Marieke Ah Hendriksen

Inverse association between dairy intake and hypertension: the Rotterdam Study

BACKGROUND Little is known about the effect of different types of dairy food products on the development of hypertension. OBJECTIVE The objective was to determine whether the incidence of hypertension in older Dutch subjects is associated with intake of dairy products. DESIGN We examined the relation between dairy intake and incident hypertension in 2245 participants of the Rotterdam Study aged > or =55 y with complete dietary and blood pressure data, who were free of hypertension at baseline (1990-1993). Blood pressure was reexamined in 1993-1995 and in 1997-1999. Hazard ratios (HRs) with 95% CIs for 2- and 6-y incidence of hypertension were obtained in quartiles of energy-adjusted dairy intake, with adjustment for age, sex, BMI, smoking, educational level, dietary factors, and intake of alcohol and total energy. RESULTS Risk of hypertension after 2 y of follow-up (664 incident cases) was inversely associated with dairy product intake. After adjustment for confounders, HRs (95% CIs) were 1.00, 0.82 (0.67, 1.02), 0.67 (0.54, 0.84), and 0.76 (0.61, 0.95) in consecutive quartiles of total dairy product intake (P for trend = 0.008). Corresponding HRs for low-fat dairy products were 1.00, 0.75 (0.60, 0.92), 0.77 (0.63, 0.96), and 0.69 (0.56, 0.86) (P for trend = 0.003). Analysis of specific types of dairy products showed an inverse association with milk and milk products (P for trend = 0.07) and no association with high-fat dairy or cheese (P > 0.6). After 6 y of follow-up (984 incident cases), the associations with hypertension were attenuated to risk reductions of approximately 20% for both total and low-fat dairy products between the extreme quartiles of intake (P for trend = 0.07 and 0.09, respectively). CONCLUSION Intake of low-fat dairy products may contribute to the prevention of hypertension at an older age.

Potential for improvement of population diet through reformulation of commonly eaten foods

FOOD REFORMULATION: Reformulation of foods is considered one of the key options to achieve population nutrient goals. The compositions of many foods are modified to assist the consumer bring his or her daily diet more in line with dietary recommendations. INITIATIVES ON FOOD REFORMULATION: Over the past few years the number of reformulated foods introduced on the European market has increased enormously and it is expected that this trend will continue for the coming years. LIMITS TO FOOD REFORMULATION: Limitations to food reformulation in terms of choice of foods appropriate for reformulation and level of feasible reformulation relate mainly to consumer acceptance, safety aspects, technological challenges and food legislation. IMPACT ON KEY NUTRIENT INTAKE AND HEALTH: The potential impact of reformulated foods on key nutrient intake and health is obvious. Evaluation of the actual impact requires not only regular food consumption surveys, but also regular updates of the food composition table including the compositions of newly launched reformulated foods.

Potential effect of salt reduction in processed foods on health

BACKGROUND Excessive salt intake has been associated with hypertension and increased cardiovascular disease morbidity and mortality. Reducing salt intake is considered an important public health strategy in the Netherlands. OBJECTIVE The objective was to evaluate the health benefits of salt-reduction strategies related to processed foods for the Dutch population. DESIGN Three salt-reduction scenarios were developed: 1) substitution of high-salt foods with low-salt foods, 2) a reduction in the sodium content of processed foods, and 3) adherence to the recommended maximum salt intake of 6 g/d. Health outcomes were obtained in 2 steps: after salt intake was modeled into blood pressure levels, the Chronic Disease Model was used to translate modeled blood pressures into incidences of cardiovascular diseases, disability-adjusted life years (DALYs), and life expectancies. Health outcomes of the scenarios were compared with health outcomes obtained with current salt intake. RESULTS In total, 4.8% of acute myocardial infarction cases, 1.7% of congestive heart failure cases, and 5.8% of stroke cases might be prevented if salt intake meets the recommended maximum intake. The burden of disease might be reduced by 56,400 DALYs, and life expectancy might increase by 0.15 y for a 40-y-old individual. Substitution of foods with comparable low-salt alternatives would lead to slightly higher salt intake reductions and thus to more health gain. The estimates for sodium reduction in processed foods would be slightly lower. CONCLUSION Substantial health benefits might be achieved when added salt is removed from processed foods and when consumers choose more low-salt food alternatives.

Monitoring salt and iodine intakes in Dutch adults between 2006 and 2010 using 24 h urinary sodium and iodine excretions.

OBJECTIVE To monitor the effectiveness of salt-reduction initiatives in processed foods and changes in Dutch iodine policy on Na and iodine intakes in Dutch adults between 2006 and 2010. DESIGN Two cross-sectional studies among adults, conducted in 2006 and 2010, using identical protocols. Participants collected single 24 h urine samples and completed two short questionnaires on food consumption and urine collection procedures. Daily intakes of salt, iodine, K and Na:K were estimated, based on the analysis of Na, K and iodine excreted in urine. SETTING Doetinchem, the Netherlands. SUBJECTS Men and women aged 19 to 70 years were recruited through random sampling of the Doetinchem population and among participants of the Doetinchem Cohort Study (2006: n 317, mean age 48·9 years, 43 % men; 2010: n 342, mean age 46·2 years, 45 % men). RESULTS While median iodine intake was lower in 2010 (179 μg/d) compared with 2006 (257 μg/d; P < 0·0001), no difference in median salt intake was observed (8·7 g/d in 2006 v. 8·5 g/d in 2010, P = 0·70). In 2006, median K intake was 2·6 g/d v. 2·8 g/d in 2010 (P < 0·01). In this 4-year period, median Na:K improved from 2·4 in 2006 to 2·2 in 2010 (P < 0·001). CONCLUSIONS Despite initiatives to lower salt in processed foods, dietary salt intake in this population remains well above the recommended intake of 6 g/d. Iodine intake is still adequate, although a decline was observed between 2006 and 2010. This reduction is probably due to changes in iodine policy.

A Tiered Approach for Risk-Benefit Assessment of Foods

Risk-benefit analyses are introduced as a new paradigm for old problems. However, in many cases it is not always necessary to perform a full comprehensive and expensive quantitative risk-benefit assessment to solve the problem, nor is it always possible, given the lack of required date. The choice to continue from a more qualitative to a full quantitative risk-benefit assessment can be made using a tiered approach. In this article, this tiered approach for risk-benefit assessment will be addressed using a decision tree. The tiered approach described uses the same four steps as the risk assessment paradigm: hazard and benefit identification, hazard and benefit characterization, exposure assessment, and risk-benefit characterization, albeit in a different order. For the purpose of this approach, the exposure assessment has been moved upward and the dose-response modeling (part of hazard and benefit characterization) is moved to a later stage. The decision tree includes several stop moments, depending on the situation where the gathered information is sufficient to answer the initial risk-benefit question. The approach has been tested for two food ingredients. The decision tree presented in this article is useful to assist on a case-by-case basis a risk-benefit assessor and policymaker in making informed choices when to stop or continue with a risk-benefit assessment.

Consuming a diet complying with front-of-pack label criteria may reduce cholesterol levels: a modeling study.

Background/Objectives:Front-of-pack nutrition labels can help consumers to make healthier choices and stimulate healthier product development. This is the first modeling study to investigate the potential impact on cholesterol levels of consuming a diet consisting of products that comply with the criteria for a ‘healthier choice logo’.Subjects/Methods:National food consumption and food composition data were used to estimate the nutrient intake of the Dutch adult population (18–70 years) before and after replacing foods that did not comply with the Choices front-of-pack label criteria. Different scenarios were established. The difference in cholesterol levels in the Dutch population was assessed before and after replacement by means of equations from meta-analyses that calculate how blood lipids change when diet composition changes.Results:After replacing non-complying products with products, which comply with the labels criteria (maximum scenario), saturated fatty acids median intake reduced from 14.5 to 9.8 en%. Trans-fatty acids reduced from 0.95 to 0.57 en%. The average predicted changes in low-density lipoprotein and total cholesterol levels were −0.25 and −0.31 mmol/l, respectively. Because high-density lipoprotein (HDL) cholesterol levels reduced as well (−0.05 mmol/l), overall, the result was a slightly positive change in the total cholesterol/HDL ratio (−0.03).Conclusions:Our findings suggest that the consumption of foods complying with the criteria for a front-of-pack label could contribute moderately to cardiovascular risk reduction via influencing blood lipids. These findings were independent of other potential effects on related health outcomes.

Health gain by salt reduction in europe: a modelling study.

Excessive salt intake is associated with hypertension and cardiovascular diseases. Salt intake exceeds the World Health Organization population nutrition goal of 5 grams per day in the European region. We assessed the health impact of salt reduction in nine European countries (Finland, France, Ireland, Italy, Netherlands, Poland, Spain, Sweden and United Kingdom). Through literature research we obtained current salt intake and systolic blood pressure levels of the nine countries. The population health modeling tool DYNAMO-HIA including country-specific disease data was used to predict the changes in prevalence of ischemic heart disease and stroke for each country estimating the effect of salt reduction through its effect on blood pressure levels. A 30% salt reduction would reduce the prevalence of stroke by 6.4% in Finland to 13.5% in Poland. Ischemic heart disease would be decreased by 4.1% in Finland to 8.9% in Poland. When salt intake is reduced to the WHO population nutrient goal, it would reduce the prevalence of stroke from 10.1% in Finland to 23.1% in Poland. Ischemic heart disease would decrease by 6.6% in Finland to 15.5% in Poland. The number of postponed deaths would be 102,100 (0.9%) in France, and 191,300 (2.3%) in Poland. A reduction of salt intake to 5 grams per day is expected to substantially reduce the burden of cardiovascular disease and mortality in several European countries.

Nutritional impact of sodium reduction strategies on sodium intake from processed foods

Background/objectives:Sodium intake in the Netherlands is substantially above the recommended intake of 2400 mg/day. This study aimed to estimate the effect of two sodium reduction strategies, that is, modification of the composition of industrially processed foods toward the technologically feasible minimum level or alteration of consumers’ behavior on sodium intake in the Netherlands.Subjects/methods:Data from the Dutch National Food Consumption Survey (2007–2010) and the Food Composition Table (2011) were used to estimate the current sodium intake. In the first scenario, levels in processed foods were reduced toward their technologically feasible minimum level (sodium reduction in processed foods scenario). The minimum feasible levels were based on literature searches or expert judgment. In the second scenario, foods consumed were divided into similar food (sub)groups. Subsequently, foods were replaced by low-sodium alternatives (substitution of processed foods scenario). Sodium intake from foods was calculated based on the mean of two observation days for the current food consumption pattern and the scenarios.Results:Sodium levels of processed foods could be reduced in most food groups by 50%, and this may reduce median sodium intake from foods by 38% (from 3042 to 1886 mg/day in adult men). Substitution of foods may reduce sodium intake by 47% (from 3042 to 1627 mg/day in adult men), owing to many low-sodium alternatives within food groups.Conclusions:In the Netherlands, reduction of sodium intake by modification of food composition or by alteration of behavior may substantially reduce the median sodium intake from foods below the recommended sodium intake.

No consistent association between consumption of energy-dense snack foods and annual weight and waist circumference changes in Dutch adults

BACKGROUND There is conflicting evidence regarding an association between the consumption of energy-dense snack (EDS) foods and the development of overweight. OBJECTIVE In the current study, we examined whether there was an association between the intake of EDS foods and annual weight and waist circumference changes in normal-weight and overweight Dutch adults. DESIGN The study population included 9383 men and women from the MORGEN-EPIC (Monitoring Project on Risk Factors for Chronic Diseases in the Netherlands-European Prospective Investigation into Cancer and Nutrition) study, which is a population-based cohort study in 3 towns in the Netherlands (Amsterdam, Maastricht, and Doetinchem), who had a body mass index (in kg/m(2)) <30 and who were not dieting. Participants were enrolled between 1993 and 1997 and followed for an average of 8.1 y (Amsterdam and Maastricht: 9.9 y; Doetinchem: 4.9 y). Intake of EDS foods (sweets, cakes and pastries, and savory snacks) was assessed at baseline by using a validated food-frequency questionnaire. Multivariate linear and multinomial logistic regression models were applied and stratified by center to examine the association between energy from EDS foods (kcal) and annual weight and waist circumference changes. RESULTS The mean (±SD) daily energy intake from EDS foods was 294 ± 192 kcal. In Amsterdam and Maastricht, the annual weight change was 168 ± 572 g/y, whereas in Doetinchem, the annual weight change was 444 ± 816 g/y. In the multivariate regression analysis adjusted for follow-up duration and anthropometric, dietary, and lifestyle factors, there was some, but inconsistent, evidence of an association of EDS-food consumption with annual weight change. CONCLUSION Our study provides some, but inconsistent, evidence that consumption of EDS foods is positively associated with an increase in annual weight in normal- to overweight Dutch adults.

Salt Reductions in Some Foods in The Netherlands: Monitoring of Food Composition and Salt Intake

Background and objectives. High salt intake increases blood pressure and thereby the risk of chronic diseases. Food reformulation (or food product improvement) may lower the dietary intake of salt. This study describes the changes in salt contents of foods in the Dutch market over a five-year period (2011–2016) and differences in estimated salt intake over a 10-year period (2006–2015). Methods. To assess the salt contents of foods; we obtained recent data from chemical analyses and from food labels. Salt content of these foods in 2016 was compared to salt contents in the 2011 version Dutch Food Composition Database (NEVO, version 2011), and statistically tested with General Linear Models. To estimate the daily dietary salt intake in 2006, 2010, and 2015, men and women aged 19 to 70 years were recruited through random population sampling in Doetinchem, a small town located in a rural area in the eastern part of the Netherlands. The characteristics of the study population were in 2006: n = 317, mean age 49 years, 43% men, in 2010: n = 342, mean age 46 years, 45% men, and in 2015: n = 289, mean age 46 years, 47% men. Sodium and potassium excretion was measured in a single 24-h urine sample. All estimates were converted to a common metric: salt intake in grams per day by multiplication of sodium with a factor of 2.54. Results. In 2016 compared to 2011, the salt content in certain types of bread was on average 19 percent lower and certain types of sauce, soup, canned vegetables and legumes, and crisps had a 12 to 26 percent lower salt content. Salt content in other types of foods had not changed significantly. Between 2006, 2010 and 2015 the estimated salt intake among adults in Doetinchem remained unchanged. In 2015, the median estimated salt intake was 9.7 g per day for men and 7.4 g per day for women. As in 2006 and 2010, the estimated salt intake in 2015 exceeded the recommended maximum intake of 6 g per day set by the Dutch Health Council. Conclusion. In the Netherlands, the salt content of bread, certain sauces, soups, potato crisps, and processed legumes and vegetables have been reduced over the period 2011–2016. However, median salt intake in 2006 and 2015 remained well above the recommended intake of 6 g.