Peter Wallström

Consumption of vegetables, fruit and other plant foods in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohorts from 10 European countries

OBJECTIVE To describe and compare the consumption of the main groups and sub-groups of vegetables and fruits (V&F) in men and women from the centres participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). DESIGN Cross-sectional analysis. Dietary intake was assessed by means of a 24-hour dietary recall using computerised interview software and standardised procedures. Crude and adjusted means were computed for the main groups and sub-groups of V&F by centre, separately for men and women. Adjusted means by season, day of the week and age were estimated using weights and covariance analysis. SETTING Twenty-seven centres in 10 European countries participating in the EPIC project. SUBJECTS In total, 35 955 subjects (13 031 men and 22 924 women), aged 35-74 years, randomly selected from each EPIC cohort. RESULTS The centres from southern countries had the highest consumption of V&F, while the lowest intake was seen in The Netherlands and Scandinavia for both genders. These differences were more evident for fruits, particularly citrus. However, slightly different patterns arose for some sub-groups of vegetables, such as root vegetables and cabbage. Adjustment for body mass index, physical activity, smoking habits and education did not substantially modify the mean intakes of vegetables and fruits. CONCLUSIONS Total vegetable and fruit intake follows a south-north gradient in both genders, whereas for several sub-groups of vegetables a different geographic distribution exists. Differences in mean intake of V&F by centre were not explained by lifestyle factors associated with V&F intake.

Use of dietary supplements in the European Prospective Investigation into Cancer and Nutrition calibration study

Background:Dietary supplement use is increasing, but there are few comparable data on supplement intakes and how they affect the nutrition and health of European consumers. The aim of this study was to describe the use of dietary supplements in subsamples of the 10 countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC).Methods:Specific questions on dietary supplement use were asked as a part of single 24-h recalls performed on 36 034 men and women aged 35–74 years from 1995 to 2000.Results:Between countries, the mean percentage of dietary supplement use varied almost 10-fold among women and even more among men. There was a clear north–south gradient in use, with a higher consumption in northern countries. The lowest crude mean percentage of use was found in Greece (2.0% among men, 6.7% among women), and the highest was in Denmark (51.0% among men, 65.8% among women). Use was higher in women than in men. Vitamins, minerals or combinations of them were the predominant types of supplements reported, but there were striking differences between countries.Conclusions:This study indicates that there are wide variations in supplement use in Europe, which may affect individual and population nutrient intakes. The results underline the need to monitor consumption of dietary supplements in Europe, as well as to evaluate the risks and benefits.

Body Size and Risk of Prostate Cancer in the European Prospective Investigation into Cancer and Nutrition

Background: Body size has been hypothesized to influence the risk of prostate cancer; however, most epidemiologic studies have relied on body mass index (BMI) to assess adiposity, whereas only a few studies have examined whether body fat distribution predicts prostate cancer. Methods: We examined the association of height, BMI, waist and hip circumference, and waist-hip ratio with prostate cancer risk among 129,502 men without cancer at baseline from 8 countries of the European Prospective Investigation into Cancer and Nutrition (EPIC), using Cox regression, with age as time metric, stratifying by study center and age at recruitment, and adjusting for education, smoking status, alcohol consumption, and physical activity. Results: During a mean follow-up of 8.5 years, 2,446 men developed prostate cancer. Waist circumference and waist-hip ratio were positively associated with risk of advanced disease. The relative risk of advanced prostate cancer was 1.06 (95% confidence interval, 1.01-1.1) per 5-cm-higher waist circumference and 1.21 (95% confidence interval, 1.04-1.39) per 0.1-unit-higher waist-hip ratio. When stratified by BMI, waist circumference and waist-hip ratio were positively related to risk of total, advanced, and high-grade prostate cancer among men with lower but not among those with higher BMI (Pinteraction for waist with BMI, 0.25, 0.02, and 0.05, respectively; Pinteraction for waist-hip ratio with BMI, 0.27, 0.22, and 0.14; respectively). Conclusions: These data suggest that abdominal adiposity may be associated with an increased risk of advanced prostate cancer. This association may be stronger among individuals with lower BMI; however, this finding needs confirmation in future studies. (Cancer Epidemiol Biomarkers Prev 2008;17(11):3252–61)

Scoring models of a diet quality index and the predictive capability of mortality in a population-based cohort of Swedish men and women.

OBJECTIVE To examine how different scoring models for a diet quality index influence associations with mortality outcomes. DESIGN A study within the Malmö Diet and Cancer cohort. Food and nutrient intakes were estimated using a diet history method. The index included six components: SFA, PUFA, fish and shellfish, fibre, fruit and vegetables, and sucrose. Component scores were assigned using predefined (based on dietary recommendations) and population-based cut-offs (based on median or quintile intakes). Multivariate Cox regression was used to model associations between index scores (low, medium, high) and all-cause and cause-specific mortality by sex. SETTING Malmö, the third largest city in Sweden. SUBJECTS Men (n 6940) and women (n 10,186) aged 44-73 years. During a mean follow-up of 14.2 years, 2450 deaths occurred, 1221 from cancer and 709 from CVD. RESULTS The predictive capability of the index for mortality outcomes varied with type of scoring model and by sex. Stronger associations were seen among men using predefined cut-offs. In contrast, the quintile-based scoring model showed greater predictability for mortality outcomes among women. The scoring model using median-based cut-offs showed low predictability for mortality among both men and women. CONCLUSIONS The scoring model used for dietary indices may have a significant impact on observed associations with disease outcomes. The rationale for selection of scoring model should be included in studies investigating the association between dietary indices and disease. Adherence to the current dietary recommendations was in the present study associated with decreased risk of all-cause and cause-specific mortality, particularly among men.

Differences in dietary intakes, food sources and determinants of total flavonoids between Mediterranean and non-Mediterranean countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study

A greater adherence to the traditional Mediterranean (MED) diet is associated with a reduced risk of developing chronic diseases. This dietary pattern is based on higher consumption of plant products that are rich in flavonoids. We compared the total flavonoid dietary intakes, their food sources and various lifestyle factors between MED and non-MED countries participating in the EPIC study. Flavonoid intakes and their food sources for 35,628 subjects, aged 35-74 years and recruited between 1992 and 2000, in twenty-six study centres were estimated using standardised 24 h dietary recall software (EPIC-Soft®). An ad hoc food composition database on flavonoids was compiled using analytical data from the United States Department of Agriculture and Phenol-Explorer databases. Moreover, it was expanded to include using recipes, estimations of missing values and flavonoid retention factors. No significant differences in total flavonoid mean intake between non-MED countries (373·7 mg/d) and MED countries (370·2 mg/d) were observed. In the non-MED region, the main contributors were proanthocyanidins (48·2%) and flavan-3-ol monomers (24·9%) and the principal food sources were tea (25·7%) and fruits (32·8%). In the MED region, proanthocyanidins (59·0%) were by far the most abundant contributor and fruits (55·1%), wines (16·7%) and tea (6·8%) were the main food sources. The present study shows similar results for total dietary flavonoid intakes, but significant differences in flavonoid class intakes, food sources and some characteristics between MED and non-MED countries. These differences should be considered in studies about the relationships between flavonoid intake and chronic diseases.

What do review papers conclude about food and dietary patterns

Nutrients and other bioactive constituents of foods may interact with each other and the surrounding food matrix in complex ways. Therefore, associations between single nutrients and chronic disease may be difficult to identify and interpret, but when dietary patterns (DPs) are examined the combination of many food factors will be considered. An explorative literature search of published review articles was conducted to obtain a fuller understanding of current DPs in epidemiological research, to discuss pros and cons of DPs in nutrition research, and to identify results of studies linking DPs to chronic disease risk in adults. Randomized feeding trials providing the experimental diets to study participants have repeatedly demonstrated that diets based on current dietary recommendations are associated with important health benefits. Systematic reviews of feeding trials and prospective population studies of DPs and chronic disease risk reach similar conclusions regardless of the methodology used to construct DPs. However, to date only a few review articles of DP studies have followed a systematic process using independent reviewers with strict inclusion, exclusion, and study quality criteria. Diets with plenty of plants foods, fish, and seafood that preferably include vegetable oils and low-fat dairy products are associated with a lower risk of most chronic diseases. In contrast, Western-type DPs with food products low in essential nutrients and high in energy, like sugar-sweetened beverages, sweets, refined cereals and solid fats (e.g. butter), and high in red and processed meats, are associated with adverse health effects. An emphasis on high-quality original research, and systematic reviews following a structured process to objectively select and judge studies, is needed in order to enforce a strong future knowledge base regarding DPs and chronic disease.

Misreporting of energy: prevalence, characteristics of misreporters and influence on observed risk estimates in the Malmö Diet and Cancer cohort.

The present study investigates the prevalence of misreporting of energy in the Malmö Diet and Cancer cohort, and examines anthropometric, socio-economic and lifestyle characteristics of the misreporters. Further, the influence of excluding misreporters on risk estimates of post-menopausal breast cancer was examined. Information of reported energy intake (EI) was obtained from a modified diet history method. A questionnaire provided information on lifestyle and socio-economic characteristics. Individual physical activity level (PAL) was calculated from self-reported information on physical activity at work, leisure time physical activity and household work, and from estimates of hours of sleeping, self-care and passive time. Energy misreporting was defined as having a ratio of EI to BMR outside the 95 % CI limits of the calculated PAL. Logistic regression analysed the risk of being a low-energy reporter or a high-energy reporter. Almost 18 % of the women and 12 % of the men were classified as low-energy reporters, 2.8 % of the women and 3.5 % of the men were classified as high-energy reporters. In both genders high BMI, large waist circumference, short education and being a blue-collar worker were significantly associated with low-energy reporting. High-energy reporting was significantly associated with low BMI, living alone and current smoking. The results add support to the practice of energy adjustment as a means to reduce the influence of errors in risk assessment.

Plasma levels of six carotenoids in nine European countries: report from the European Prospective Investigation into Cancer and Nutrition (EPIC)

BACKGROUND In addition to their possible direct biological effects, plasma carotenoids can be used as biochemical markers of fruit and vegetable consumption for identifying diet-disease associations in epidemiological studies. Few studies have compared levels of these carotenoids between countries in Europe. OBJECTIVE Our aim was to assess the variability of plasma carotenoid levels within the cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC). METHODS Plasma levels of six carotenoids--alpha-carotene, beta-carotene, beta-cryptoxanthin, lycopene, lutein and zeaxanthin--were measured cross-sectionally in 3043 study subjects from 16 regions in nine European countries. We investigated the relative influence of gender, season, age, body mass index (BMI), alcohol intake and smoking status on plasma levels of the carotenoids. RESULTS Mean plasma level of the sum of the six carotenoids varied twofold between regions (1.35 micromol l(-1) for men in Malmö, Sweden vs. 2.79 micromol l(-1) for men in Ragusa/Naples, Italy; 1.61 micromol l(-1) for women in The Netherlands vs. 3.52 micromol l(-1) in Ragusa/Naples, Italy). Mean levels of individual carotenoids varied up to fourfold (alpha-carotene: 0.06 micromol l(-1) for men in Murcia, Spain vs. 0.25 micromol l(-1) for vegetarian men living in the UK). In multivariate regression analyses, region was the most important predictor of total plasma carotenoid level (partial R(2)=27.3%), followed by BMI (partial R(2)=5.2%), gender (partial R(2)=2.7%) and smoking status (partial R(2)=2.8%). Females had higher total carotenoid levels than males across Europe. CONCLUSIONS Plasma levels of carotenoids vary substantially between 16 different regions in Italy, Greece, Spain, France, Germany, the UK, Sweden, Denmark and The Netherlands. Compared with region of residence, the other demographic and lifestyle factors and laboratory measurements have limited predictive value for plasma carotenoid levels in Europe.

Food sources of fat may clarify the inconsistent role of dietary fat intake for incidence of type 2 diabetes

BACKGROUND Dietary fats could affect glucose metabolism and obesity development and, thereby, may have a crucial role in the cause of type 2 diabetes (T2D). Studies indicated that replacing saturated with unsaturated fats might be favorable, and plant foods might be a better choice than animal foods. Nevertheless, epidemiologic studies suggested that dairy foods are protective. OBJECTIVE We hypothesized that, by examining dietary fat and its food sources classified according to fat type and fat content, some clarification regarding the role of dietary fat in T2D incidence could be provided. DESIGN A total of 26,930 individuals (61% women), aged 45-74 y, from the Malmö Diet and Cancer cohort were included in the study. Dietary data were collected by using a modified diet-history method. During 14 y of follow-up, 2860 incident T2D cases were identified. RESULTS Total intake of high-fat dairy products (regular-fat alternatives) was inversely associated with incident T2D (HR for highest compared with lowest quintiles: 0.77; 95% CI: 0.68, 0.87; P-trend < 0.001). Most robust inverse associations were seen for intakes of cream and high-fat fermented milk (P-trend < 0.01) and for cheese in women (P-trend = 0.02). High intake of low-fat dairy products was associated with increased risk, but this association disappeared when low- and high-fat dairy were mutually adjusted (P-trend = 0.18). Intakes of both high-fat meat (P-trend = 0.04) and low-fat meat (P-trend < 0.001) were associated with increased risk. Finally, we did not observe significant association between total dietary fat content and T2D (P-trend = 0.24), but intakes of saturated fatty acids with 4-10 carbons, lauric acid (12:0), and myristic acid (14:0) were associated with decreased risk (P-trend < 0.01). CONCLUSIONS Decreased T2D risk at high intake of high- but not of low-fat dairy products suggests that dairy fat partly could have contributed to previously observed protective associations between dairy intake and T2D. Meat intake was associated with increased risk independently of the fat content.

A prospective Swedish study on body size, body composition, diabetes, and prostate cancer risk.

Obesity may be associated with increased risk of prostate cancer (PCa). According to one hypothesis, obesity could lower the risk of non-aggressive tumours, while simultaneously increasing the risk of aggressive cancer. Furthermore, central adiposity may be independently associated with PCa risk; it is also associated with diabetes, which itself may influence risk of PCa. We studied the associations between height, body composition, and fat distribution, diabetes prevalence and risk of total, aggressive, and non-aggressive PCa in 10 564 initially cancer-free men (aged 45–73 years) of the population-based Malmö Diet and Cancer cohort. Anthropometric and body composition measurements, including bioelectrical impedance for estimation of fat mass, were performed by study nurses. Diabetes prevalence was self-reported. Cancer cases and clinical characteristics were ascertained through national and regional registry data. Dietary and other background data were obtained through a modified diet history method and an extensive questionnaire. During a mean follow-up of 11.0 years, 817 incidental PCa cases were diagnosed. Of these, 281 were classified as aggressive. There were 202 cases occurring before 65 years of age. Height was positively associated with total and non-aggressive PCa risk. Waist–hip ratio (WHR), a measure of central adiposity, was positively associated with PCa before age 65, and less strongly, with total PCa. This association was independent of body mass index (BMI) and other potential confounders. General adiposity, expressed as BMI or body fat percentage, and prevalent diabetes were not associated with PCa risk. In this study, WHR and body height were stronger PCa predictors than general adiposity.