in the same direction when occupation instead of education was used as an indicator of SES.Conclusions: Although we cannot exclude over-reporting of intake by those with highest SES, it is unlikely that this potential bias could fully explain the differences we have found. Our results suggest that an unhealthier nutrition pattern may exist among adults belonging to lower socio-economic levels in Europe.Sponsorship: The present study was supported by the European Unions FAIR programme (FAIR-97-3096).European Journal of Clinical Nutrition (2000) 54, 706–714

Social determinants of dietary habits in Denmark

Objective: To investigate whether there is an association between socioeconomic status and a healthy diet, taking the possible influence of other social variables such as age, gender, income and household composition into consideration.Design: Cross-sectional study.Setting: Nationwide study in Denmark, 1995.Subjects: Random sample from the civil registration system. A total of 852 men and 870 women aged 18-80 y participated, a response rate of 58%.Interventions: A 7 day estimated dietary record was used to obtain information about the diet. Information about social background was gained through face-to-face interview.Results: The intake of fruit and vegetables and the percentage energy (E%) from fat in the diet were significantly associated with the educational level of both men and women. For men with only basic schooling, the mean intake of vegetables and fat was 84 g/10 MJ and 41 E% respectively. Men with long higher education had a mean intake of 119 g/10 MJ of vegetables and 37 E% of fat. For women, the corresponding figures for the intake of vegetables and fat were 131 g/10 MJ and 38 E% and 175 g/10 MJ and 37 E%, respectively. For women, age, income and household composition were also significantly associated with the intake of fruit and vegetables.Conclusions: Education seems to be the most important social variable to explain social differences in dietary habits. Additional variables are needed to explain dietary habits of women. Differences are seen for both foods and nutrients.Sponsorship: The data analysis was financially supported by the Health Insurance Fund.European Journal of Clinical Nutrition (2001) 55, 959–966

Prevalence and trends in overweight and obesity among children and adolescents in Denmark

Aim: To study the current prevalence and trends in overweight and obesity among children and adolescents in Denmark from 1995 to 2000—2002. Methods: Cross-sectional national dietary surveys were conducted in 1995 and 2000—2002. The analysis was based on two random population samples from the Danish civil registration system. Body mass index (BMI) was calculated from self-reported height and weight for 1,026 and 1,152 children and adolescents (4—18 years), who participated in 1995 and 2000—2002, respectively. The prevalence of overweight and obesity was defined according to the international age and gender-specific child BMI cut-off points. In the statistical analysis, overweight and obesity were included in the prevalence of overweight. Results: Mean BMI increased significantly between 1995 and 2000—2002 for all combinations of age groups (4—6, 7—10, 11—14 and 15—18 years) and genders. Prevalence of overweight increased between survey years for boys and girls for all age groups (4—6, 7—10, 11—14 and 15—18 years), although formal statistical significance was not reached (p>0.05). When all children and adolescents (4—18 years) were analysed, the prevalence of overweight rose significantly from 10.9% (95% confidence interval (CI) 9.0—12.8) to 14.4% (95% CI 12.5—16.3) between 1995 and 2000— 2002 (p=0.01), whereas the increase in the prevalence of obesity did not reach significance (1995, 2.3% (95% CI 1.3—3.3) vs. 2000—2002, 2.4% (95% CI 1.6—3.3); p=0.74). Conclusions: The present study revealed a significant increase from 1995 to 2000—2002 in mean BMI for boys and girls for all age groups and a significant increase in the prevalence of overweight when all Danish children and adolescents (4—18 years) were analysed.

Validation of the Danish 7-day pre-coded food diary among adults: energy intake v. energy expenditure and recording length.

Under-reporting of energy intake (EI) is a well-known problem when measuring dietary intake in free-living populations. The present study aimed at quantifying misreporting by comparing EI estimated from the Danish pre-coded food diary against energy expenditure (EE) measured with a validated position-and-motion instrument (ActiReg). Further, the influence of recording length on EI:BMR, percentage consumers, the number of meal occasions and recorded food items per meal was examined. A total of 138 Danish volunteers aged 20-59 years wore the ActiReg and recorded their food intake for 7 consecutive days. Data for 2504 participants from the National Dietary Survey 2000-2 were used for comparison of characteristics and recording length. The results showed that EI was underestimated by 12 % on average compared with EE measured by ActiReg (PreMed AS, Oslo, Norway). The 95 % limits of agreement for EI and EE were - 6.29 and 3.09 MJ/d. Of the participants, 73 % were classified as acceptable reporters, 26 % as under-reporters and 1 % as over-reporters. EI:BMR was significantly lower on 1-3 consecutive recording days compared with 4-7 recording days (P < 0.03). Percentage consumers of selected food items increased with number of recording days. When recording length was 7 d, the number of reported food items per meal differed between acceptable reporters and under-reporters. EI:BMR was the same on 4 and 7 consecutive recording days. This was, however, a result of under-reporting in the beginning and the end of the 7 d reporting. Together, the results indicate that EI was underestimated at group level and that a 7 d recording is preferable to a 4 d recording period.

Dimensions of socioeconomic position related to body mass index and obesity among Danish women and men

Aims: The aim of this study was to examine the association between different dimensions of socioeconomic position, body mass index (BMI) and obesity in the Danish population. Possible interactions between the different dimensions and gender differences were also investigated. Methods: This was a cross-sectional survey conducted in 2000—2002 including a simple random sample from the civil registration system, comprising 1953 males and 2167 females aged 4—75 years. Information about different dimensions of socioeconomic position, height and weight was obtained by face-to-face interview. Associations between dimensions of socioeconomic position and weight status were examined by use of linear multiple regression analysis and logistic regression analysis. Results: BMI and prevalence of obesity were significantly associated with education for both men and women. Odds ratios (ORs) for obesity were 2.9 (95% confidence interval (CI) 1.4—5.9) and 6.5 (95% CI 2.3—18.7) for those with basic school as compared with those with long higher education for men and women, respectively. Women outside the labour market had higher BMIs and a greater prevalence of obesity (OR 2.5 (95% CI 1.6—3.9)) after adjustment for educational level. Conclusions: Education was the dimension most consistently associated with BMI and obesity, indicating the importance of cultural capital for weight status. The gender-specific pattern showed a stronger social gradient for women, and indicated that a high relative body weight was associated with less favourable social and material conditions for women, but not for men. A public health strategy to prevent and reduce obesity should be gender-specific, focus on groups with short education, and incorporate cultural norms.

Evaluation of dietary intake in Danish adults by means of an index based on food-based dietary guidelines

Background Data on dietary intake and physical activity has been collected from a representative sample of the Danish population from 2003–2008. Objectives The aim of the present study was to describe the habitual diet in Denmark and to evaluate the overall diet quality using a diet quality index based on the National Food-Based Dietary Guidelines (FBDG), which consists of seven guidelines regarding diet and one regarding physical activity. Design Data from the Danish National Survey of Diet and Physical Activity 2003–2008 (n=3354) were included. The diet quality index was constructed based on five of the seven dietary guidelines. Individuals were categorised according to quartiles of the diet quality index, and food and nutrient intakes were estimated in each of the groups. Results Macronutrient distribution did not meet recommendations in any of the groups, as energy from total fat and especially saturated fat was too high. A high intake of high-fat milk products, fat on bread and processed meat contributed to a high intake of total fat and saturated fat, and sugar-sweetened soft drinks contributed to a high intake of added sugars in the group below the lowest quartile of the diet quality index. Individuals above in the highest quartile had higher intakes of ‘healthy foods’ such as fish, fruit and vegetables, rye bread, and also a higher consumption of water and wine. Overall, intakes of micronutrients were sufficient in all groups. Conclusions The diet quality index is a useful tool in assessing food and nutrient intake in individuals with high vs. low degree of compliance towards the dietary guidelines, and provides a valuable tool in future studies investigating variations in dietary intakes with respect to lifestyle, demographic and regional differences in Denmark.

Comparison of estimated energy intake from 2×24-hour recalls and a seven-day food record with objective measurements of energy expenditure in children

Objective The objective of the present study was to evaluate energy intake (EI) estimated from two non-consecutive 24-hour recalls (24-HDRs) and a pre-coded seven-day food record (7-dFR) against objective measurements of energy expenditure (EE) in children. Design A total of 67 7–8 year-olds and 64 12–13 year-olds completed the 2×24-HDRs, the 7-dFR, and wore ActiReg® (PreMed AS, Oslo, Norway), a combined position and motion recording instrument, during the same seven days as the 7-dFR was filled in. Results In the 7–8 year-olds, EI from the 2×24-HDRs (EI2×24-HDR) was overestimated with 3% compared to EE (not significantly different), while EI from the 7-dFR (EI7-dFR) was underestimated with 7% compared to EE (P=0.001). In the 12–13 year-olds, the corresponding figures was underestimation by 10% with the 2×24-HDRs (P<0.001) and by 20% with the 7-dFR (P<0.001). For both age groups combined, the 95% limits of agreement were −4·38 and 3.52 MJ/d for the 2×24-HDRs, and −5.90 and 2.94 MJ/d for the 7-dFR. Pearson correlation coefficients between EI and EE were 0.51 for EI2×24-HDR and 0.29 for EI7-dFR, respectively. The proportion classified in the same or adjacent quartiles was 76% for EI2×24-HDR and 73% for EI7-dFR in the 7–8 year-olds, and 83% for EI2×24-HDR and 70% for EI7-dFR in the 12–13 year-olds. Conclusion Misreporting of EI seemed modest with both the 2×24-HDRs and the 7-dFR in the 7–8 year-olds when compared to EE measured with ActiReg®. Under-reporting appeared to be more evident in the 12–13 year-olds, especially with the 7-dFR. Compared to measurements of EE, the 2×24-HDRs seemed to perform slightly better than the 7-dFR in terms of ranking of individuals according to EI.

Trends in overweight and obesity in Danish children and adolescents: 2000-2008 – exploring changes according to parental education:

Aims: To examine the hypotheses that an overall levelling off in the prevalence of overweight and obesity during the period 2000–2008 has occurred, and that increasing social inequality in overweight and obesity exists in a nationally representative sample of Danish children and adolescents. Methods: The population comprised a random sample of 1849 children aged 4–14 years who participated in the Danish National Survey of Diet and Physical Activity in 2000–2002, 2003–2004 and 2005–2008. Parental education was chosen as an indicator of children’s socioeconomic status. Body mass index (BMI) was calculated from parent-reported weight and height. Subjects were classified as overweight and obese according to the International Obesity Task Force age- and gender-specific BMI cut-off values. Crude prevalence estimates and logistic regression models were used to analyse trends in overweight and obesity as the main outcome measures. Results: An increase was found in the crude prevalence of overweight (including obesity) in boys (12.8–21.7%, p = 0.0006), but not in girls (17.6–15.9%, p = 0.56), between 2000–2002 and 2005–2008. The prevalence of overweight increased significantly in boys of parents with low educational level only. A strong inverse social gradient in overweight and obesity was documented for boys and girls during the whole survey period. Conclusions: The present study showed an increase in the prevalence of overweight in Danish boys, but not in girls. This increase was due to increasing social inequality in overweight among boys. Public health initiatives aimed at preventing and reducing overweight and obesity should consider gender difference and especially target boys with parents of low educational level.

The intake of saturated fat and dietary fibre: a possible indicator of diet quality.

The aim of the present study was to assess if a simple dietary quality index (SDQI) is a useful indicator for nutritional quality in the Danish diet. Data from the Danish National Dietary Survey 2000-2 for adults (n 3151; age 18-75 years) were used to construct an SDQI based on the intake of dietary fibre and saturated fat. The SDQI was used to rank the individuals into three subgroups: the 25 % closest in meeting the recommended intakes of saturated fat and dietary fibre (compliers), the 25 % furthest away (non-compliers) and the 50 % in between (intermediates). Significant differences in food and nutrient intake between these subgroups were identified by intakes of food groups and intakes of nutrients followed by non-parametric tests. Compared with the Nordic Nutrition Recommendations 2004 and the Danish Dietary Guidelines 2005, compliers had a significantly better nutrient profile than intermediates and non-compliers, as the diet of compliers contained more whole-grain cereals, fruits, vegetables and fish, and more frequently low-fat dairy products, lean meats and boiled potatoes. The diet of all subgroups, especially non-compliers, had a high content of nutrient-poor, energy-dense foods, for example, salty snacks, confectionery, and beverages, for example, soft drinks and alcohol. The SDQI is a simple and useful tool to characterise the diet quality of Danish adults.

Disparities in dietary habits and physical activity in Denmark and trends from 1995 to 2008

Aims: To examine social disparities in dietary-, alcohol- and leisure-time physical activity habits in Danish adults from 1995 to 2008 and to test the hypothesis of widening disparities. Methods: Four cross-sectional surveys of representative samples of the Danish population aged 20–75 years were analysed, a total of 7900 respondents. Dietary and alcohol habits were measured by a 7-day pre-coded food diary and physical activity and education by a face-to-face interview. Multivariate analyses were used to test associations between explanatory variables and response variables and the hypothesis of widening disparities. Results: In all analyses, both diet quality and physical inactivity differed systematically with educational group and with healthier habits for the group with long education. Only for alcohol habits was an opposite social gradient seen. Disparities persisted over all time periods. The analyses using “The Concentration Index” did not change any of the conclusions. Gender also influenced diet quality. Men had dietary and alcohol habits furthest away from the guidelines. A trend of healthier habits was also found over the time period. Conclusions: Social disparities in diet quality and leisure-time physical activity were seen for all examined time periods and with no significant change. Therefore, there is no support to the hypothesis of widening social disparities. In all educational groups some improvement of dietary habits was found, especially for those foods where comprehensive initiatives had taken place. However, social disparities still exist. There is an ongoing need to address these disparities in order to reduce social inequality in health.