Sisse Fagt

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

Size makes a difference

OBJECTIVE To elucidate status and trends in portion size of foods rich in fat and/or added sugars during the past decades, and to bring portion size into perspective in its role in obesity and dietary guidelines in Denmark. DATA SOURCES Information about portion sizes of low-fat and full-fat food items was obtained from a 4-day weighed food record (Study 1). Trends in portion sizes of commercial foods were examined by gathering information from major food manufacturers and fast food chains (Study 2). Data on intakes and sales of sugar-sweetened soft drinks and confectionery were obtained through nation-wide dietary surveys and official sales statistics (Study 3). RESULTS Study 1: Subjects ate and drank significantly more when they chose low-fat food and meal items (milk used as a drink, sauce and sliced cold meat), compared with their counterparts who chose food and meal items with a higher fat content. As a result, almost the same amounts of energy and fat were consumed both ways, with the exception of sliced cold meat (energy and fat) and milk (fat). Study 2: Portion sizes of commercial energy-dense foods and beverages, and fast food meals rich in fat and/or added sugars, seem to have increased over time, and in particular in the last 10 years. Study 3: The development in portion sizes of commercial foods has been paralleled by a sharp increase of more than 50% in the sales of sugar-sweetened soft drinks and confectionery like sweets, chocolate and ice creams since the 1970s. CONCLUSIONS Larger portion sizes of foods low in fat and commercial energy-dense foods and beverages could be important factors in maintaining a high energy intake, causing over-consumption and enhancing the prevalence of obesity in the population. In light of this development, portion size ought to take central place in dietary guidelines and public campaigns.

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.

para-aminobenzoic acid used as a marker for completeness of 24 hour urine : assessment of control limits for a specific HPLC method

Objective and design: The study comprised three protocols. Protocol 1 compared a HPLC method with the commonly employed colorimetric diazocoupling method. Protocol 2 examined, if the last dosage of p-aminobenzoic acid (PABA) could be advanced in the old to allow for a delayed age-dependent urinary excretion of PABA. Protocol 3 established limits for recovery of PABA in 24 h urine applying the HPLC method. Subjects and setting: A total of 151 healthy volunteers participated in the study of which 140 were accepted. In protocol 1: 37 subjects aged 20–78 y were included. All subjects took PABA as recommended (80 mg orally at 08.00, 12.00 and 18.00 h). Protocol 2: compared urinary PABA excretion in two groups of 80 y old subjects who had their last PABA dosage administered at 15.00 h (n=16) and at 18.00 h (n=31), respectively. Protocol 3: comprised 56 subjects aged 20–80 y. In the younger age group (20–59 y; n=34) PABA was taken as recommended, whereas in the older age group (60–80 y; n=22) the last PABA dosage was advanced three hours. Results: Protocol 1: HPLC gave significantly lower PABA recovery results compared to colorimetry, the difference between methods being 23.9±8.5 mg/24 h (P<0.001). Protocol 2: higher PABA recoveries were demonstrated with the advanced dosage schedule compared to the recommended schedule (208±14 mg/24 h vs 181±22 mg/24 h; P<0.001). Protocol 3: PABA recovery with HPLC was 211±12 mg/24 h, and the lower limit comprising 95% of subjects was 187 mg/24 h. Similar PABA recoveries were demonstrated in the younger subjects and the older subjects (211±11 mg/24 h vs 211±13 mg/24 h; NS). Conclusion: An advanced dosage schedule for PABA in the aged is recommended. Because of lower recoveries with HPLC, the low limit for recovered PABA in a complete 24 h urine differs from the limit based on colorimetry. This study found a limit of 187 mg/24 h corresponding to the lower 95% confidence limit for a single subject. Sponsorship: Supported by the National Food Agency, the Velux Foundation of 1981, and the Health Insurance Foundation.

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.

A Model of Hygiene Practices and Consumption Patterns in the Consumer Phase

A mathematical model is presented, which addresses individual hygiene practices during food preparation and consumption patterns in private homes. Further, the model links food preparers and consumers based on their relationship to household types. For different age and gender groups, the model estimates (i) the probability of ingesting a meal where precautions have not been taken to avoid the transfer of microorganisms from raw food to final meal (a risk meal), exemplified by the event that the cutting board was not washed during food preparation, and (ii) the probability of ingesting a risk meal in a private home, where chicken was the prepared food item (a chicken risk meal). Chicken was included in the model, as chickens are believed to be the major source of human exposure to the foodborne pathogen Campylobacter. Monte Carlo simulations showed that the probability of ingesting a risk meal was highest for young males (aged 18-29 years) and lowest for the elderly above 60 years of age. Children aged 0-4 years had a higher probability of ingesting a risk meal than children aged 5-17 years. This difference between age and gender groups was ascribed to the variations in the hygiene levels of food preparers. By including the probability of ingesting a chicken meal at home, simulations revealed that all age groups, except the group above 60 years of age, had approximately the same probability of ingesting a chicken risk meal, the probability of females being slightly higher than that of males. The simulated results show that the probability of ingesting a chicken risk meal at home does not only depend on the hygiene practices of the persons preparing the food, but also on the consumption patterns of consumers, and the relationship between people preparing and ingesting food. This finding supports the need of including information on consumer behavior and preparation hygiene in the consumer phase of exposure assessments.

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.

Dietary intake and main sources of plant lignans in five European countries

Background Dietary intakes of plant lignans have been hypothesized to be inversely associated with the risk of developing cardiovascular disease and cancer. Earlier studies were based on a Finnish lignan database (Fineli®) with two lignan precursors, secoisolariciresinol (SECO) and matairesinol (MAT). More recently, a Dutch database, including SECO and MAT and the newly recognized lignan precursors lariciresinol (LARI) and pinoresinol (PINO), was compiled. The objective was to re-estimate and re-evaluate plant lignan intakes and to identify the main sources of plant lignans in five European countries using the Finnish and Dutch lignan databases, respectively. Methods Forty-two food groups known to contribute to the total lignan intake were selected and attributed a value for SECO and MAT from the Finnish lignan database (Fineli®) or for SECO, MAT, LARI, and PINO from the Dutch database. Total intake of lignans was estimated from food consumption data for adult men and women (19–79 years) from Denmark, Finland, Italy, Sweden, United Kingdom, and the contribution of aggregated food groups calculated using the Dutch lignin database. Results Mean dietary lignan intakes estimated using the Dutch database ranged from 1 to 2 mg/day, which was approximately four-fold higher than the intakes estimated from the Fineli® database. When LARI and PINO were included in the estimation of the total lignan intakes, cereals, grain products, vegetables, fruit and berries were the most important dietary sources of lignans. Conclusion Total lignin intake was approximately four-fold higher in the Dutch lignin database, which includes the lignin precursors LARI and PINO, compared to estimates based on the Finnish database based only on SECO and MAT. The main sources of lignans according to the Dutch database in the five countries studied were cereals and grain products, vegetables, fruit, berries, and beverages.

Salt content in canteen and fast food meals in Denmark.

Background A high salt (=NaCl) intake is associated with high blood pressure, and knowledge of salt content in food and meals is important, if the salt intake has to be decreased in the general population. Objective To determine the salt content in worksite canteen meals and fast food. Design For the first part of this study, 180 canteen meals were collected from a total of 15 worksites with in-house catering facilities. Duplicate portions of a lunch meal were collected from 12 randomly selected employees at each canteen on two non-consecutive days. For the second part of the study, a total of 250 fast food samples were collected from 52 retail places representing both city (Aarhus) and provincial towns. The canteen meals and fast food samples were analyzed for chloride by potentiometric titration with silver nitrate solution, and the salt content was estimated. Results The salt content in lunch meals in worksite canteens were 3.8±1.8 g per meal and 14.7±5.1 g per 10 MJ for men (n=109), and 2.8±1.2 g per meal and 14.4±6.2 g per 10 MJ for women (n=71). Salt content in fast food ranged from 11.8±2.5 g per 10 MJ (burgers) to 16.3±4.4 g per 10 MJ (sausages) with a mean content of 13.8±3.8 g per 10 MJ. Conclusion Salt content in both fast food and in worksite canteen meals is high and should be decreased.