Forum of Nutrition (formerly Bibliotheca Nutritio et Dieta)
Editor: I. Elmadfa
Vol. 58
European Nutrition and Health Report 2004 Editors
I. Elmadfa E. Weichselbaum
European Nutrition and Health Report 2004
Forum of Nutrition Vol. 58
Series Editor
Ibrahim Elmadfa
Vienna
The European Nutrition and Health Report project has been financially supported by the European Commission (EC), Health and Consumer Protection Directorate-General, Directorate C – Public Health and Risk Assessment – within the Health Monitoring Programme (Grant agreement No SPC.2002356). However, neither the EC nor any person acting on its behalf is liable for any use made of the information available in this report.
European Nutrition and Health Report 2004
Volume Editors
Ibrahim Elmadfa Vienna Elisabeth Weichselbaum
Vienna
80 figures and 233 tables, 2005
Authors
Elmadfa I, Weichselbaum E, König J Austria Remaut de Winter A-M Belgium Trolle E Denmark Haapala I, Uusitalo U Finland Mennen L, Hercberg S France Wolfram G Germany Trichopoulou A, Naska A, Benetou V, Kritsellis E Rodler I, Zajkás G Hungary Branca F, D’Acapito P Italy Klepp K-I, Ali-Madar A Norway De Almeida MDV, Alves E, Rodrigues S Portugal Sarra-Majem L, Roman B Spain Sjöström M, Poortvliet E Sweden Margetts B UK
Basel · Freiburg · Paris · London · New York · Bangalore · Bangkok · Singapore · Tokyo · Sydney
Greece
Ibrahim Elmadfa Institute of Nutritional Sciences University of Vienna Vienna, Austria
Elisabeth Weichselbaum Institute of Nutritional Sciences University of Vienna Vienna, Austria
Library of Congress Cataloging-in-Publication Data European nutrition and health report / Elmadfa, I. ... [et al.]. p. ; cm. – (Forum of nutrition ; v. 58) Includes bibliographical references and index. European Commission, Health and Consumer Protection Directorate-General No. SPC.2002356 ISBN 3-8055-7905-5 (hardcover : alk. paper) 1. Nutrition–Europe. 2. Public health–Europe. [DNLM: 1. Nutrition Surveys–Europe. 2. Food Supply–statistics & numerical data–Europe. 3. Health Status–Europe. ] I. Elmadfa, I. II. European Commission. Directorate-General for Health and Consumer Protection. III. Series. RA601.E976 2005 363.8⬘094–dc22 2005001665
Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents® and Index Medicus. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microscopying, or by any information storage and retrieval system, without permission in writing from the publisher. © Copyright 2005 by European Commission, Health and Consumer Protection, Directorate-General Printed on acid-free paper www.karger.com ISSN 1660–0347 ISBN 3–8055–7905–5
Contents
VII List of Abbreviations VIII List of Participants IX Introduction XI Executive Summary XVI Outlook 1 Trends of Average Food Supply in the European Union 12 Food Availability at the Household Level in the European Union 19 Energy and Nutrient Intake in the European Union 19 25 32 41
Energy and Nutrient Intake in European Children Energy and Nutrient Intake in European Adolescents Energy and Nutrient Intake in European Adults Energy and Nutrient Intake in European Elderly
47 Health Indicators and Status in the European Union 47 49 51 54 56 60
Prevalence of Overweight and Obesity Blood Lipids Mortality Morbidity Physical Activity Smoking
62 General Discussion 66 Annexes 66 Illustrations of Food Supply Data, Based on FBS Data 76 Annex DAFNE Project 80 National Reports 80 Austria 96 Belgium 99 Denmark 111 Finland 119 France 124 Germany 133 Greece 150 Hungary 162 Italy
V
167 173 176 197 204
Norway Portugal Spain Sweden United Kingdom
213 References 221 Subject Index
VI
Contents
List of Abbreviations
A B BMI CHO D DK DAFNE E %E F FAO FBS FFQ FIN GR H HBS I MUFA N NSP P PUFA S SCF SD SFA UK WHO
Austria Belgium Body mass index (body weight in kg/body height in m2) Carbohydrates Germany Denmark Data Food Networking project Spain % of total energy France Food and Agriculture Organization Food balance sheets Food frequency questionnaire Finland Greece Hungary Household budget surveys Italy Monounsaturated fatty acids Norway Non-starch polysaccharides Portugal Polyunsaturated fatty acids Sweden Scientific Committee of Food Standard deviation Saturated fatty acids United Kingdom World Health Organization
VII
List of Participants
Coordinator of the European Nutrition and Health Report Ibrahim Elmadfa
Imre Rodler, Gábor Zajkás National Institute of Food Hygiene and Nutrition Budapest, Hungary
Coordinating Centre Ibrahim Elmadfa, Elisabeth Weichselbaum, Jürgen König Institute of Nutritional Sciences University of Vienna, Austria
Francesco Branca, Paola D’Acapito National Institute of Research on Food and Nutrition Human Nutrition Unit Roma, Italy
Partners Anne-Marie Remaut de Winter Nutrition Unit, Faculty of Agricultural and Applied Biological Sciences University of Gent, Belgium
Knut-Inge Klepp, Ahmed Ali-Madar Department of Nutrition Faculty of Medicine University of Oslo, Norway
Ellen Trolle Danish Inst. for Food and Vet. Research Copenhagen, Denmark Irja Haapala, Ulla Uusitalo Department of Public Health and General Practice University of Kuopio, Finland Louise Mennen, Serge Hercberg Institut Scientifique et Technique de la Nutrition et l’Alimentation Paris, France Günther Wolfram Department für Lebensmittel und Ernährung der TU München Weihenstephan, Germany Antonia Trichopoulou, Androniki Naska, Vassiliki Benetou, Elena Kritsellis Department of Hygiene and Epidemiology School of Medicine University of Athens, Greece
VIII
Maria Daniel Vaz de Almeida, Elsa Alves, Sara Rodrigues Faculty of Nutrition and Food Sciences Porto University, Portugal Lluis Serra Majem, Blanca Roman Department of Clinical Sciences University of Las Palmas de Gran Canaria, Spain Nutrition Research Foundation (FIN) Barcelona, Spain Michael Sjöström, Eric Poortvliet PrevNut at Novum Karolinska Institutet Huddinge, Sweden Barrie Margetts Public Health Nutrition Institute of Human Nutrition University of Southampton, UK
Introduction
The European Nutrition and Health Report, funded by the European Commission, is the first report combining health and nutrition data from European countries. Thirteen countries of the European Union and Norway expressed their interest in participating in this project. These countries of the EU are Austria, Belgium, Denmark, Finland, France, Germany, Greece, Italy, Portugal, Spain, Sweden, the United Kingdom and Hungary which was included in the very last minute replacing Ireland. Thus it is the first and only new member state of the European Union (EU) included in a project which was designed to cover the European Union before May 2004. The Institute of Nutritional Sciences of the University of Vienna (Austria) acted as coordinating centre of this project under the supervision of Prof. Ibrahim Elmadfa. The main task of the participating countries was the collection of national data. These data were then forwarded to the coordinating centre. Where necessary, the data set was transferred into another format by the coordinating centre, which was responsible for the preparation of the final report. The main goals of this report were • the compilation of available food and nutrient intake and health data, • the identification of major nutrition and health problems in the participating countries and the EU regions, • the identification of inadequacies of data collected in the participating countries, which would make a comparability of the collected data difficult. In the chapter, Trends of Average Food Supply in the European Union, data from food balance sheets (FBS) of the FAO (Food and Agriculture Organization) were used. In this chapter food supply trends in the participating countries during the past four decades are presented. These data were downloaded from the FAO database (http://faostat.fao.org/
faostat/collections, FAO 2003) and transformed by the coordinating centre. The chapter, Food Availability at the Household Level in the European Union dealt with the food availability data at the household level, obtained through house-hold budget surveys (HBS) of the participating countries. It was prepared by the coordinating centre of the DAFNE (Data Food Networking) project under the supervision of Prof. Antonia Trichopoulou, University of Athens. In the chapter, Energy and Nutrient Intake in the European Union, national nutrient intake data from all participating countries are presented. Each participant had to collect these data which were brought into a consolidated form by the coordinating centre. Data were available for children, adolescents, adults and elderly. Only a few countries had intake data of other population groups (e.g. pregnant and lactating women, athletes) which are thus not included in this chapter, but presented in the national reports (see annex, National Reports). It has to be mentioned that the references used in this report are sometimes not up to date (e.g. the recommendations of the SCF), but were still taken as clues when no other more recent reference values, at a European level, were not available. The chapter, Health Indicators and Status in the European Union, consists of national data as well. The amount and kind of data concerning health issues was varying. Thus, for some parts (e.g. Mortality and Morbidity), data from other organisations or statistical centres (e.g. WHO, Globocan 2000) were taken. In the annex a national report of each participating country is included. These national reports provide more detailed nutrition and health data of the participating countries.
IX
This report should not only compile data from the participating European countries, but should be an impulse for future projects in the area of nutrition and health. It should serve as a basis for improvements and for the planning of such future projects. Further, it shows what still has to be done in order to obtain comparable and representative data.
X
Introduction
Acknowledgement The excellent and patient editorial assistance of Dr. Lisa Kessler in the preparation of this manuscript is acknowledged.
Executive Summary
Trends of Food Supply in the European Union, on the Basis of the FAO Food Balance Sheets – In the EU1, an increase in per capita supply during the past four decades was observed for fruit, vegetables, sugar and sweeteners, oilcrops, vegetable oils, animal fats, red meat, poultry, fish and seafood, milk (excluding butter), eggs and beer. – The average supply of potatoes, cereals and wine showed a decrease, that of pulses stayed at a relatively consistent level. – Despite an increasing tendency in vegetable and fruit supply, the current supply situation cannot be regarded as sufficient. – The average supply of meat is high in the participating countries. – The proportion of fat in total energy supply increased during the past four decades. – The average supply of total carbohydrates decreased, with a simultaneous increase of sugar and sweeteners. • In the EU the average per capita supply of fruit and vegetables increased between 1961 and 2001. This increasing tendency was observed in the whole EU and also in each participating country. The highest supplies of vegetables were observed in countries of South Europe. • The mean potatoes and cereal supply decreased during the observation period. • An increase was observed in the supply of sugar and sweeteners in the EU. However, the UK and Finland showed considerable decreases in the supply of this food group. 1
• The supply of pulses hardly changed in the EU average. The countries with the highest initial values showed in general a decrease in pulses supply. The highest per capita supplies of pulses were found in countries of South Europe. • The mean supply of oilcrops in the EU showed an increasing tendency. The highest increase but also the highest supply – the 4-fold of the EU average – was found in Greece. • The average per capita supply of vegetable oils increased in the EU during the past four decades. This trend was also observed in most participating countries. Here again, the highest per capita supplies were found in countries of South Europe (Spain, Greece and Italy). In these countries the high supply of vegetable oils is primarily determined by the generally high supply and consumption of olive oil in Mediterranean regions. • In contrast to the increasing supply of vegetable fats, the average per capita supply of animal fats did not show any noticeable changes, only a slight increase was observed. • In general, the total supply of meat increased in the EU average, but also in each participating country. Only the UK showed a decrease in the supply of nearly all meat varieties, except for poultry. Especially the supply of poultry showed a noticeable increase in the EU and all participating countries, but also the supply of red meat showed an increasing tendency. However, the mean supply of bovine meat in the EU in 2001 was about as high as it was in 1961. It showed an increasing tendency until the early 1990s and a decrease in the following years. The reason for this was probably the appearance of BSE (Bovine Spongiform Encephalopathy). Also the supply of mutton and goat did hardly change in the EU average. • The average supply of fish and seafood in the EU increased during the observation period. The lowest supplies were found in countries of Central Europe.
The 15 member states of the EU before May 2004.
XI
• Also the mean supply of milk and milk products in the EU increased in the past four decades. • The supply of beer increased on average during the observation period, whereas the average supply of wine showed a decreasing tendency. • The total energy supply increased in the EU from 14.6 to 17.1 MJ/capita/day and was thus clearly sufficient. • In the period of 1997–1999 the proportion of animal products in total energy supply was 28% and that of plant products 72%. The energy supply of animal products increased in the period of 1967–1999 by 8%, that of plant products increased by 14%. • The average absolute energy, fat and protein per capita supply in the EU increased during the period of 1961– 2001. The relative share of protein and alcohol in total energy supply remained at a consistent level (14 and 2 %E, respectively). The proportion of fat increased from 34 to 41 %E, that of carbohydrates decreased from 50 to 43 %E. • The data derived from FAO food balance sheets often differ from nationally published data.
Food Availability in the European Union on the Basis of Household Budget Surveys, Data from DAFNE Project – The average availability of fruit and vegetables was particularly low in the UK and in Scandinavian countries. – The average availability of meat and meat products, as well as of sugared soft drinks was in general high in European households. – In countries participating in the DAFNE project the average availability of potatoes, cereals and cereal products, meat and meat products, and of added lipids2 decreased with increasing educational level of the household head. – The average availability of fruit and juices of fruit and vegetables was higher in households of higher educated household head. – The average vegetable availability in South Europe was higher in household with a household head of elementary education compared to households with a household head of higher education. In Central and North Europe the opposite trend was observed. – In countries with a high consumption of cheese, the average milk and milk products availability increased with increasing educational level of the household head, in those with a generally low consumption it decreased. 2 In the DAFNE food classification scheme, added lipids include animal lipids, vegetable fats and vegetable oils.
XII
Executive Summary
• The highest potato availability in the participating countries which also were part of the DAFNE project was observed in Portugal, the lowest in Italy. In all countries the average availability decreased with increasing educational level of the household head. • Pulses were preferably consumed in South Europe. In general, households with household heads of low educational level recorded higher values. • The same trend was observed for the availability of cereals and cereal products. The highest availability of this food group was observed in Italy. • Finland recorded the highest availability values for milk and milk products, Belgium the lowest. A higher milk and milk product availability in households of lower education was observed in Austria, Finland, Norway and Spain, a higher availability in households of higher education in Belgium, Germany, Greece, Portugal and Norway. Greece and Belgium were the high consumers of cheese, which was on average preferred in households with higher education. • Meat and meat products are commonly consumed in European households. In the late 1990s, the daily availability values ranged between 129 g/person (Norway) and 182 g/person (Austria). Disparities are also observed in the type of meat preferred in the different European regions. Poultry was particularly consumed in Spain and Hungary, processed meat in Central Europe. In general a decrease in the daily availability of meat and meat products was observed with increasing educational level of the household head. • The highest fish and seafood availability was found in Portugal, followed by Spain, Norway and Greece. The lowest availability was found in Austria in 1999–2000 and in Hungary in 1991. Urban areas had in general higher fish consumption. • Greece recorded the highest vegetable availability, Finland and Norway the lowest. In South Europe elementary education of the household head was found to be associated with higher vegetable availability, whereas the reverse trend was found in Central and Northern Europe. • The average fruit availability was also relatively high in Mediterranean countries, but it was also considerable in Austria and Germany. Apart from Austria, Italy and Spain, the highest fruit consumers were households with a household head of college or university education. • The range of availability of fruit and vegetable juices was substantially large. In general, countries with high fruit availability had a lower availability of juices. Juices were preferably consumed by people living in households with a highly educated household head.
• South European countries recorded the highest fruit and vegetable availability. Some Central European countries, however, seemed to be forging ahead, particularly in relation to the availability of fruit and juices of fruit and vegetables. The deficit however remained in the UK and in Scandinavian countries. • The highest availabilities of total added lipids were noted in Greece, Italy and Spain, with olive oil being the predominant added lipid. In all countries lipid availability was higher among households of elementary education. • In Hungary, Norway and Austria the highest availabilities of sugar and sugar products were recorded. • The daily availability of soft drinks ranged from 38 ml/ person/day in Portugal (1995) to 202 ml/person/day in the UK (1999). Values should however be interpreted with caution, since beverages consumed out of the household are not included. The effect of education on the availability of soft drinks does not follow a constant pattern.
Energy and Nutrient Intake in the European Union
– In the participating countries, the average share of fat in total energy intake was in general above the recommended level of ⱕ30 %E [Eurodiet, 2000]. – That of protein was either within or also above the recommended range of 10–15 %E. – As a consequence of this, the mean proportion of carbohydrates was generally below the recommendation of Eurodiet (ⱖ55 %E). – The intake of sucrose was relatively high (⬎10 %E) in nearly all population groups and countries. – In contrast the mean intake of dietary fibre was too low. – The average intake of saturated fatty acids was in the participating countries too high, whereas the intake of polyunsaturated fatty acids was low in many of the participating countries. – The proportion of alcohol in total energy intake was particularly in men of most countries considerable. – Food folate and vitamin D were critical micronutrients in all participating countries. – In some countries inadequate intakes of potassium, calcium and iodine were observed. – The average intake of iron was too low in women at fertile age of all participating countries. – The sodium intake was in general too high.
Executive Summary
The methods used for nutritional assessment in the participating countries were various, and also the age groups were not uniform. Thus, a direct comparison was not aspired to in this report.
Children In European children, the average share of protein in total energy intake was between 12 and 17%. In Germany this proportion was particularly low, in Spain it was relatively high compared to the other countries. Spanish children further had a low average carbohydrate intake (43–45 %E). In all other countries it was at least 50 %E or only slightly below. In Austrian and Norwegian boys and girls, and in Finnish infants, the share of this nutrient in total energy intake was particularly high. The average proportion of sucrose in total energy intake was – apart from Finnish children aged 3 years or less – higher than 10%. The mean proportion of fat in total energy was in children of the participating countries higher than 30%, and it was notably high in Spanish and Belgian children. The average intake of saturated fatty acids (SFA) was between 14 and 18 %E. Only in Italian and Hungarian children it was lower. Apart from Hungarian and German children, the average intake of polyunsaturated fatty acids (PUFA) was in this population group below the recommended level of the WHO. The mean intake of vitamin D and folate was in general low in children of the participating countries and mostly not satisfying. Further, insufficient potassium intakes were observed in Austrian, German, Hungarian and Italian children, and in Danish girls. In contrast, the sodium intake in children of some countries (especially Hungary and Italy) was already considerable, and in some countries even above 5 g/day. In the participating countries younger children had on average a more sufficient calcium intake than children of higher age groups. A low intake was observed in Austrian, German, Hungarian, Italian and Norwegian children. As expected, the average intake of iron was too low in girls at fertile age.
Adolescents Apart from Spain and Austria, the average share of protein in total energy intake of adolescents was within the recommended range of the WHO (2003). The highest proportion of carbohydrates was found in Norwegian adolescents and corresponded to the recommended intake of at least 55 %E [Eurodiet, 2000]. In all the other countries it was clearly below this level, the lowest proportion to be found in Spain with only 42 %E. The average proportion of sucrose in total energy intake was above the level proposed by the WHO (2003) in all countries with data from adolescents. Sugar-sweetened
XIII
beverages make a considerable contribution to total sucrose intake, not only in adolescents. Apart from Norwegian girls, the upper level of fat intake of Eurodiet (30 %E) was exceeded by all countries. The highest intake was observed in Spain. However, in Spain – beside Norway – the lowest proportion of SFA in total energy intake (%E) was recorded. On average the mean intake of PUFA (%E) was too low in European adolescents. The average cholesterol intake was in general higher in boys than in girls. The vitamin D intake was in general low, especially in Austrian male and female adolescents, and in Spanish female adolescents. In Norwegian male adolescents it was particularly high with an average of 5.4 µg/day. The mean folate intake was low and clearly below the recommended level of 400 µg/day [Eurodiet, 2000]. Female adolescents of all participating countries with data of adolescents had an insufficient potassium intake. In Austria and Germany it was also too low in boys. The supply of calcium was on average good. Only in Austrian adolescents the mean intake was too low. In some of the participating countries low magnesium intakes were observed as well. The iron intake was too low in female adolescents.
Adults The average share of protein in total energy intake in adults was above the recommended upper level (15 %E, by Eurodiet, 2000) in some countries, whereas the mean carbohydrate intake in European adults was low. In Belgium and France it was even lower than 40 %E (compared to the recommended 55 %E, by Eurodiet, 2000). Apart from Hungary and the UK, the mean proportion of sucrose in total energy intake was relatively low in European men. As a consequence of the low proportion of carbohydrates (%E) the average intake of dietary fibre (g/day) was low in European adults, especially in women. The highest intakes were recorded in Germany, Portugal, Finland and Norway. On average, the fat intake in the participating countries was high (%E). The highest proportion of fat in total energy intake was found in Belgian men and women. In contrast, Portugal and Norwegian women had the lowest fat intakes (%E). The intake of SFA (%E) was very high in Austrian and Belgian adults, whereas in Italian and Portuguese adults it was relatively low. In many of the participating countries the average PUFA intake (%E) was below the recommended lower level of the WHO (2003). As a consequence of the high fat intake, the average intake of cholesterol (mg/day) was relatively high in the participating countries as well. In Hungary and in France the highest average cholesterol intakes were recorded, in both men and women.
XIV
Executive Summary
The intake of vitamins in European adults was in general relatively good. However, the vitamin D intake was low in UK and Swedish women (below 2 µg/day), but particularly high in Swedish men (6.3 µg/day) and Finnish men (6.3 µg/ day). The average folate intake was below the recommended level of 400 µg/day [Eurodiet, 2000] in men and women of all participating countries. Typical for the usual diet of industrial countries, the average estimated sodium intake (g/day) was relatively high in European adults, especially in Hungary and Italy. An insufficient intake of potassium (g/day) was more prevalent in women than in men. The mean supply of calcium was relatively good in European adults. Only in Austria, Hungary and the UK low calcium intakes were observed. Apart from Portugal, the average iron intake in women was clearly below the guideline of 15 mg/day [Eurodiet, 2000]. The average iodine intake was particularly high in adults of Finland and the UK.
Elderly The share of protein in total energy intake was in European elderly in general within the recommended range of the WHO (2003). Like in adults, the average intake of carbohydrates (%E) was too low and that of fat too high. The carbohydrate intake was particularly low in Belgian and Danish elderly men. The average sucrose intake was above the recommended upper level of 10%E [WHO, 2003] in Germany, Greece and the UK. Especially in the countries with a high total fat intake, the average intake of SFA (%E) was very high. The PUFA (%E) intake was in general too low in European elderly. The vitamin A intake in elderly of the participating countries was on average sufficient. Only in Hungarian elderly it was clearly below the recommendations. The mean vitamin D intake was below the recommended intake of 10 µg/day [Eurodiet, 2000] in elderly men and women of all participating countries. The highest mean intakes were found in Norwegian and Austrian elderly men. Low intakes of riboflavin were more prevalent in male than in female elderly. The mean folate intake was among women and men of all countries below the recommended level of 400 µg/day. Like in adults, the mean estimated sodium intake was relatively high in European elderly, especially in Hungarian men and Italian elderly of both sexes. The mean supply of potassium was not sufficient in elderly of most participating countries. In Austrian, Hungarian and Spanish elderly the average calcium intake was below the recommended level of 800 mg/day [Eurodiet, 2000].
Health Indicators and Status in the European Union – The prevalence of overweight and obesity in the participating countries was very high. It was already considerable in childhood. – The average blood cholesterol levels were in general elevated. – In some countries the amount of exercise and the proportion of people doing exercise were assessed and were in most of them low. – The proportion of smokers in the participating countries was high and increased in most countries between 1995 and 2002. • The prevalence of overweight and obesity is already considerable in children. In Spanish boys the prevalence of obesity was particularly high with more than 20%. In European girls overweight and obesity were less prevalent than in European boys of the corresponding age group. In adult men of the participating countries which had data about overweight and obesity, the prevalence of overweight was between 35 and 53%, in women between 20 and 35%. The prevalence of obesity was on average between 6 and 26% and 6 and 31%, respectively. The highest percentage of overweight and obese men and women was recorded in Greece.
Executive Summary
• In European adults the total blood cholesterol level was on average too high, whereas the status of HDL-cholesterol was relatively good. The quotient of total cholesterol to HDL-cholesterol was within the recommended range (3–5) in all countries. The serum LDL-cholesterol concentration was on average too high in European adults. • Cardiovascular diseases (CVD) are the leading cause of death in European countries. Most death cases due to CVD can be attributed to cardiac heart disease, followed by cerebrovascular disease. • Malignant neoplasms are the second most prevalent reason for death in the participating countries. • The incidence of cancer was in 2001 on average higher in men than in women. In men, the most prevalent types of cancer were lung and prostate cancer, in women it was breast cancer. The prevalence of malignant neoplasms of the lung was in men clearly more prevalent than in women. However, it has to be considered that the amount of smokers in women has noticeably increased during the past years and that in the future the prevalence of lung cancer in women might not differ very much from that in men. • The proportion of smokers – in men as well as in women – is relatively high in the participating countries. On average it was higher in men than in women. Apart from Denmark and Belgium, the prevalence of smokers increased in the participating countries during the period of 1995–2002.
XV
Outlook
The description of dietary habits, nutrient and food intake, and health status of people of the participating countries was not the only aim of the European Nutrition and Health Report. It should also be a basis for other projects or assessments, which will be accomplished in the future. Concerning the outcomes of the presented data, the most prevalent inadequacies in health and dietary lifestyle are: • A too low availability (and in some countries intake as well) of fruits and vegetables, despite an increasing supply of these food groups. • A too high supply and availability of meat and meat products. • A generally too high intake of fat, especially of saturated fatty acids. • A generally low intake of complex carbohydrates and, consequently, a low intake of dietary fibre. • A relatively high proportion of sucrose in carbohydrate intake in most population groups and countries. • A generally inadequate intake of some vitamins (especially vitamin D and folate). • A generally inadequate intake of some minerals (e.g. calcium, iodine, and iron in women). • A generally too high intake of sodium (particularly in the form of table salt). • A generally high intake of alcohol, particularly in men.
• An alarming high prevalence of overweight and obesity. • A low amount of exercise and low proportion of people doing regular exercise in some countries. • A high proportion of smokers, which even shows an increasing tendency in most participating countries. In order to obtain comparable data for future European nutrition and health reports, the following goals should be considered for further assessments: • Standardised methods for the assessment of nutritional status, including food and nutrient intake, should be used (e.g. according to the suggestions of the EFCOSUM group). • For the assessment of overweight and obesity a consistent method should be considered (preferably measured data should be used). • For children uniform cut-off points for the definition of overweight and obesity should be chosen. • A standardised method for the assessment of physical activity should be used (e.g. International Physical Activity Questionnaire3). • Uniform age groups should be used. • Uniform educational levels should be used. • Reference values for nutrient intake valid for whole Europe should be updated including also aspects of health promotion and disease prevention.
3
More details to the International Physical Activity Questionnaire can be found at http://www.ipaq.ki.se (accessed September 7, 2004).
XVI
Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 2004. Forum Nutr. Basel, Karger, 2005, vol 58, pp 1–11
Trends of Average Food Supply in the European Union On the Basis of the FAO Food Balance Sheets
The food balance sheets (FBS) of the FAO (Food and Agriculture Organization of the United Nations) are agricultural statistics which are available for numerous countries in the world. They are available from 1961 on and for each following year, currently until 2001. Due to the fact that the method used for the assessment of food supply is equal for each country, FBS deliver internationally comparable data and are a unique source for showing international trends in food supply. However, FBS can only show national and international trends within one country but cannot show any differences between regions, different age groups, ethnic groups or men and women. Only per capita average food supply can be shown by FBS. Supply data obtained by agricultural statistics are in general clearly higher than the actual intake. The total food supply is calculated from production, imports, stock changes and exports. Per caput average supply, i.e. the utilisation side is then determined by considering feed, seed, losses through processing, storage and transportation, as well as waste and other use [FAO, 2001]. The average intake can still not be calculated. Considering all the positive and negative aspects of FBS, they are still very useful for showing trends within the past four decades and are thus used in this chapter. The FBS for the European Union (EU) are from the 15 member countries who were members already at the beginning of 2004. For Belgium no separate data exists, but only supply data for Belgium and Luxembourg combined. It has to be considered that the data derived from FBS do not always correspond to national agricultural statistics. In Denmark for example, the data derived from FAO FBS differ from the nationally published supply data.
In the following figures of this chapter, the highest and lowest level of supply of different food groups (table 1) in the participating countries are presented, as well as the EU calculated average (EU 15). The developments in food supply are given in five year intervals starting in 1961. During these four decades the highest and lowest food supply levels were usually observed in different countries. More detailed figures can be found in Annex (Illustrations of Food Supply Data, Based on FBS Data). Fruit The average fruit supply in the EU increased during the past four decades and still shows an increasing tendency (71 to 114 kg/capita/year; fig. 1). This is a positive and desirable development. Still the supply cannot be regarded as sufficient (see chapter ‘General Discussion’). Austria is the only country where the average fruit supply was lower in 2001 than in 1961 (126 compared to 134 kg/capita/ year). It was still higher than the average of the EU. Greece (145 kg), Italy (140 kg), Portugal (132 kg), Spain (123 kg) and Germany (120 kg/capita/year) had availabilities above the EU average in 2001 as well. All the other participating countries had a mean supply below the average of the EU. The lowest supply of fruit was observed in Hungary (62 kg), Belgium/Luxembourg (84 kg), the UK (91 kg/capita/year) and Finland (94 kg). The highest supply in the EU was reported in 1992. Vegetables The amounts of vegetables available in European countries differ notably from each other; a south-north gradient can be observed (fig. 2). The highest vegetable supply was observed in Greece (272 kg/capita/year) in 2001, followed by Portugal (188 kg), Italy (178 kg) and
Table 1. List of commodities classified by major food groups Fruits
Melons, Watermelons, Apples, Apricots, Avocados, Cherries, Figs, Grapes, Mangoes, Papaya, Peaches, Pears, Persimmons, Pineapples, Plums, Quinces, Blueberries, Cranberries, Gooseberries, Raspberries, Strawberries, Kiwi, Other fruits (fresh), Dates, Figs (dried), Prunes Currants, Raisins, Other dried fruits
Vegetables
Beets, Carrots, Turnips, Rutabagas or Swedes, Onions (green), Onions (dry), Artichokes, Tomatoes, Asparagus, Cabbage, Cauliflower, Celery, Kale, Lettuce, Spinach, Beans (green), Broad beans (green), Chilli peppers, Garlic, Cucumbers, Mushrooms, Eggplant, Peas (green), Pumpkins, Squash, Gourds, Okra, Radishes, Other vegetables
Cereals
Wheat, Rye, Barley, Oats, Maize, Rice, Mixed grains, Buckwheat, Sorghum, Millet, Quinoa, Other cereals
Sugar and sweeteners
Sugar (raw equivalent), Sweeteners (other), Honey
Pulses
Beans (dry), Broad beans (dry), Peas (dry), Chick peas, Cow peas, Pigeon peas, Lentils, Vetches, Lupins, Other pulses
Oilcrops
Soybeans, Coconuts (incl. copra), Oil palm fruit, Groundnuts, Olives, Rape and mustard seed, Sunflower seed, Cottonseed, Linseed, Hempseed, Sesame seed, Other oilcrops
Vegetable oils
Rape and mustard seed oil, Sunflower seed oil, Cottonseed oil, Linseed oil, Hempseed oil, Sesame seed oil, Copra and coconut oil, Palm kernel oil, Palm oil, Soybean oil, Olive oil, Maize oil
Animal fats
Butter, Ghee, Other animal fats, Fish liver oil, Whale oil
Red meat
Beef and veal, Buffalo meat, Pig meat, Mutton and lamb, Goat meat
Poultry
Chicken meat, Goose meat, Duck meat, Turkey meat
Fish and seafood
Freshwater fish, Demersal fish, Pelagic fish, Crustaceans, Molluscs, Aquatic mammals meat, Aquatic plants
Milk (excluding butter)
Cow milk, Goat milk, Sheep milk, Buffalo milk, Skim milk, Evaporated (unsweetened, whole), Condensed (sweetened, whole), Evaporated (unsweetened, skim), Condensed (sweetened, skim), Dried (whole), Dried (skim), Cream, Cheese, Hard cheese, Semi-soft cheese, Soft cheese
Eggs
Hen eggs, Other eggs
Fruit (kg/capita/year)
175
HS
EU mean
LS
150 125 100 75 50 25
Vegetables (kg/capita/year)
Source: FAO, 2001.
350
HS
EU mean
LS
300 250 200 150 100 50 0
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
1961 1966 1971 1976 1981 1986 1991 1996 2001
Fig. 1. Average supply of fruit in the EU. HS highest supply in the EU: A/GR (1961), GR (1966), I (1971), A/I (1976), GR (1981), A (1986), GR (1991–2001); LS lowest supply in the EU: FIN (1961–1971), UK (1976), P (1981), FIN (1986), H (1991–2001). Source of raw data: FAO, 2003.
Fig. 2. Average supply of vegetables in the EU. HS highest supply in the EU: E (1961), GR (1966–2001); LS lowest supply in the EU: FIN (1961–1986), N/FIN (1991), N (1996–2001). Source of raw data: FAO, 2003.
Spain (154 kg). This high vegetable supply is characteristic for the countries of Southern Europe. The average vegetable supply in France (130 kg) was slightly above the EU average of 126 kg/capita/year in 2001. All the other participating countries were below this European average. The lowest vegetable supply was observed in
the Scandinavian countries with 63 kg/capita/year in Norway, 70 kg in Finland and 74 kg in Sweden (data from 2001). In the EU an increase from an average of 94 kg per capita in 1961 to 126 kg in 2001 was observed. All participating countries showed an increase in vegetable
2
Trends of Average Food Supply in the European Union
HS
EU mean
LS Cereals (kg/capita/year)
Potatoes (kg/capita/year)
160 140 120 100 80 60 40 20 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
HS
200 180 160 140 120 100 80 60 40 20 0 1961
1966
1971
1976
1981
1986
EU mean
1991
1996
LS
2001
Fig. 3. Average supply of potatoes in the EU. HS highest supply in the EU: D (1961), BL (1966), BL/D (1971), E (1976), BL (1981), P (1986–2001); LS lowest supply in the EU: GR (1961–1966), I (1971–2001). Source of raw data: FAO, 2003.
Fig. 4. Average supply of cereals in the EU. HS highest supply in the EU: H (1961–1966), I (1971–2001); LS lowest supply in the EU: S (1961–1971), DK (1976), S (1981–1991), FIN (1996), E/D (2001). Source of raw data: FAO, 2003.
supply, apart from France (150 to 130 kg/capita/year) and Spain (162 to 154 kg). The most significant increase in vegetable supply was observed in Greece (115 to 227 kg/capita/year).
and Greece had about the same supply (between 67 and 73 kg/capita/year) and were thus slightly below the mean supply of the EU. The average potato supply in Germany was identical with that of the EU.
Potatoes Figure 3 shows that the mean potato supply in the EU decreased from 105 kg/capita/year in 1961 to 78 kg in 2001. This trend can be observed among nearly all participating countries, except for Portugal, Greece and the UK. The most significant increase was observed in Greece with a supply of 73 kg/capita/year in 2001 compared to 32 kg in 1961 but it was still below that of the EU. The mean potato supply in Portugal has increased from 88 kg/capita/year in 1961 to 123 kg in 2001. This was the highest supply among the participating countries in 2001 followed by Belgium/Luxembourg (113 kg) and the UK (111 kg/capita/year). However, the peak level of potato supply in Portugal was observed in 1987 and has decreased since that time. A noticeable point is the meaningful increase of the supply of potatoes in 1986, the year of the entry to the EU. In 1985 the mean potato supply in Portugal was 95 kg and in 1986 145 kg/capita/year. In the UK the average supply has increased continuously in the past 40 years (98 kg/capita/year in 1961 to 111 kg in 2001). Beside Portugal, Belgium/Luxembourg and the UK, the average potato supply of Spain (83 kg) and Denmark (82 kg/capita/year) was slightly above that of the EU in 2001 as well. All the other European countries had mean supplies below it. Italy showed the lowest mean potato supply of 40 kg/capita/year in 2001, followed by Sweden with 53 kg. France, Austria, Finland, Hungary, Norway
Cereals The mean cereal supply in the EU has decreased in the past 40 years from 126 kg/capita/year in 1961 to 116 kg in 2001 (fig. 4). This decreasing trend is to be valuated negatively as cereals are very important sources for dietary fibres and many vitamins, minerals and trace elements. The average supply in Austria and France in 2001 (118 and 117 kg/capita/year, respectively) was about equal to that of the EU. In both countries the mean cereal supply is lower than in 1961. However, an increasing tendency was observed from the early 1970s in France and from the early 1990s in Austria. Italy had the highest cereal supply in 2001 (162 kg/ capita/year). Italy is followed by Greece with an average supply of 154 kg/capita/year in 2001 which was below the amount of 1961 (167 kg) as well. The mean cereal supply further decreased in Hungary (which had the highest supply in 1961), Spain, Finland and the UK. The mean supply in Spain fell from 144 kg/capita/year in 1961 to only 101 kg in 2001 which was below the EU average. The supply data of the UK and Finland of 2001 (103 and 113 kg/capita/year, respectively) were lower than those of 1961 (110 and 137 kg, respectively) as well, but they have shown an increasing tendency within the past few years. Their mean supply is however still below that of the EU. The rest of the participating countries showed
Trends of Average Food Supply in the European Union
3
HS
EU mean
12
LS Pulses (kg/capita/year)
Sugar and sweeteners (kg/capita/year)
60 50 40 30 20 10
HS
EU mean
LS
10 8 6 4 2 0
0 1961 1966 1971 1976 1981 1986 1991 1996 2001
1961
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 5. Average supply of sugar and sweeteners in the EU. HS highest supply in the EU: DK (1961–1991), H (1996), BL (2001); LS lowest supply in the EU: GR (1961–1971), P (1976–1981), E (1986–1991), I (1996–2001). Source of raw data: FAO, 2003.
Fig. 6. Average supply of pulses in the EU. HS highest supply in the EU: E (1961), GR (1966), P (1971), GR (1976–1981), GR/E (1986), GR (1991), E (1996), UK (2001); LS lowest supply in the EU: DK (1961–1976), S (1981), DK (1986), S (1991), A (1996– 2001). Source of raw data: FAO, 2003.
an increase during the observation period. In Portugal a slight increase of cereal intake was recorded (123 kg/capita/year in 1961 compared to 132 kg in 2001). In Norway and Denmark the increase was larger (100 kg/ capita/year in 1961 to 128 kg in 2001 and 101 kg in 1961 to 127 kg in 2001, respectively). In these three countries the average supply was, in 2001, above that of the EU. Germany and Sweden had a mean supply below that of the EU but both showed an increasing tendency as well which was more meaningful in Sweden (77 kg/capita/ year to 103 kg) than in Germany (97 to 102 kg).
EU as a total, the supply amounts have changed in its member states. The largest decreases were observed in the three countries which had the highest amounts of pulses available in 1961: Spain (9.8 to 5.7 kg), Greece (7.9 to 4.5 kg) and Portugal (7 to 3.9 kg/capita/year). Italy showed a slight increase from 4.8 kg/capita/year in 1961 to 5.5 kg in 2001. The UK showed a substantial increase between 1961 and 2001. The average pulses supply in all the other participating countries was clearly below that of the EU. The lowest supply was observed in Austria with 0.9 kg/capita/ year, followed by Norway (1 kg), Denmark (1.1 kg), Finland (1.4 kg), Germany and Sweden (1.6 kg both) and France with 2 kg/capita/year. In most of these countries the mean supply slightly increased in the period of 1961 to 2001 with the exception of France (2.5 to 2 kg) and Norway (2 to 1 kg/capita/year). In Denmark the supply of pulses was practically zero until 1979, suddenly rose up to 1.14 kg/capita/year in 1980 and stayed at about the same level during the following years.
Sugar and Sweeteners In the EU the mean sugar and sweeteners supply increased from 34.3 kg/capita/year in 1961 to 40.2 kg in 2001 (fig. 5). The trends in the different participating countries were very diverse. Noticeable increases were observed in Greece (15.3 to 35.8 kg), Portugal (18.8 to 34.1 kg), Spain (20.5 to 32.6 kg), Italy (24.7 to 31.6 kg), Austria (40.9 to 50.1 kg), Germany (34.7 to 46.6 kg), Hungary (30.2 to 50.4 kg), Belgium/Luxembourg (27.7 to 52.2 kg) and France (40.9 kg/capita/year). Denmark (⬃51 kg), Norway (⬃46 kg) and Sweden (⬃47 kg/capita/ year) had about the same supply in 2001 as in 1961. The UK and Finland showed considerable decreases (51.9 to 38.9 kg and 45.2 to 36.7 kg/capita/year, respectively). The highest supply in 2001 was found in Belgium/ Luxembourg. Pulses Figure 6 shows that the average supply of pulses in the EU scarcely changed in the period of 1961 to 2001 (3.5 and 3.7 kg/capita/year, respectively). Different from the 4
Trends of Average Food Supply in the European Union
Oilcrops Oil-bearing crops are plants whose seeds, fruits or mesocarp and nuts are mainly used for extraction of culinary and industrial oils, excluding essential oils. Consequently, dessert or table nuts, such as walnuts, are excluded because although they are high in oil content, they are not used mainly for extraction [FAO, 2001]. The average oilcrops supply in the EU increased from 1.6 kg/capita/year in 1961 to 4 kg in 2001 (fig. 7). The highest supply of oilcrops was recorded in Greece with 15.1 kg/capita/year in 2001 compared to 6.1 kg in 1961.
HS
EU mean
LS
14 12 10 8 6 4 2 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Vegetable oils (kg/capita/year)
Oilcrops (kg/capita/year)
16
HS
30
Spain and the UK had an average supply above the EU mean in 2001 with 6 and 4.3 kg/capita/year, respectively. All the other countries were below the EU average. A decrease in oilcrops supply was only observed in one country, in Portugal (2.8 to 2.4 kg/ capita/year). Vegetable Oils The supply of vegetable oils showed an increasing trend in the EU (fig. 8). Between 1961 and 2001 the amount of vegetable oil available in the EU doubled from 10.7 kg/capita/year in 1961 to 21.5 kg in 2001. The increase shows a continuous curve progression. Denmark was the only country which showed a decrease in vegetable oil supply. This trend significantly differs from that of all the other countries. In Denmark the average supply in 1961 was 11.9 kg/capita/year and fell to a mean supply of 6.9 kg in 2001. This was the lowest supply among all participating countries in 2001. All the other countries showed an increase in vegetable oil supply. The highest increases were observed in Italy, Spain, Hungary and Norway. Norway had a supply of only 1.6 kg/capita/year in 1961 (the lowest supply of this year) and increased up to 15.6 kg (13.8), nearly the decuple of the initial value. Further, Norway showed big fluctuations in vegetable oil supply during these years, especially from the early 1960s to the early 1990s. Austria, France, Germany, Greece, Belgium/ Luxembourg and the UK showed about the same increases of approximately 10–12 kg/capita/year between 1961 and 2001. The increase during this time was slightly lower in Finland, with 7.8 kg/capita/year, but was relatively high referring to its initial value of 3.4 kg
Trends of Average Food Supply in the European Union
LS
25 20 15 10 5 0 1961
Fig. 7. Average supply of oilcrops in the EU. HS highest supply in the EU: GR (1961–2001); LS lowest supply in the EU: FIN (1961–1971), H (1976–1991), H/DK (1996), FIN (2001). Source of raw data: FAO, 2003.
EU mean
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 8. Average supply of vegetable oils in the EU. HS highest supply in the EU: GR (1961–2001); LS lowest supply in the EU: H (1961–1981), FIN (1986–1991), DK (1996–2001). Source of raw data: FAO, 2003.
in 1961. The average supply of vegetable oils in 1961 in Portugal was about 7 kg/capita/year lower than in 2001. It showed an increase until about 1990 and a decreasing tendency from that time on. The lowest increase in vegetable oil supply was observed in Sweden with 3.6 kg/ capita/year. However, it has to be considered that – compared to its neighbour countries Finland and Norway – it showed a relatively high initial supply of 13.5 kg/capita/ year in 1961 and still had the highest supply among the Scandinavian countries in 2001 with 17 kg/capita/year. The highest amounts of vegetable oils in 2001 were available in Spain, Greece and Italy with about 28 kg/ capita/year and were thus far above the EU average. The average supply in Germany was slightly above the EU average, that of all the other countries was below it. Olive Oil The olive oil supply was as expected very high in the Mediterranean countries Greece, Italy and Spain as well as in Portugal. Greece had the highest supply of 18.6 kg/ capita/year in 2001 compared to 14.6 kg in 1961. It is followed by Italy (9 kg/capita/year in 1961 to 13.1 kg in 2001) and Spain (8.2 to 12.1 kg/capita/year). Portugal showed a decrease in the supply of olive oil (6.6 to 4.4 kg/capita/year). In 2001 the European average was 4.4 kg/capita/year (compared to 2.9 kg in 1961) but was mainly determined by the four countries mentioned above. Apart from France, with an average supply of 1.5 kg, the rest of the participating countries had a mean olive oil supply of less than 1 kg/capita/year. This result may mean that only a small number of inhabitants use olive oil. 5
EU mean
LS
40 30 20 10
120 Red meat (kg/capita/year)
Animal fats (kg/capita/year)
HS
50
EU mean
LS
80 60 40 20 0
0 1966
1971
1976
1981
1986
1991
1996
1961
2001
Fig. 9. Average supply of animal fats in the EU. HS highest supply in the EU: DK (1961–1971), H (1976–2001); LS lowest supply in the EU: E (1961), E/GR (1966), GR (1971–2001). Source of raw data: FAO, 2003.
Animal Fats In the EU no significant change in animal fat supply during the past four decades has been found. Only a slight increase was observed during the observation period (12.8 to 14 kg/capita/year) (fig. 9). In general, the supply of animal products and thus animal fats is too high. The average supply of animal fats in the countries with a high supply of vegetables and vegetable oils was, as expected, lower than the EU average. These countries are Greece, Spain, Italy and Portugal. Also in Finland and the UK the average supply in 2001 was below that of the EU. In contrast to these two countries, which showed a meaningful decrease in animal fat supply between 1961 and 2001 (UK: 19.2 to 6.9 kg; Finland: 21.6 to 11.4 kg/capita/year), Greece, Italy, Spain and Portugal showed a substantial increase. In Greece the average supply rose from 1.9 kg/capita/year in 1961 to 3.1 kg, in Italy from 3.4 to 10.8 kg, in Spain from 1.5 to 4.7 kg and in Portugal it quadrupled from 3.3 to 12.9 kg/capita/year. The mean supply of all the other countries was above the EU average, although most of them showed a decreasing tendency. Hungary had the highest supply of animal fat in 2001 (37 kg/capita/year), followed by Denmark (27.5 kg) and Belgium/Luxembourg (24.9 kg). Norway showed a noticeable decrease in the supply of animal fats from 29.3 kg/capita/year in 1961 to 14.8 kg in 2001, which was only the half of the initial value. It showed big fluctuations, particularly during the period of the early 1960s to the early 1990s. Red Meat The supply of meat and meat products in general and particularly of red meat is high in industrial countries.
Trends of Average Food Supply in the European Union
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 10. Average supply of red meat in the EU. HS highest supply in the EU: UK (1961), A (1966), D (1971), A (1976–1981), D (1986), A (1991–1996), DK (2001); LS lowest supply in the EU: E/P (1961), P (1966–1986), N (1991), UK (1996–2001). Source of raw data: FAO, 2003.
Bovine meat (kg/capita/year)
1961
6
HS
100
40
HS
EU mean
LS
35 30 25 20 15 10 5 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 11. Average supply of bovine meat in the EU. HS highest supply in the EU: F (1961–2001); LS lowest supply in the EU: GR (1961), P (1966), H (1971–2001). Source of raw data: FAO, 2003.
The average supply of red meat in the EU increased from 45 kg/capita/year in 1961 to 66 kg in 2001 (fig. 10). This increasing tendency was observed in all participating countries except for the UK, Hungary and Germany. The UK showed a continuous decrease whereas in Germany and Hungary the supply increased until the late 1980s and then showed a meaningful decrease. Bovine Meat According to figure 11 the average bovine meat supply in the EU in 1961 was about 19 kg/capita/year, increased until 1991 up to about 23 kg and showed a decreasing tendency between 1992 and 2001, where the average per capita supply was 18.6 kg/capita/year. The decrease in bovine meat supply during this last decade may be related to the appearance of BSE (Bovine Spongiform Encephalopathy). The peak level
Pork The average pork supply in the EU nearly doubled during the four decades of evaluation (from 23 to 44.4 kg/ capita/year; fig. 12). The supply increased in most participating countries. In the UK it did not change significantly during this time and the supply was exactly the same in 2001 than in 1961 (25.4 kg/capita/year). The most significant increases were observed in Spain and Greece, followed by Italy and Portugal. The mean supply in Spain
Trends of Average Food Supply in the European Union
HS
80 Pork (kg/capita/year)
of its prevalence was observed between 1991 and 1994 in Great Britain. The UK, the country with the highest BSE incidence, already showed a decreasing tendency before the first occurrence of the mad cow disease. The largest decrease however took place in 1993. In 1987 and the following years, no notable decrease was observed. The peak level of bovine meat supply was observed in 1979. From the start of the observation period 1961 until about 1990 the average bovine meat supply in Germany was nearly identical with that of the EU. Since the early 1990s it has fallen far below the EU average. Austria and Finland too showed an average supply which was nearly identical with that of the EU and had about the same curve progression even during the BSE crisis. In France, the mean supply of bovine meat increased until 1991 with a peak level of 34.5 kg/capita/year. After 1991 the supply fell to about 28 kg/capita/year in 2001. The curve progression of bovine meat supply in Denmark showed a very discontinuous trend. An increase was observed until the late 1960s, a decrease until the early 1980s and then a further increase up to the year 2001, with a decrease in the curve during the BSE crisis. The average supply in 2001 of 24.4 kg/capita/year was much higher than that in 1961 of 16.6 kg. A noticeable increase in bovine meat supply was observed for Greece, Spain and Portugal. These three countries had the lowest availabilities (5.2, 6 and 6.2 kg/ capita/year) in 1961. Greece even exceeded the EU average with 22.1 kg/capita/year in 2001, Spain (14.7 kg) and Portugal (14.3 kg) stayed below it. Sweden was in 2001 at about the same level as in 1961 (⬃20 kg/capita/year), but with an increasing tendency within the last decade of the observation period. Norway and Italy showed a continuous increase during this period. Still, the mean supply in 2001 with 17.9 kg/capita/year was slightly higher than that of 1961 with 15.7 kg. The lowest supply of bovine meat in 2001 was noticed in Hungary with 5 kg/capita/year.
EU mean
LS
70 60 50 40 30 20 10 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 12. Average supply of pork meat in the EU. HS highest supply in the EU: H (1961–1991), A (1996–2001); LS lowest supply in the EU: GR (1961–1976), GR/P (1981), P (1986), GR (1991), N/UK/GR (1996), N (2001). Source of raw data: FAO, 2003.
increased from 8 kg/capita/year in 1961 to 66.5 kg in 2001, in Greece from 4.4 to 35.2 kg (in both cases the 8-fold of the initial value). In Italy the mean supply rose from 7.8 kg/capita/year in 1961 to 42.5 kg in 2001 (6-fold) and in Portugal from 9.1 to 41.9 kg (4-fold). In all the other participating countries the amount of pork available increased as well. Hungary was the only country which showed a decrease during these four decades. In 1961 it had the highest supply of pork with 46.9 kg/ capita/year, in 2001 it was 43.2 kg and even below the EU average. In Germany the average supply has decreased since the late 1980s. It was however still higher in 2001 (52.4 kg) than in 1961 (37.5 kg/capita/year). The highest availabilities in 2001 were recorded in Austria (71.5 kg), Denmark (70.3 kg), Spain (66.5 kg) and in Germany (52.4 kg/capita/year). The mean pork supply of these countries was clearly above the EU average; that of all the other countries was lower than that of the EU. Mutton and Goat Meat The total amount of mutton and goat meat available in the EU barely changed during the observation period and only showed a slight decrease from 3.4 kg/capita/ year in 1961 to 3.1 kg in 2001 (fig. 13). The by far highest supply of mutton and goat meat was recorded in Greece. The average supply increased from 9.2 kg/ capita/year in 1961 to 12.9 kg in 2001 whereby the peak level was reached in the years around 1970 with about 16 to 17 kg. Greece was followed by Spain with an average supply of 6.1 kg/capita/year in 2001 (compared to 3.7 kg in 1961), Norway with 5.6 kg in 2001 (compared 7
HS
EU mean
LS
EU mean
LS
30 25 20 15 10 5 0 1961
1961 1966 1971 1976 1981 1986 1991 1996 2001
to 4.3 kg in 1961) and the UK, which showed a significant decrease (from 11.6 kg/capita/year in 1961 to 5.4 kg in 2001). With a mean supply in 2001 of 3.5 and 3.4 kg/ capita/year, respectively, France and Portugal were slightly above the EU average. Sweden, Germany, Denmark, Austria and Italy had an average supply between 0.9 and 1.5 kg/capita/year; a slight increase was observed in these countries. The lowest supply was recorded in Finland with 0.3 kg/capita/year in 2001, in Hungary it was 0.8 kg. Poultry The supply of poultry showed on average an increasing tendency during the past four decades. This increase was not only observed in the whole EU (5.6 to 21.1 kg/ capita/year) but in each single participating country as well (fig. 14). The largest increases were observed in Portugal (1.6 to 27.4 kg), Spain (2.7 to 26.8 kg), the UK (6.3 to 28.9 kg), Hungary (9.4 to 31.3 kg) and Greece (1.5 to 19.1 kg/capita/year). The average supply in Hungary, the UK, France, Portugal, Spain and Belgium/ Luxembourg was in 2001 above that of the whole EU, that of all the other participating countries was below it. The lowest availabilities of poultry were recorded in the Scandinavian countries (between 7 and 14 kg/capita/ year). The highest supply was found in Hungary (31.3 kg/ capita/year). Fish and Seafood According to figure 15 the amount of fish available continuously increased during the observation period in each of the participating countries and the EU in general.
Trends of Average Food Supply in the European Union
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 14. Average supply of poultry in the EU. HS highest supply in the EU: F (1961), H (1966–1971), E (1976–1981), H (1986), E (1991), UK (1996), H (2001); LS lowest supply in the EU: N (1961–1966), FIN (1971), N (1976–2001). Source of raw data: FAO, 2003.
Fish and seafood (kg/capita/year)
Fig. 13. Average supply of mutton and goat meat in the EU. HS highest supply in the EU: UK (1961), GR (1966–2001); LS lowest supply in the EU: DK/S (1961), FIN/A (1966), A (1971), FIN (1976– 1981), FIN/H (1986), FIN (1991), H (1996), FIN (2001). Source of raw data: FAO, 2003.
8
HS
35 Poultry (kg/capita/year)
Mutton and goat meat (kg/capita/year)
20 18 16 14 12 10 8 6 4 2 0
HS
90 80 70 60 50 40 30 20 10 0 1961
1966
1971
1976
1981
1986
EU mean
1991
1996
LS
2001
Fig. 15. Average supply of fish and seafood in the EU. HS highest supply in the EU: P (1961–1976), N (1981), P (1986–2001); LS lowest supply in the EU: H (1961–2001). Source of raw data: FAO, 2003.
The EU average rose from 17.4 to 26.2 kg/capita/year (50%). This increasing tendency is desirable as an increased supply of fish is associated with a decreased prevalence of CVD, due to their high content of omega3-fatty acids. The highest increases in absolute numbers were observed in Portugal and Spain with a plus of ⬃20 kg/capita/year each (56 to 76 kg and 26 to 45 kg/ capita/year, respectively). The highest relative increase was observed in Finland with a plus of 80% (17.8 to 32.1 kg/capita/year). In 2001, Portugal showed the highest supply, followed by Norway (51 kg/capita/year) and Spain. The average fish supply in France, Finland and Sweden was higher than that of the EU as well. All the other countries were below the EU average. The lowest supply in 2001 was observed in Hungary (4.4 kg/capita/year).
EU mean
25
LS Eggs (kg/capita/year)
Milk, excl. butter (kg/capita/year)
HS 400 350 300 250 200 150
HS
EU mean
LS
20 15 10 5
100
0
50
1961
0 1961
1966
1971
1976
1981
1986
1991
1996
1966
1971
1976
1981
1986
1991
1996
2001
2001
Fig. 16. Average supply of milk excl. butter in the EU. HS highest supply in the EU: FIN (1961–1971), S (1976–2001); LS lowest supply in the EU: P (1961–1991), H (1996), E (2001). Source of raw data: FAO, 2003.
Milk (Excluding Butter) The average milk supply in the participating countries either increased or did not change in the period of 1961 to 2001. The EU average increased from 183 to 246 kg/ capita/year (fig. 16). The increase was particularly high in countries which initially had a relatively low supply, such as Portugal (61 to 227 kg), Greece (101 to 242 kg), Italy (145 to 247 kg) and Spain (83 to 165 kg/capita/ year). The average supply in Finland, Sweden and the UK barely changed during the observation period, in all the other countries it increased comparably to that of the whole EU. The highest supply of milk in 2001 was observed in Sweden and Finland with about 360 kg/ capita/year, followed by Austria, France and Norway with a mean supply between 267 and 291 kg/capita/year. Germany, Denmark, Greece and Italy were around the EU average. The lowest supply was observed in Spain (165 kg), followed by Hungary with 176 kg/capita/year. Eggs The average eggs supply in the EU increased until the mid 1980s with a peak level of 14.3 kg/capita/year, and then showed a decreasing tendency, with a mean supply of 12.6 kg/capita/year in 2001 (compared to 11.2 kg in 1961; fig. 17). With the exception of the UK which showed a significant decrease during the observation period (14.9 to 10.5 kg/capita/year), most participating countries showed an increasing tendency. The average supply significantly increased in Hungary (9.3 to 16.8 kg), Denmark (10.5 to 16.3 kg), France (10.6 to 15.6 kg), Greece (5.7 to 9.2 kg), Portugal (3.3 to 10.7 kg) and Spain (7.9 to 12 kg/capita/year). However, following
Trends of Average Food Supply in the European Union
Fig. 17. Average supply of eggs in the EU. HS highest supply in the EU: BL (1961), UK (1966), D (1971), H (1976–1991), H/F (1996), H (2001); LS lowest supply in the EU: P (1961–1996), FIN (2001). Source of raw data: FAO, 2003.
the EU trend, the supply showed a decreasing tendency during the last years of the observation period. In all the other countries the supply did not significantly change. Germany is an exception as – comparable to the total EU – its supply increased until the mid 1980s and then showed a decreasing tendency. The average intake in 2001 with 12.5 kg/capita/year hardly differed from that of 1961 with 12.7 kg. The highest supply was observed in Hungary, followed by Denmark and France, the lowest in Finland, followed by Greece and Norway. Beer Figure 18 shows that in the EU the average beer supply increased continuously during the observation period from 53 l/capita/year in 1961 to 74 l in 2001. The most significant increases were observed in Portugal (59 l), Finland (58 l) and Spain (55 l/capita/year). In relative numbers, the highest increase was observed in Portugal as well, where in 2001 (64 l) the 13-fold increase in amount of beer compared to 1961 (5 l/capita/year) was available. Portugal was followed by Greece and Spain (both 5-fold), and Italy (4-fold). The mean beer supply in these countries was still below that of the EU as well as the mean supply of France, Sweden and Norway. All the other participating countries had a mean supply higher than that of the EU average. The highest availabilities in 2001 was recorded in Austria and Denmark (both 118 l), and Germany (115 l/capita/year). Wine The EU shows a decreasing tendency in wine supply. The average supply was 33 l/capita/year in 2001 9
Table 2. Trends in food supply in the EU, in g/capita/day HS
EU mean
LS
160 Beer (l/capita/year)
140 120 100 80 60 40 20 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 18. Average supply of beer in the EU. HS highest supply in the EU: BL (1961–1966), D (1971–1996), DK (2001); LS lowest supply in the EU: P (1961–1966), GR (1971), I (1976–2001). Source of raw data: FAO, 2003.
Wine (l/capita/year)
140
HS
EU mean
LS
120 100 80
1961
1971
1981
1991
2001
Fruit Vegetables Potatoes Cereals Sugar and sweeteners Pulses Oilcrops Vegetable oils Animal fats Red meat, total: Bovine meat Pork Mutton and goat meat Poultry Fish and seafood Milk (excl. butter) Eggs Beer Wine
196 258 288 345 94 9.6 4.3 29 35 124 52 63 9.2 15 48 502 31 145 127
252 284 252 312 108 8.7 5.6 38 37 154 63 81 9.4 28 54 544 36 202 132
232 304 223 305 106 7.1 6.5 42 38 175 63 104 8.9 39 54 629 39 221 124
288 338 224 299 106 9.5 9.0 52 37 182 63 109 10.2 48 66 655 36 228 98
313 344 214 318 110 10.0 11.0 59 38 181 51 122 8.6 59 72 675 34 202 91
Source of raw data: FAO, 2003.
60 40 20
Calculated Total Alcohol Supply
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Fig. 19. Average supply of wine in the EU. HS highest supply in the EU: F (1961–1966), I (1971), F/P (1976), F (1981–1996), I (2001); LS lowest supply in the EU: FIN (1961–2001). Source of raw data: FAO, 2003.
compared to 46 l in 1961 (fig. 19). All participating countries which had a higher supply than the EU average showed a significant decrease. France showed the most significant decrease with 119 l/ capita/year in 1961 compared to 54 l in 2001, followed by Italy (108 to 55 l), Spain (59 to 37 l) and Portugal (65 to 52 l/capita/year). Greece was the only country with an average supply below the EU mean and still showed a further decrease (34 l/capita/year in 1961 compared to 26 l in 2001). All the other countries showed a significant increase during the observation period. The highest increase was observed in Denmark with a mean supply of 34 l/capita/year in 2001, about the EU average, compared to only 3 l in 1961. Table 2 shows the trends in food supply in the EU indicated as g per capita per day instead of kg per capita and year. 10
Food group (g/capita/day)
Trends of Average Food Supply in the European Union
On the basis of the FBS data, the average alcohol supply was calculated, using the German database (Bundeslebensmittelschlüssel II.3). In the EU the supply of alcohol increased from about 11.3 g/capita/day in 1961 up to 14.9 g in 1976 but then decreased to a level of 12.2 g in 2001 (fig. 20). During the first 20 years of the observation period France had the highest alcohol supply among all participating countries. In the following years Germany showed the highest amount of alcohol available, in 2001 it was Denmark. The lowest supplies were mainly observed in Norway and Greece. In 1961 Finland had the lowest alcohol supply but showed a notable increase in the following four decades. Also the difference between the lowest and the highest level clearly changed. In 1961 the highest alcohol supply was nearly 7 times higher than the lowest; in 2001 it was only about 3 times higher. Development of the Proportion of Macronutrients in Total Energy Supply
On the basis of the FBS and by using the German database (Bundeslebensmittelschlüssel II.3) the
Alcohol (g/days)
25
HS
EU mean
LS
20
1961
2001
A 2%
A 2%
15 10
F 34%
5
1971
1976
1981
1986
1991
1996
2001
Fig. 20. Average supply of alcohol in the EU. HS highest supply in the EU: F (1961–1971), D/F (1976), D (1981–1996), DK (2001); LS lowest supply in the EU: FIN (1961), N (1966), GR (1971– 1976), GR/N (1981), N (1986), GR (1991–1996), N/GR (2001). Source of raw data: FAO, 2003.
Table 3. Development of the proportion of macronutrients in the daily diet of the participating countries
F 41%
CHO 50%
0 1961 1966
P 15%
P 14%
CHO 42%
Fig. 21. Development of the proportion of macronutrients in the daily diet (EU). P Protein; CHO carbohydrates; F fat; A alcohol. Source of raw data: FAO, 2003.
1961
Austria Belgium/Luxembourg Denmark Finland France Germany Greece Hungary Italy Norway Portugal Spain Sweden UK EU
2001
Protein %E
CHO %E
Fat %E
Alcohol %E
Protein %E
CHO %E
Fat %E
Alcohol %E
13 13 12 13 16 13 14 14 14 13 16 15 13 14 14
49 44 44 52 48 46 54 53 56 46 51 56 43 48 50
36 40 43 34 32 39 31 32 27 40 31 27 43 36 36
2 3 1 1 4 2 1 1 3 1 2 2 1 2 2
14 13 15 15 15 12 15 11 15 15 17 16 14 15 15
43 41 43 46 41 41 45 42 44 46 43 39 43 46 42
40 44 39 37 42 44 39 45 40 38 38 43 41 37 41
3 2 3 2 2 3 1 2 1 1 2 2 2 2 2
CHO Carbohydrates. Source of raw data: FAO, 2003.
proportion of macronutrients in total energy supply was calculated. The total energy supply by food increased in the EU during the observation period from 14.6 to 17.1 MJ/capita/day. Figure 21 illustrates the consequences of an increasing consumption of animal products on the contribution of the different macronutrients to total energy supply. The proportion of fat increased and that of carbohydrates decreased between 1961 and 2001. The
Trends of Average Food Supply in the European Union
proportion of protein and alcohol remained at a consistent level. Table 3 shows the development of the proportion of macronutrient supply in all participating countries. Like in the total EU, the average per capita supply of fat increased in most of the participating countries, whereas the supply of carbohydrates decreased during the observation period of 1961 to 2001. The share of protein and alcohol in total energy supply did hardly change. 11
Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 2004. Forum Nutr. Basel, Karger, 2005, vol 58, pp 12–18
Food Availability at the Household Level in the European Union On the Basis of Household Budget Surveys, Data from the DAFNE Databank
Comparable information on food availability between countries can be provided by data collected in the household budget surveys (HBS). The HBS can be thought of occupying a position between the food balance sheets of the FAO and the specially designed individual nutrition surveys. Like food balance sheets, the HBS allow between-country comparisons at a regular basis but, moving from total population to household level, the HBS can provide a more detailed and valid description of the dietary choices of the population, as well as of population sub-groups defined by their demographic and socioeconomic characteristics. HBS, on which the DAFNE data are based [Trichopoulou et al., 2001; 2003], provide regularly updated dietary data that can be linked to sociodemographic indicators and are undertaken in nationally representative population samples. Since, however, they are not primarily designed to collect nutritional information, the food data have limitations which need to be taken into consideration [Southgate DAT, 1991; Trichopoulou A, 1992]. Thus in most cases, no records are collected on the type and quantity of food items and beverages consumed outside the home. With the exception of the UK where data on the out-of-home consumption have been recorded since 1992, the majority of the European countries collect data only on expenses related to this food occasion. Lastly, the HBS data are collected at household level and estimation of the individuals’ intake requires the application of non-parametric modelling. The data presented in this chapter refer to 12 DAFNE countries, which also participate in the European Nutrition and Health Report project and results are only presented based on the most recent
dataset available for each country. The DAFNE database, however, comprises of food data for 16 European countries, spanned over the last 20 years. From the twelve countries presented, four are South European (Greece, Italy, Portugal and Spain), five are Central European (Austria, Belgium, France, Germany and Hungary) and three are North European (Finland, Norway and the UK). From the socioeconomic indicators available in the DAFNE databank, we have chosen to present the effect of the household head’s education on daily dietary practices. Education has been reported as the strongest and most consistent indicator in assessing socioeconomic differences [Liberatos, 1988]. Education expresses not only the individual’s attainment and years of schooling, but it might also reflect occupation, income and, even more importantly, the way people perceive and apply current nutritional advice [Johansson et al., 1999]. Information on the educational level of the household head was available for ten out of the twelve countries studied.
Food Availability Tables 4a–4c present the mean daily availability of DAFNE food groups, by European region and country. In Tables 5a and 5b, data on the daily food availability according to the educational level of the household head (defined as elementary, secondary and higher education) are also presented. The dietary patterns in Europe, as depicted using the DAFNE data comparable between countries, are summarised below for main DAFNE food groups.
Table 4a. Mean availability of food and beverages in South European countries in the nineties (unit/person/day) Survey year
Greece 1998– 1999
Italy 1996
Spain 1990– 1991
Portugal 1995
Eggs (pieces) Potatoes (g) Pulses (g) Nuts (g) Cereals (g) Milk and milk products (g) Cheese (g) Meat and meat products (g) Red meat (g) Poultry (g) Processed meat (g) Vegetables (g) Fresh vegetables (g) Processed vegetables (g) Fish and seafood (g) Fruits (g) Fresh fruit (g) Processed fruit (g) Fruit and vegetable juices (ml) Lipids, added (g) Animal fat (g) Vegetable fat (g) Vegetable oils (g) Beverages, alcoholic (ml) Beverages, nonalcoholic (ml) Soft drinks (ml) Sugar and sugar products (g)
0.25 137 14 4.7 253 298
0.34 76 4.1 0.9 335 271
0.56 143 18 2.1 206 398
0.23 230 11 2.4 257 261
53 149
49 136
19 176
11 163
100 39 8.7 271 248 23
71 38 24 184 128 56
71 58 41 179 155 24
91 48 14 147 140 7.5
45 306 305 0.47 23
38 233 232 1.4 9.6
74 289 286 3.0 18
85 175 173 2.1 1.6
84 0.80 5.8 77 48
63 5.6 1.5 56 149
59 1.0 1.9 57 110
56 2.4 5.9 48 139
328
824
358
129
65 N/A
42 49
84 35
38 34
N/A⫽ not available. Source: The DAFNE databank (www.nut.uoa.gr).
Potatoes and Other Starchy Roots
The highest potato availability was recorded in Portugal (230 g/person/day in 1995) and the lowest in Italy (76 g/person/day in 1996). The majority of the Central and Northern European countries under study recorded a potato availability of around 100 g/person/day. With respect to the effect of education, in all countries the potato availability decreased as the educational level of the household head increased.
Food Availability at the Household Level in the European Union
Pulses (Legumes)
Pulses, plant foods of high dietary fibre and protein content, can generally be considered as a food preferably consumed in South Europe. In Greece, Spain and Portugal the mean pulses availability exceeded 10 g/ person/day, while in Central and North Europe the availability values barely exceeded 1 g/person/day. An exception stands for France and Hungary, which in 1991 recorded 4.9 g/person/day and 6.0 g/person/day, respectively. The consumption of pulses was also not popular in Italy, which recorded similar availability values with France (4.1 g/person/day in Italy). With the exception of Finland and Germany, households of low educational level recorded higher values, even in countries where the consumption of pulses was not popular. In South Europe, the particularly high preference towards pulses consumption among households of elementary education probably reflects the adherence of these populations to traditional eating patterns.
Cereals and Cereal Products
The group of cereals and cereal products includes cereal grains, flour, rice and pasta (used as recipe ingredients), together with bread, rusks, pizza, and bakery products. As expected, Italy had the highest daily availability of these countries with 335 g/person/day. With the exception of Germany, where cereal availability was slightly elevated among highly educated households, individuals of elementary education recorded higher values of cereal availability within their households.
Milk and Milk Products
Different patterns were observed with respect to the daily individual availability of milk and milk products. In late 1990s, the highest availability values were recorded in Finland (507 g/person/day) and the lowest in Belgium (255 g/person/day). Although a North/South gradient in consumption cannot be observed, an interesting pattern emerged when cheese was separated from the group. Countries consuming higher quantities of cheese, like Belgium (55 g/person/day) and Greece (53 g/person/day), tended to consume lower quantities of milk and other milk products (200 g/person/day and 246 g/person/day, for Belgium and Greece, 13
Table 4b. Mean availability of food and beverages in Central European countries in the nineties (unit/person/day)
Survey year
Austria 1999–2000
Belgium 1999
France 1991
Germany 1998
Hungary 1991
Eggs (pieces) Potatoes (g) Pulses (g) Nuts (g) Cereals (g) Milk and milk products (g) Cheese (g) Meat and meat products (g) Red meat (g) Poultry (g) Processed meat (g) Vegetables (g) Fresh vegetables (g) Processed vegetables (g) Fish and seafood (g) Fruits (g) Fresh fruit (g) Processed fruit (g) Fruit and vegetable juices (ml) Lipids, added (g) Animal fat (g) Vegetable fat (g) Vegetable oils (g) Beverages, alcoholic (ml) Beverages, non-alcoholic (ml) Soft drinks (ml) Sugar and sugar products (g)
0.50 100 N/A N/A 303 284
0.21 97 N/A 2.64 238 255
0.38 95 4.9 1.7 161 291
0.36 115 0.6 7.5 217 311
0.66 139 6.1 3.2 319 301
28 182
55 127
48 161
55 132
11 190
65 23 92 142 114 28
54 25 35 167 127 40
77 36 33 187 157 29
48 16 59 180 142 38
61 52 66 201 185 16
9.3 192 186 6.2 90
21 123 117 6.0 54
19 157 153 4.4 33
16 182 169 13 123
4.4 159 149 10 N/A*
42 12 11 2.9 171
29 7.6 13 8.4 135
41 16 5.9 19 114
37 15 15 6.4 200
652
500
373
915
N/A
116 74
191 56
47 44
108 59
41 80
53 30 7.5 15 85
N/A ⫽ not available. * Fruit and vegetable juices are grouped in the processed fruit and vegetables categories, respectively. Source: The DAFNE databank (www.nut.uoa.gr).
respectively). Among all the DAFNE countries, the highest milk and milk product availability (excluding cheese) was noted in Ireland (465 g/person/day), where the household consumption of cheese was rather low (15 g/person/day). Higher milk and milk product availability was recorded in households of lower education in Austria, Finland, Norway, Spain and to a lesser extent in France and Italy. Higher availabilities were noted among households of college/university education in Belgium, Germany, Greece, Portugal and Norway. The increase in milk and milk product availability as the educational 14
Food Availability at the Household Level in the European Union
level increased, particularly in countries where cheese was preferred, agreed with findings that cheese was more frequently consumed by individuals of college and university education.
Meat and Meat Products
Based on data collected in the nineties, the lowest meat and meat product availability was recorded in Norway (126 g/person/day) and the highest in Hungary
Table 4c. Mean availability of food and beverages in Northern European countries in the nineties (unit/person/day) Survey year
Finland 1998
Norway 1996/1997/ 1998
United Kingdom 1999
Eggs (pieces) Potatoes (g) Pulses (g) Nuts (g) Cereals (g) Milk and milk products (g) Cheese (g) Meat and meat products (g) Red meat (g) Poultry (g) Processed meat (g) Vegetables (g) Fresh vegetables (g) Processed vegetables (g) Fish and seafood (g) Fruits (g) Fresh fruit (g) Processed fruit (g) Fruit and vegetable juices (ml) Lipids, added (g) Animal fat (g) Vegetable fat (g) Vegetable oils (g) Beverages, alcoholic (ml) Beverages, nonalcoholic (ml) Soft drinks (ml) Sugar and sugar products (g)
0.31 111 1.3 1.6 206 507 48 148 52 12 67 123 103 20 30 157 147 11 82
0.34 114 0.82 3.8 201 386 39 126 53 14 41 109 84 24 50 135 129 6.1 48
0.24 128 0.99 1.7 199 320 20 130 34 33 25 150 103 48 20 106 99 7.6 41
31 11 16 3.5 102
32 6.4 23 1.7 73
26 9.7 11 6.0 51
531
720
812
81 53
177 79
202 31
generally remained when different meat types were also studied, it should be noted that in Greece households of higher education consumed slightly more meat products, and the Norwegian highly educated households recorded higher poultry availability values, when compared to their lower educated counterparts.
Fish and Seafood
Portugal had the highest fish availability with 85 g/person/day, followed by Spain (74 g/person/day), Norway (50 g/person/day) and Greece (45 g/person/day). The lowest fish and seafood availability was recorded in Austria in 1999–2000 (9.3 g/person/day) and in Hungary in 1991 (4.4 g/person/day), probably reflecting distance from the sea. Urban areas generally recorded higher fish consumption, indicating the recent improvement of food availability in urban markets (DAFNE data on locality not shown). Fish availability was found to differ between different education attainment levels in Austria, where fish availability increased as the educational level of the household head increased, and in Norway, Finland, Spain and Greece, where elementary educated households recorded higher fish availability. It should however be noted that, in recent years, the Greek low educated households had the biggest increase in fish availability, while in Norway highly educated households increased their fish consumption more than the low educated ones (DAFNE data on time trends not shown). Vegetables (Fresh and Processed)
Source: The DAFNE databank (www.nut.uoa.gr).
(190 g/person/day). Interesting disparities further emerged when different types of meat were studied. The highest red meat consumer was Greece (100 g/person/ day in 1998–1999) indicating the country’s departure from the eating habits in early 1960s, when meat consumption was substantially lower. Poultry was consumed more in Spain (58 g/person/day) and Hungary (52 g/person/day); while a preference towards the consumption of processed meat could be noted in Central Europe. With the exception of Portugal, a social gradient in the availability of meat and meat products was noted, with the daily availability values decreasing as the educational level of the household increased. Although this pattern
Food Availability at the Household Level in the European Union
According to HBS data collected in the late 1990s, Greece recorded the highest vegetable availability within the household (271 g/person/day). Finland and Norway, the two Scandinavian countries of the DAFNE network recorded the lowest vegetable availabilities (123 g/person/day and 109 g/person/day, respectively). South European countries were expected to be identified as the higher vegetable consumers; nonetheless, several Central European countries recorded availability values of similar magnitude. An increase in the availability of fruit, and vegetables in many Northern and Western European countries has been documented in recent years. In southern Europe, fruit and vegetable intakes have not shown the same increase, although they began at a much higher baseline. Given current recommendations for at least 3
15
Table 5a. Mean availability of foods and beverages (g-ml/person/day) by country (survey year) and educational attainment Austria (1999–2000)
Cereals and cereal products (g) Meat and meat products (g) Red meat (g) Poultry (g) Processed meat (g) Fish and seafood (g) Milk and milk products (g) Cheese (g) Vegetables (g) Fresh vegetables (g) Proc. vegetables (g) Fruit (g) Fresh fruit (g) Proc. fruit (g) Fruit and vegetable juices (ml) Potatoes (g) Pulses (g) Lipids, added (g) Animal lipids (g) Vegetable fats (g) Vegetable oils (g) Beverages alcoholic (ml) Beverages, non-alcoholic (ml) Soft drinks (ml) Sugar and sugar products (g)
Greece (1998–1999)
Italy (1996)
Portugal (1995)
Spain (1990–1991)
Il/El
Sec
C/U
Il/El
Sec
C/U
Il/El
Sec
C/U
Il/El
Sec
C/U
Il/El
Sec
C/U
339
302
305
295
224
206
367
320
289
315
270
224
220
164
155
197
185
140
155
144
144
149
130
118
150
168
155
182
160
147
80 67 38 28 23 18 87 93 83 7.1 9.0 12 343 285 267
105 41 7.2 49 267
96 36 9.6 41 307
94 37 11 45 360
77 43 25 38 276
68 35 24 37 269
61 33 20 38 266
77 56 12 81 208
94 50 15 86 247
92 42 12 79 280
73 62 42 75 402
65 48 40 71 378
63 43 35 70 389
26 193 162 31 260 255 4.9 94
28 140 112 27 191 185 5.9 87
30 159 123 36 191 182 9.9 117
49 288 265 23 291 291 0.37 15
52 255 233 22 299 299 0.42 26
62 259 234 25 358 357 0.85 37
51 191 135 56 242 241 1.2 6.6
48 179 123 56 227 226 1.5 11
51 193 138 55 231 230 1.3 12
6.8 161 156 5.2 139 138 0.88 1.1
9.9 150 143 6.9 172 170 1.9 1.3
8.6 134 126 7.7 171 169 2.2 1.5
18 182 159 23 293 290 3.1 17
21 164 135 29 273 270 3.1 23
23 173 144 29 278 275 2.9 22
151 N/A 67 14 12 40 172
103 N/A 43 12 11 20 174
67 146 134 117 85 71 69 291 N/A 18 11 9.9 4.4 4.0 3.7 16 30 94 74 80 71 59 51 63 11 0.63 0.84 1.2 6.3 5.2 5.0 1.6 6.2 5.6 6.0 6.1 1.6 1.5 1.2 5.5 13 88 67 73 64 52 45 55 142 50 46 44 175 136 123 189
245 198 156 101 13 8.1 20 13 58 47 62 49 1.9 2.2 0.94 0.93 5.9 5.9 1.8 2.1 51 39 59 46 152 96 113 100
684
660
551
322
320
360
852
807
811
95
115
124
354
372
374
121 97
119 75
86 57
60 N/A
69 N/A
72 N/A
39 55
45 46
39 38
26 43
37 35
39 29
86 37
81 27
69 28
94 11 52 1.9 2.4 48 95
N/A ⫽ not available; Il/EL ⫽ illiterate/elementary education; Sec ⫽ secondary education; C/U ⫽ college/university. Source: The DAFNE databank (www.nut.uoa.gr).
portions of vegetables (approx. 250 g/person/day) on a daily basis, Europeans are still far from meeting this target. If we further consider that the presented values refer to vegetable purchases, which are generally higher than the actual intake, the deficit is more pronounced. In terms of socioeconomic disparities in vegetable consumption, South Europe elementary education was found to be associated with higher vegetable availability. The picture was, however, reversed in Central and Northern Europe. With the exception of Austria and France, the highest vegetable availability was noted for the trend-leading highly educated households. 16
Food Availability at the Household Level in the European Union
Fruits (Fresh and Processed)
Fruits, together with vegetables, are the two food groups most frequently mentioned for their beneficial attributes. In the case of fruits, all the Mediterranean countries clearly lead the way with a mean daily availability exceeding the WHO recommendations of at least 2 portions (approx. 150 g) of fruit per day. In Central Europe, Austria and Germany recorded household fruit consumption of more than 180 g/person/day; the lowest values were recorded in the United Kingdom (106 g/ person/day). In general, the highest fruit consumers are
Table 5b. Mean availability of foods and beverages (g-ml/person/day) by country (survey year) and educational attainment Belgium (1999)
Cereals and cereal products (g) Meat and meat products (g) Red meat (g) Poultry (g) Processed meat (g) Fish and seafood (g) Milk and milk products (g) Cheese (g) Vegetables (g) Fresh vegetables (g) Proc. vegetables (g) Fruit (g) Fresh fruit (g) Proc. fruit (g) Fruit and vegetable juices (ml) Potatoes (g) Pulses (g) Lipids, added (g) Animal lipids (g) Vegetable fats (g) Vegetable oils (g) Beverages alcoholic (ml) Beverages, non-alcoholic (ml) Soft drinks (ml) Sugar and sugar products (g)
Finland (1998)
France (1991)
Germany (1998)
Norway (1996/97/98)
Il/El
Sec
C/U
Il/El
Sec
C/U
Il/El Sec
C/U
Il/El Sec
C/U
Il/El
Sec
C/U
270
236
232
223
191
203
187
149
127
216
224
213
197
199
152
130
117
167
144
131
179
156
131
137
114
138
129
114
71 27 38 20 233
55 24 36 19 236
47 26 32 22 284
62 11 78 36 564
49 12 65 26 501
45 14 57 28 450
89 42 34 20 294
71 34 34 18 290
62 28 27 20 287
51 16 61 16 307
40 15 52 18 322
61 9.4 46 58 429
55 14 42 50 377
45 15 36 47 387
48 162 122 40 115 110 5.2 37
50 163 122 40 115 109 5.6 46
62 175 135 40 134 127 6.7 68
44 126 107 19 161 151 10 71
47 111 91 19 145 135 9.4 82
53 135 112 23 169 156 13 94
48 47 52 53 203 176 176 176 176 145 145 138 27 31 30 37 168 144 166 N/A 177 163 140 162 165 4.2 4.7 4.3 13 25 34 51 120
62 192 151 41 197 183 14 134
39 107 85 22 131 126 5.2 32
38 104 80 23 129 123 5.7 45
40 118 91 27 150 143 7.1 63
132 103 81 144 105 81 117 87 N/A N/A N/A 1.1 0.78 2.1 6.3 4.3 36 29 26 39 29 25 48 38 11 7.16 7.04 16 9.89 7.37 17 15 17 14 10 19 15 14 6.6 5.8 8.9 8.4 8.4 3.6 3.5 3.5 24 16 127 119 155 86 107 115 132 108
62 3.3 32 14 4.6 14 82
117 103 178 111 0.59 0.79 1.3 0.78 37 34 40 32 15 15 7.9 6.2 16 13 31 24 6.5 5.9 0.92 1.5 199 212 45 71
90 0.6 27 6.1 19 2.3 92
463
489
524
588
476
533
395
369
332
925
887
896
725
637
163 56
209 54
184 57
74 64
84 48
85 47
42 47
50 41
52 43
117 59
81 56
154 89
193 78
163 76
Il/EL ⫽ illiterate/elementary education; Sec ⫽ secondary education; C/U ⫽ college/university; N/A ⫽ not available. Source: The DAFNE databank (www.nut.uoa.gr).
of college or university education. An exception stands for Austria, Italy and Spain, where the association between household fruit availability and educational attainment was reversed.
Juices (Fruit and Vegetable)
Because of the increased importance fruit and vegetable juices gain in consumers’ preference, this beverage group is separately addressed in the DAFNE
Food Availability at the Household Level in the European Union
classification scheme. In the twelve countries under study, the range of availability values was substantially large and ranges between 1.6 ml/person/day in Portugal and 123 ml/person/day in Germany. It should further be noted that countries which were identified as high fruit consumers reported lower juice consumption. In terms of socioeconomic disparities, in all countries and survey years, juices were preferably consumed by highly educated individuals, or individuals exercising nonmanual professions (DAFNE data on occupation not shown). 17
Total Added Lipids
The added lipid group includes all added fats (e.g. butter, margarine) and oils (olive oil and seed oils). As expected the highest lipid availabilities were noted in Greece (84 g/person/day), Italy (63 g/person/day) and Spain (59 g/person/day), with olive oil being the predominant added lipid (data not shown). When different types of lipids were examined, regional disparities prominently emerged. South Europeans consumed mainly vegetable oils. Margarine was mostly preferred in the Scandinavian countries, the UK and to some extent in Germany and Austria. In the latter two countries, as well as in France, animal fat mostly in the form of butter was also commonly purchased for household consumption. The highest availability of animal fat was recorded in 1991 in Hungary (30 g/person/day). Irrespective of differences in the type of dietary lipid consumed, in all countries lipid availability was higher among households of elementary education, indicating that high lipid availability may be related to traditional eating patterns.
Alcoholic Beverages
The lack of information on meals and beverages consumed outside the household is expected to impair observations related to the alcoholic beverage intake. It should thus be considered, when interpreting HBS data, that values on alcohol intake are only related to household availability. In this context, the highest availability values were recorded in Germany (200 ml/person/day) and the lowest in the UK and Greece (51 and 48 ml/ person/day, respectively). With the exception of the two Scandinavian countries, Belgium and Germany, more alcoholic drinks were available in households with heads of elementary education.
Non-Alcoholic Beverages
In accordance to alcoholic beverages, due caution is also required when interpreting data on the daily availability of non-alcoholic beverages (including soft drinks, mineral water, coffee and tea) at household level. As
18
Food Availability at the Household Level in the European Union
mineral water, coffee, tea and similar infusions are included in the grouping, Germany was leading the availability (915 ml/person/day), followed by Italy and the UK (824 ml/person/day and 812 ml/person/day, respectively). Because of the public health implications, data are separately presented for the soft drinks availability, within the European households. The highest values were recorded in the UK (202 ml/person/day), followed by Belgium (191 ml/person/day) and Norway (177 ml/ person/day). The lowest soft drink availability at household level was recorded in South European countries, France and Hungary. With the exception of three South European countries, Greece, Portugal and Spain, the availability of non-alcoholic beverages decreased as the education of the household head increased.
Sugar and Sugar Products
The highest daily availabilities of sugar and sugar products were recorded in Hungary (80 g/person/day), Norway (79 g/person/day) and Austria (74 g/person/ day). In response to current nutritional trends, most of the countries recorded a decrease in the availability of these products over time (DAFNE data on time trends not shown). In general, sugar and sugar product availability was higher among households of elementary education. The findings on how education affects food availability agree well with recent observations that low educational level, and by extension low socioeconomic status, was generally associated with increased consumption of sugar products, potatoes, cereals (including bread), meat and meat products and lower consumption of fresh fruit [Hulshof et al., 1991; Smith and Baghurst, 1992; Roos et al., 1996; Johansson et al., 1999; Irala-Estevez et al., 2002]. However, it was observed that lower educational levels were associated with higher availability of fresh fruit in Southern European countries. The observation that fresh vegetable and legume availability decreased with the educational level of the household head may reflect the adherence of less educated Southern households to traditional dietary choices. The data retrieved from the DAFNE databank supported previous findings on disparities in food habits among the various European regions.
Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 2004. Forum Nutr. Basel, Karger, 2005, vol 58, pp 19–46
Energy and Nutrient Intake in the European Union On the Basis of the National Data
Beside agricultural statistics, such as food balance sheets, or availability data at the household level, most European countries also accomplish assessments of nutrient and energy intake at an individual level. In this chapter, intake data of the participating countries based on an individual level are presented by sex and age group. These data have to be interpreted cautiously as the participating countries used different assessment methods which make direct comparability difficult. Further the assessments were conducted in different years and the age classifications are in general not uniform. The presented data still give a good overview of the nutritional situation in European countries.
Energy and Nutrient Intake in European Children Most of the participating countries had data about energy and nutrient intake in children. As Finland was the only country with available data for infants, these data were included here as well. The methods used for the assessment of dietary data in children are listed in table 6. Energy and Macronutrients Tables 7a and 7b show that the average energy intake in children of the participating countries increased with increasing age. Further, the difference in energy intake between girls and boys became more considerable with increasing age. In Finland and Italy no separate intake data for boys and girls exist. The relative share of protein in total energy intake was between 12 and 17% in girls and boys of the participating countries. In Germany this proportion seemed to be
particularly low compared to other countries, with only 12 %E in all age groups (except for girls aged 7–9 years). Also in the UK it was very low with 12–13 %E in all age groups. In Spanish children the mean proportion of this macronutrient seemed to be relatively high with 17 %E in girls and boys of both age groups (2–5 and 6–13 years). Also in 13 months old Finnish children the average intake of protein was 17 %E. There was hardly any difference between boys and girls of the same age group and country. Only in Austrian boys the proportion Table 6. Methods and period of dietary assessment in children of European countries Country
Age group
Method
Year of survey
Austria
3–6 years 7–14 years 6–12 years 1–14 years
3-day-weighed record 7-day-weighed record 1-day-weighed record 7-day-record, personal interview 3-day-record 3-day and 4-day-record
2001 2000–2001 1989–1990 1995
Belgium Denmark Finland
Germany Greece Hungary Italy Norway Portugal Spain UK
8 months 13 months– 4 years 1–7 years 4–14 years 2–14 years 12–13 years 14–15 years 1–14 years 4–13 years 7–9 years 2–13 years 1–14 years
3-day-record HBS 3-day-household measured record 3 24-hour-records 3 24-hour-records Not indicated 4-day-record 24-hour-recall 24-hour-recall 4-day-weighed record (1–4 years) 7-day-weighed record (4–14 years)
1999 1999 1992 1998 1985–1987 1995 1997 1994–1996 2000 2000–2002 1998–2000 1992–1993 (1–4 years) 1997 (4–14 years)
20
Table 7a. Intake of energy and macronutrients (mean SD) in children of European countries (boys) Age (years)
Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark
Finland4
Germany
Greece
Hungary Italy4 Norway
Portugal Spain UK
Reference values* 1
*
3–6 7–91 7–92 10–121 10–122 13–141 13–142 6–12 1–3 4–6 7–10 11–14 83 133 2 3 4 1–3 4–7 4–6 7–9 10–12 13–14 2–3 4–5 6–7 8–9 10–11 12–14 12–13 14–15 1–9 10–14 4 9 13 7–9 2–5 6–13 1–4 4–6 7–10 11–14
N
66 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 129 136 185 162 215 449 433 398 359 30 47 559 679 640 376 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 206 404 492 2,184 192 464 848 184 256 237
Energy (MJ)
5.7 1.5 7.8 1.4 6.3 1.8 8.8 2.3 6.7 1.6 8.9 2.5 8.0 2.8 8.4 6.9 8.1 9.8 10.9 3.5 0.6 4.2 7.6 4.8 8.6 5.2 1.0 5.7 1.1 5.7 1.3 7.0 1.3 6.1 7.2 8.4 9.9 n.a. n.a. n.a. n.a. n.a. n.a. 10.3 2.7 11.1 3.2 7.1 1.9 9.9 2.3 6.3 1.4 8.6 2.0 9.5 3.5 10.2 2.5 6.7 0.6 9.0 1.3 4.9 1.1 6.5 1.3 7.5 1.5 8.3 1.9
Protein %E
13 2 15 3 15 3 15 3 15 3 16 4 16 4 14 13 14 14 14 12 3 17 4 16 3 15 4 15 3 15 4 15 4 12 12 12 12 16 4 15 4 16 3 15 4 16 4 16 4 14 2 14 2 16 4 16 4 14 4 14 2 15 3 17 4 17 2 17 2 13 3 12 2 12 2 13 2 10–15**
Carbohydrates %E Total
Sucrose
55 6 50 7 51 7 52 6 49 7 53 6 47 5 49 51 52 51 51 58 11 54 10 50 10 50 11 51 10 49 11 51 12 51 52 52 52 43 8 44 8 44 8 45 8 44 9 45 9 50 5 49 6 49 16 49 14 52 13 54 6 54 7 49 8 44 3 44 5 51 6 55 5 56 4 56 5 55
15 5 13 4 10 4 11 3 11 3 14 5 94 n.a. 115 145 135 145 32 53 84 10 4 11 5 14 4 17 7 16 16 15 15 n.a. n.a. n.a. n.a. n.a. n.a. 12 5 12 6 n.a. n.a. 15 6 16 6 18 8 23 7 n.a. n.a. 29 7 n.a. n.a. n.a. 10**
Eastern Austria, 2 Western Austria, 3 months, 4 boys and girls, 5 added sugar. Eurodiet, 2000; ** WHO (2003); n.a. not available.
Dietary fib. (g)
Fat %E
SFA %E
MUFA %E
PUFA %E
Cholesterol (mg)
12 5 14 4 13 5 17 5 11 3 15 5 16 7 21 15 17 20 21 73 93 93 10 3 11 3 11 3 13 3 14 17 21 24 11 6 12 6 14 7 15 7 16 8 17 8 20 7 20 7 14 6 20 7 12 5 16 7 16 8 19 8 11 1 16 3 62 93 10 3 12 4
32 5 35 6 34 5 33 5 36 6 31 6 37 6 37 36 34 35 35 29 4 28 5 33 5 33 5 33 5 36 11 34 10 36 35 35 34 41 7 41 7 40 7 40 7 40 7 40 7 37 5 36 6 35 10 35 9 33 10 32 5 31 6 35 7 38 4 39 3 36 5 35 4 34 4 35 4 30
16 2 17 2 16 2 15 2 17 1 15 2 17 2 15 17 16 15 15 13 2 12 3 15 3 15 3 15 3 16 5 14 5 15 14 14 14 n.a. n.a. n.a. n.a. n.a. n.a. 11 11 2 11 3 10 3 14 4 14 3 13 3 13 3 14 2 14 2 16 3 15 2 14 2 14 2 10
12 1 13 1 13 1 12 1 13 2 11 2 14 2 14 10 10 10 10 92 92 11 2 11 2 11 2 13 4 12 4 12 12 12 11 n.a. n.a. n.a. n.a. n.a. n.a. 12 11 2 12 4 13 4 10 3 10 2 10 2 15 4 15 3 16 2 11 2 11 2 11 2 11 2
42 52 51 52 63 52 62 6 5 4 5 5 51 41 41 51 51 63 63 6 6 7 7 n.a. n.a. n.a. n.a. n.a. n.a. 8 93 43 52 62 62 52 52 41 51 52 51 61 61 6–10
220 102 350 142 242 96 350 119 223 94 409 371 233 94 267 207 265 345 371 73 31 109 45 157 65 171 66 182 68 217 86 255 112 176 199 220 257 352 169 334 194 350 194 337 178 353 207 358 229 359 148 394 161 296 146 369 118 180 81 221 102 239 134 n.a. 290 101 363 117 137 65 161 76 183 69 202 80
Table 7b. Intake of energy and macronutrients (mean SD) in children of European countries (girls) Age (years)
Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark
Finland4
Germany
Greece
Hungary Italy4 Norway
Portugal Spain UK
Reference values* 1
*
3–6 7–91 7–92 10–121 10–122 13–141 13–142 6–12 1–3 4–6 7–10 11–14 83 133 2 3 4 1–3 4–7 4–6 7–9 10–12 13–14 2–3 4–5 6–7 8–9 10–11 12–14 12–13 14–15 1–9 10–14 4 9 13 7–9 2–5 6–13 1–4 4–6 7–10 11–14
N
85 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 149 137 191 172 215 449 433 398 359 30 47 528 627 600 381 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 185 411 517 2,113 175 448 827 172 225 238
Energy (MJ)
5.6 1.1 7.2 1.2 4.9 1.6 7.4 2.4 6.7 1.5 7.5 2.3 6.7 2.5 7.9 6.4 7.3 8.8 8.7 3.5 0.6 4.2 7.6 4.8 8.6 5.2 1.0 5.7 1.1 5.7 1.3 7.0 1.3 5.8 6.4 7.6 8.2 n.a. n.a. n.a. n.a. n.a. n.a. 9.5 2.3 9.3 2.4 7.1 1.9 9.9 2.3 6.0 1.2 7.7 2.0 8.0 2.6 9.6 2.4 6.3 0.7 7.9 1.0 4.7 1.1 5.8 1.2 6.7 1.6 7.0 1.6
Protein %E
Carbohydrates %E Total
Sucrose
13 3 14 3 14 2 15 3 15 3 15 3 14 2 13 14 13 14 15 12 3 17 4 16 3 15 4 15 3 15 4 15 4 12 13 12 12 16 4 16 4 15 3 15 4 16 4 15 3 13 2 14 2 16 4 16 4 14 3 14 3 14 3 17 4 17 2 17 2 13 3 12 2 12 2 13 2
54 6 50 6 50 2 54 7 50 7 51 6 52 6 49 50 52 49 51 58 11 54 10 50 10 50 11 51 10 49 11 51 12 50 51 52 53 42 8 43 9 44 8 44 9 44 9 45 9 50 6 50 5 49 16 49 14 53 11 55 6 55 6 49 8 45 3 43 3 51 6 55 5 55 5 55 5
15 5 13 4 11 5 13 5 10 4 11 4 12 6 n.a. 115 145 135 135 32 53 84 10 4 11 5 14 4 17 7 16 15 15 16 n.a. n.a. n.a. n.a. n.a. n.a. 12 5 13 6 n.a. n.a. 15 7 18 6 19 7 22 7 n.a. n.a. 29 7 n.a. n.a. n.a.
10–15**
55
10**
Eastern Austria, 2 Western Austria, 3 months, 4 boys and girls, 5 added sugar. Eurodiet, 2000; ** WHO (2003); n.a. not available.
Dietary fib. (g)
Fat %E
SFA %E
MUFA %E
PUFA %E
Cholesterol (mg)
12 4 14 3 84 16 6 13 5 15 5 13 6 19 14 15 17 19 73 93 93 10 3 11 3 11 3 13 3 14 16 19 21 10 5 12 7 13 7 13 6 14 7 15 8 20 7 19 6 14 6 20 7 12 4 14 6 14 7 18 8 10 3 14 2 62 83 10 3 10 3
33 5 36 6 36 5 31 5 35 5 34 6 34 6 38 36 34 35 35 29 4 28 5 33 5 33 5 33 5 36 11 34 10 37 36 35 34 42 7 41 7 40 6 40 7 41 7 41 8 37 5 36 5 35 10 35 9 33 9 31 5 31 5 35 7 38 3 40 3 36 5 35 4 35 4 35 5
17 2 17 2 18 2 15 2 16 2 17 2 17 3 15 17 16 15 15 13 2 12 3 15 3 15 3 15 3 16 5 14 5 15 14 14 14 n.a. n.a. n.a. n.a. n.a. n.a. 11 11 2 11 3 10 3 15 4 14 3 14 3 13 3 14 3 14 2 16 3 15 2 14 2 14 2
12 1 13 2 13 1 11 2 13 1 12 2 12 2 14 10 10 10 10 92 92 11 2 11 2 11 2 13 4 12 4 12 12 11 11 n.a. n.a. n.a. n.a. n.a. n.a. 12 11 2 12 4 13 4 10 3 10 2 10 2 15 4 15 2 16 2 11 2 11 2 11 2 12 2
42 62 62 52 62 52 53 7 5 4 5 5 51 41 41 51 51 63 63 6 6 7 7 n.a. n.a. n.a. n.a. n.a. n.a. 8 92 43 52 62 62 52 52 41 51 52 51 61 62
206 89 314 205 212 115 293 149 245 139 299 128 234 140 245 221 234 334 281 73 31 109 45 157 65 171 66 182 68 217 86 255 112 177 176 196 208 354 203 329 174 318 167 323 194 329 196 349 248 317 138 320 118 296 146 369 118 168 65 197 105 196 105 n.a. 254 96 329 118 140 72 155 58 171 67 172 73
30
10
6–10
21
seemed on average to be slightly higher in boys than in girls. In Spain and Greece the mean carbohydrate intake in children was, with 42–45 %E, particularly low. In all other countries the proportion was on average at least 50 %E or only slightly below it. In Finnish infants (8 months) it was particularly high with 58 %E as well as in those aged 13 months. In the UK, children aged 4–14 years had a high proportion of carbohydrates in their daily diet with 55–56 %E in both boys and girls. Also in Norwegian girls (55 %E) and boys (54 %E) at the age of 9 and 13 years and in Austrian girls (54 %E) and boys (55 %E) aged 3–6 years the mean proportion of carbohydrates was relatively high. The share of sucrose in total energy intake should preferably be below 10%. In Finnish children aged 8 and 13 months, 2 years and 3 years this upper level of the WHO (2003) was not exceeded. Children of all other countries and age groups had a mean sucrose intake which was higher than 10 %E. In Norwegian and German children of all age groups but also in Austrian children of the first age group it was particularly high with an average proportion of 15 %E or more. The mean intake of dietary fibre in children of the participating countries generally increased with increasing age. Apart from Finnish children aged 2 years or less and children living in the UK aged 1–6 years, it was between 10 and 20 g/day. Only German children of the last age group (13–14 years) had an average intake higher than 20 g/day. Apart from Finnish infants at the age of 8 and 13 months, the mean proportion of fat in total energy intake was above 30%. In Greek children the average fat intake was particularly high and was between 40 and 42 %E. With 38–40 %E it was very high in Spanish children as well, but also in Belgian children with 38 %E in girls and 37 %E in boys. The share of saturated fatty acids (SFA) in total energy intake should be below 10%. The lowest intake of SFA was found in Italian children with 10–11 %E and in Hungary with 11 %E in boys and girls aged 12–15 years. Also in Finnish infants at the age of 8 and 13 months the intake was still low with 12–13 %E. Children of other participating countries had a mean intake which was between 14 and 18 %E which was clearly above the upper level of the WHO (2003). There was hardly any difference between boys and girls. The proportion of monounsaturated fatty acids (MUFA) was on average between 10 and 13 %E in children of the participating countries. It was only slightly lower in 22
Energy and Nutrient Intake in the European Union
Finnish infants (8 and 13 months) with 9 %E. The highest intake of MUFA was found in Spain with 15 %E in boys and girls at the age of 2–5 years and 16 %E in those aged 6–13 years. In Belgian children the average intake of MUFA was 14 %E. The WHO recommends an intake of polyunsaturated fatty acid (PUFA) of at least 6 %E. Based on this recommendation the average intake of PUFA was too low in Danish, Italian and Spanish children of all examined age groups, as well as Finnish, Austrian and Norwegian children of some age groups. The mean supply was very good in Hungarian children with 8–9 %E in girls and boys, but also in Germany it can be regarded as sufficient. The mean intake of cholesterol was relatively high in children of some of the European countries. In Austrian children aged 7–14 years of Eastern Austria it was around 300 mg/day in girls and between 350 and 410 mg/day in boys. Also in Hungarian and Italian children, in Spanish boys (2–13 years) and girls (6–13 years), as well as in Danish girls (7–10 years) and boys (7–14 years) the mean cholesterol intake was high. A relatively low intake of cholesterol was observed in German and in Norwegian children. Vitamins Based on the population reference intakes of vitamin A indicated by the SCF (1993), the intake of this nutrient can on average be regarded as sufficient in children of the participating countries (tables 8a and 8b). The lowest vitamin A intake was found in Spanish children with 0.4–0.5 mg RE/day. The -carotene intake in children was not assessed in all countries. Of those who had intake data of this nutrient, Denmark had the highest mean intake in both girls and boys. On average, there was no meaningful difference in -carotene intake between boys and girls. Only in Germany it was higher in girls than in boys of the same age groups. The average vitamin D intake in children of European countries was low. Apart from Italian children at the age of 10–14 years and 9 year old Norwegian boys, the average intake was below 3 g/day. As the requirement for vitamin D from food depends on the endogenously produced amount of this vitamin, the SCF (1993) does not give any exact recommendations for children older than 3 years but only a range of 0–10 g/day. In regard to a relatively low amount of sun exposure during winter months, and a generally low amount of sun irradiation in countries of Northern Europe, this low average intake in European children may not always be sufficient. For
Table 8a. Vitamin intake (mean SD) in children of European countries (boys)
Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark
Finland8
Germany
Greece
Hungary Italy8 Norway
Spain UK
Reference values*
Age (years)
N
Vitamin A1 (mg)
-Carotene (mg)
Vitamin D (g)
Vitamin E2 (mg)
Thiamine (mg)
Riboflavin (mg)
Niacin3 (mg)
Vitamin B6 (mg)
Folate4 (g)
Cobalamin (g)
Ascorbic acid (mg)
3–6 7–95 7–96 10–125 10–126 13–145 13–146 6–12 1–3 4–6 7–10 11–14 87 137 2 3 4 1–3 4–7 4–6 7–9 10–12 13–14 2–3 4–5 6–7 8–9 10–11 12–14 12–13 14–15 1–9 10–14 4 9 13 2–5 6–13 1–4 4–6 7–10 11–14
66 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 129 136 185 162 215 449 433 398 359 30 47 559 679 640 376 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 206 404 492 192 464 848 184 256 237
0.8 0.5 1.0 0.8 0.7 0.4 0.8 0.4 0.9 0.7 0.7 0.5 0.8 0.4 1.0 0.9 1.1 1.4 1.6 0.7 0.7 0.7 0.6 0.7 0.5 0.8 0.6 0.9 0.7 0.8 0.6 0.8 0.4 0.6 0.7 0.8 0.8 1.0 1.3 1.0 1.6 1.0 1.3 1.0 1.0 1.2 1.8 1.2 2.8 1.1 1.2 0.8 0.9 0.8 0.6 0.9 0.5 0.9 0.5 1.3 0.7 1.2 2.4 0.5 0.04 0.5 0.1 0.5 1.010 0.3 0.210 0.3 0.310 0.3 0.510 0.4/0.4/ 0.5/0.6
1.6 1.4 2.0 1.9 1.5 1.3 2.0 1.2 1.4 0.9 1.5 0.8 1.8 1.7 n.a. 1.9 2.9 2.9 3.2 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1.5 1.7 1.6 1.6 n.a. n.a. n.a. n.a. n.a. n.a. 1.9 1.4 1.7 1.8 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0.9 0.8 1.3 1.1 1.3 1.0 1.5 1.0 –
2.1 2.2 1.8 1.1 1.6 1.1 2.1 1.9 1.4 0.7 1.7 1.2 1.5 0.8 n.a. 1.7 2.3 2.9 2.6 0.6 1.0 1.4 1.3 1.8 1.0 1.9 1.0 2.1 1.1 2.1 2.1 2.4 1.7 1.6 2.0 2.1 2.4 4.1 7.0 4.7 19.0 4.6 9.0 5.2 9.0 5.3 10.0 4.8 8.0 2.6 1.3 2.5 1.5 2.3 1.3 3.1 2.0 2.7 2.1 3.1 3.0 2.8 3.0 1.4 0.4 2.1 0.5 1.8 2.1 2.5 1.8 2.7 1.5 2.7 1.3 10/0–10/ 0–10/0–15
5.8 2.5 8.5 3.1 7.2 2.6 8.0 3.2 9.0 3.4 7.4 2.9 10.5 4.0 n.a. 5.3 6.3 7.7 8.4 5.9 1.7 3.7 1.7 4.7 1.8 5.3 1.7 5.5 1.7 n.a. n.a. 9.2 10.3 11.9 14.3 n.a. n.a. n.a. n.a. n.a. n.a. 14.8 5.8 15.0 6.3 7.0 4.6 10.7 4.6 4.6 1.6 6.5 2.4 7.4 4.1 4.7 0.5 6.7 1.4 4.4 2.0 7.1 4.0 8.2 3.2 9.2 3.4 –
0.9 0.4 1.3 2.0 1.0 0.6 1.4 0.6 1.0 0.4 1.1 0.5 1.2 0.5 1.0 0.9 1.1 1.3 1.5 n.a. n.a. n.a. n.a. n.a. 1.0 0.3 1.2 0.3 0.8 0.9 1.1 1.3 n.a. n.a. n.a. n.a. n.a. n.a. 0.9 0.4 1.0 0.4 0.9 0.3 1.2 0.3 0.9 0.2 1.2 0.4 1.2 0.5 1.2 0.3 1.4 0.3 0.8 0.3 1.3 0.5 1.4 0.4 1.8 1.5 0.5/0.7/ 0.8/1.0
1.2 0.5 1.5 0.4 1.2 0.6 1.5 0.5 1.2 0.5 1.3 0.5 1.2 0.6 1.0 1.5 1.7 2.1 2.2 n.a. n.a. n.a. n.a. n.a. 1.7 0.6 1.9 0.5 0.9 1.0 1.2 1.4 n.a. n.a. n.a. n.a. n.a. n.a. 1.1 0.4 1.3 0.5 1.4 0.4 1.5 0.4 1.2 0.4 1.6 1.0 1.6 0.7 1.8 0.3 1.9 0.4 1.2 0.5 1.6 0.6 1.6 0.6 1.7 0.7 0.8/1.0/ 1.2/1.3
16 6 26 4 19 9 28 9 20 7 29 12 25 8 n.a. 15 18 24 27 n.a. n.a. n.a. n.a. n.a. 20 6 23 5 15 17 20 24 n.a. n.a. n.a. n.a. n.a. n.a. 28 8 32 10 n.a. n.a. n.a. n.a. n.a. 16 3 23 4 16 5 23 7 26 6 30 8 9/11/ 13/15
1.1 0.4 1.7 0.6 1.2 0.8 1.5 0.6 1.2 0.5 1.5 1.0 1.4 0.7 1.4 1.0 1.1 1.4 1.7 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1.0 1.1 1.4 1.6 n.a. n.a. n.a. n.a. n.a. n.a. 1.4 0.5 1.6 0.6 n.a. n.a. n.a. n.a. n.a. 1.4 0.4 1.8 0.4 1.3 0.5 1.7 0.5 1.9 0.6 2.2 0.7 0.7/0.9/ 1.1/1.3
155 57 207 63 169 91 222 80 152 81 203 62 152 61 n.a. 189 209 270 304 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 116 145 168 195 n.a. n.a. n.a. n.a. n.a. n.a. 120 509 132 659 184 71 278 96 n.a. n.a. n.a. 132 28 152 33 133 49 193 62 213 63 248 82 100/130/ 150/180
2.7 1.3 4.4 2.6 3.5 1.6 4.2 1.5 4.2 2.2 4.9 3.1 4.5 1.7 n.a. 4.1 4.9 6.7 6.7 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2.8 3.2 3.6 4.2 n.a. n.a. n.a. n.a. n.a. n.a. 3.4 3.3 3.2 2.2 n.a. n.a. n.a. n.a. n.a. 5.1 0.7 7.9 1.2 2.9 2.0 4.1 1.7 4.0 1.5 4.5 2.6 0.7/0.9/ 1.0/1.3
105 71 130 77 85 55 119 65 70 42 71 45 81 45 94 55 65 71 79 99 30 67 32 73 38 76 44 75 40 87 39 116 64 73 80 92 103 77 93 78 84 104 119 102 103 119 137 118 122 57 42 77 67 88 54 102 55 66 32 87 48 94 64 81 29 73 34 51 42 76 51 75 48 80 55 25/25/ 20/35
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR- -Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate0.5 g folic acid (PGA)0.6 g folic acid taken with meals), 5 Eastern Austria, 6 Western Austria, 7 months, 8 boys and girl, 9 Folic acid (1 g pteroylmonoglutamate1 g free folic acid2 g food folate), 10 preformed-retinol. * SCF, 1993; reference values refer to age groups 1–3 years/4–6 years/7–10 years/11–14 years; n.a. not available. 1
23
24
Table 8b. Vitamin intake (mean SD) in children of European countries (girls)
Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark
Finland8
Germany
Greece
Hungary Italy8 Norway
Spain UK
Reference values*
Age (years)
N
Vitamin A1 (mg)
-Carotene (mg)
Vitamin D (g)
Vitamin E2 (mg)
Thiamine (mg)
Riboflavin (mg)
Niacin3 (mg)
Vitamin B6 (mg)
Folate4 (g)
Cobalamin (g)
Ascorbic acid (mg)
3–6 7–95 7–96 10–125 10–126 13–145 13–146 6–12 1–3 4–6 7–10 11–14 87 137 2 3 4 1–3 4–7 4–6 7–9 10–12 13–14 2–3 4–5 6–7 8–9 10–11 12–14 12–13 14–15 1–9 10–14 4 9 13 2–5 6–13 1–4 4–6 7–10 11–14
85 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 149 137 191 172 215 449 433 398 359 30 47 528 627 600 381 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 185 411 517 175 448 827 172 225 238
0.7 0.5 0.8 0.7 0.7 0.5 0.7 0.5 0.7 0.3 0.8 0.6 0.6 0.3 0.8 0.9 1.0 1.3 1.2 0.7 0.7 0.7 0.6 0.7 0.5 0.8 0.6 0.9 0.7 0.8 0.6 0.8 0.4 0.8 0.8 0.9 0.9 1.0 2.0 0.9 1.2 0.8 1.4 1.0 1.6 1.0 1.5 0.9 1.1 0.9 0.9 0.8 0.6 0.8 0.6 0.9 0.5 1.0 1.0 1.1 1.5 1.0 1.2 0.4 0.2 0.5 0.1 0.4 0.610 0.3 0.210 0.3 0.310 0.3 0.410 0.4/0.4/ 0.5/0.6
1.8 1.7 1.8 1.7 1.3 1.2 1.9 1.1 1.5 1.0 2.1 2.0 1.4 1.2 n.a. 2.4 2.6 4.1 2.9 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2.2 2.2 2.1 2.0 n.a. n.a. n.a. n.a. n.a. n.a. 1.8 1.3 1.7 1.6 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0.8 0.7 1.2 0.7 1.3 0.8 1.3 1.0 –
1.9 2.1 1.9 1.2 1.3 0.8 1.5 1.1 1.4 1.0 1.5 0.8 1.3 0.8 n.a. 1.8 1.7 2.4 2.3 0.6 1.0 1.4 1.3 1.8 1.0 1.9 1.0 2.1 1.1 2.1 2.1 2.4 1.7 1.9 1.5 1.6 1.7 3.6 6.0 4.4 7.0 3.8 6.0 5.9 23.0 4.3 8.0 6.2 11.0 2.2 1.3 2.3 1.4 2.3 1.3 3.1 2.0 2.4 1.5 2.6 2.1 2.4 2.5 1.2 0.6 1.7 0.5 2.0 2.3 2.2 1.3 2.3 1.4 2.3 1.3 10/0–10/ 0–10/0–15
5.9 2.7 8.0 3.0 5.9 3.0 7.1 2.9 9.9 3.4 6.5 2.3 9.2 5.9 n.a. 5.1 6.1 7.1 6.3 5.9 1.7 3.7 1.7 4.7 1.8 5.3 1.7 5.5 1.7 n.a. n.a. 8.8 9.2 11.2 12.4 n.a. n.a. n.a. n.a. n.a. n.a. 13.3 5.7 13.0 5.0 7.0 4.6 10.7 4.6 4.4 1.3 5.7 2.0 6.4 3.4 4.6 1.6 6.4 2.2 4.4 2.0 6.6 2.7 7.7 3.0 8.3 3.2 –
0.9 0.3 1.1 0.4 0.8 0.4 1.1 0.5 1.1 0.5 1.1 0.5 0.9 0.3 0.9 0.9 0.9 1.1 1.1 n.a. n.a. n.a. n.a. n.a. 1.0 0.3 1.2 0.3 0.8 0.9 1.0 1.0 n.a. n.a. n.a. n.a. n.a. n.a. 0.8 0.3 0.8 0.3 0.9 0.3 1.2 0.3 0.8 0.2 1.0 0.3 1.0 0.4 1.0 0.2 1.2 0.2 0.8 0.3 1.2 0.5 1.3 0.4 1.4 0.9 0.5/0.7/ 0.8/0.9
1.2 0.5 1.3 0.4 0.9 0.4 1.3 0.5 1.2 0.5 1.2 0.5 1.0 0.3 0.8 1.6 1.5 1.8 1.7 n.a. n.a. n.a. n.a. n.a. 1.7 0.6 1.9 0.5 0.9 1.0 1.1 1.2 n.a. n.a. n.a. n.a. n.a. n.a. 1.0 0.4 1.1 0.4 1.4 0.4 1.5 0.4 1.2 0.3 1.3 0.4 1.3 0.5 1.7 0.5 1.6 0.2 1.2 0.5 1.4 0.5 1.4 0.5 1.4 0.6 0.8/1.0/ 1.2/1.2
16 5 23 6 14 6 25 15 20 7 24 10 18 7 ??? 16 16 22 23 n.a. n.a. n.a. n.a. n.a. 20 6 23 5 14 16 18 19 n.a. n.a. n.a. n.a. n.a. n.a. 26 8 26 8 n.a. n.a. n.a. n.a. n.a. 15 3 20 3 16 5 21 6 24 6 25 6 9/11/ 13/14
1.1 0.4 1.5 0.5 1.0 0.4 1.6 2.6 1.3 0.6 1.3 0.6 1.1 0.5 1.3 1.0 1.0 1.3 1.4 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0.9 1.1 1.3 1.3 n.a. n.a. n.a. n.a. n.a. n.a. 1.4 0.5 1.4 0.5 1.6 0.5 2.1 0.6 n.a. n.a. n.a. 1.3 0.2 1.5 0.3 1.2 0.5 1.6 0.5 1.8 0.7 1.9 0.7 0.7/0.9/ 1.1/1.1
172 118 189 51 132 68 196 73 169 86 183 60 151 61 n.a. 183 189 229 238 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 129 134 155 174 n.a. n.a. n.a. n.a. n.a. n.a. 109 429 110 509 184 71 278 96 n.a. n.a. n.a. 109 24 137 22 130 48 170 56 192 57 212 85 100/130/ 150/180
2.5 1.2 4.1 3.1 2.9 1.6 3.8 4.5 3.2 1.4 3.9 2.5 2.8 1.0 n.a. 4.7 4.1 5.2 5.1 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2.8 2.9 3.2 3.3 n.a. n.a. n.a. n.a. n.a. n.a. 2.8 2.5 2.6 1.9 n.a. n.a. n.a. n.a. n.a. 5.5 0.7 6.4 0.9 2.8 1.6 3.6 1.5 3.5 1.5 3.4 1.7 0.7/0.9/ 1.0/1.3
95 60 115 66 63 33 102 66 77 35 99 73 85 50 99 64 61 66 72 99 30 67 32 73 38 76 44 75 40 87 39 116 64 86 85 85 90 67 76 84 80 93 94 101 113 108 119 118 135 61 43 72 50 88 54 102 55 68 30 81 42 85 52 72 32 70 24 53 43 70 36 82 60 77 57 25/25/ 20/35
1 Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR- -Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals), 5 Eastern Austria, 6 Western Austria, 7 months, 8 boys and girls, 9 Folic acid (1 g pteroylmonoglutamate 1 g free folic acid 2 g food folate), 10 preformed-retinol; * SCF, 1993; reference values refer to age groups 1–3 years/4–6 years/7–10 years/11–14 years; n.a. not available.
children at the age of 1–3 years the SCF (1993) indicates a population reference intake of 10 g/day. In Denmark as well as in Finland, where children of this age group were examined, the average intake was far below this recommendation. The mean vitamin E intake increased with increasing age. There was no noticeable difference between girls and boys or between the participating European countries. The SCF (1993) does not give any absolute guideline but only recommends that the intake of vitamin E should refer to the intake of PUFA (mg tocopherol equivalent 0.4 g PUFA). In most children of the participating countries the mean intake of thiamine as well as of riboflavin seemed to be sufficient. The mean thiamine intake was below the recommendations of the SCF (1993) in Hungarian boys and girls only. In the male group the mean riboflavin intake was too low in Hungarian boys aged 12–13 years. In Hungarian, German and Western Austrian girls some age groups had an intake which was below the recommended level. The supply of niacin was on average clearly above the recommended level of the SCF (1993) and can thus be regarded as sufficient in children of the participating countries. Also the mean vitamin B6 intakes approximately corresponded to the guidelines or were above them. The mean folate intake in children was not satisfying in some of the countries. Compared to the population reference intakes of the SCF (1993), the average intake was too low in Austrian boys and girls of Western Austria, as well as in German and Spanish children. The mean intake of cobalamin as well as of ascorbic acid was above the recommendations of the SCF (1993) in boys and girls of all age groups. Minerals In Hungary and Italy the mean estimated sodium intake was already considerable in children of all age groups. In Hungarian boys and girls aged 12–15 years it was between 5 and 5.4 g/day, in Italian 10–14 year olds it was 5 g/day as well (see tables 9a and 9b). These average intakes were already far above the upper level of the acceptable range of intake indicated for adults by the SCF (1993). An insufficient intake of potassium was found in Austrian and German boys and girls aged 7–14 years, in Hungarian children of both age groups, in Italian boys and girls at 10–14 years of age and in boys and girls of the UK aged 11–14 years. In the participating countries younger children had on average a more
Energy and Nutrient Intake in the European Union
sufficient calcium supply than children of higher age groups. The mean intake was too low in Austrian and German children at the age of 10–14 years, in Hungarian children aged 12–15 years, as well as in UK, Italian and Norwegian children of the last age group. The mean intake of calcium was particularly high in Danish and Finnish children. On average, the supply of magnesium was slightly better in boys than it was in girls. An insufficient intake was observed in girls (7–14 years) and boys (10–14 years) of Western Austria, in Italian children aged 10–14 years, in girls and boys of the UK aged 7–14 years, and in Danish girls of the last age group (11–14 years). In children of all other age groups and countries the mean intake was above the guidelines. The supply of iron in European boys can on average be regarded as sufficient. Girls at fertile age seemed to have an insufficient intake of this nutrient. The mean iodine intake through food was too low in Austrian, Danish and German children. In Finnish children the mean iodine intake was very high and considerably exceeded the guidelines of the SCF (1993). All other countries did not assess the iodine intake in children.
Energy and Nutrient Intake in European Adolescents Only half of the participating countries had available intake data of adolescents (see table 10). The data of these countries is not older than 10 years, which is a good basis for comparing the data. However, as different assessment methods were used in adolescents as well, the comparability between these countries is limited. The following methods were used for the assessment of energy and nutrient intake in this population group. Energy and Macronutrients The average intake of energy was as expected higher in male than in female adolescents (table 11). The share of protein in total energy intake was within the recommended range of the WHO (2003) in most of the participating countries. Only in Spanish adolescents and in Austrian male adolescents the upper level was exceeded. The proportion of carbohydrates in total energy intake should – according to Eurodiet (2000) – be at least 55%. The highest proportion was found in Norwegian adolescents with 54–55%. Also in the UK it was relatively high with an average of 53 %E (excl. alcohol). Adolescents of all other countries had clearly lower intakes of 25
26
Table 9a. Mineral intake (mean SD) in children of European countries (boys)
Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark
Finland4
Germany
Greece
Hungary Italy4 Norway
Portugal Spain UK
Reference values*
1
*
Age (years)
N
Sodium (g)
Potassium Calcium (g) (mg)
Phosphorous (mg)
Magnesium Iron (mg) (mg)
Zinc (mg)
Iodine (g)
Copper (mg)
Manganese Selenium (mg) (g)
3–6 7–91 7–92 10–121 10–122 13–141 13–142 6–12 1–3 4–6 7–10 11–14 83 133 2 3 4 1–3 4–7 4–6 7–9 10–12 13–14 2–3 4–5 6–7 8–9 10–11 12–14 12–13 14–15 1–9 10–14 4 9 13 7–9 2–5 6–13 1–4 4–6 7–10 11–14
66 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 129 136 185 162 215 449 433 398 359 30 47 559 679 640 376 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 206 404 492 2,184 192 464 848 184 256 237
n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2.0 2.2 2.6 3.3 3.4 0.7 0.3 1.6 0.5 1.8 0.5 2.0 0.5 2.1 0.5 n.a. n.a. 1.2 1.6 2.0 2.4 n.a. n.a. n.a. n.a. n.a. n.a. 5.9 1.7 6.3 1.8 3.3 1.5 5.0 1.8 n.a. n.a. n.a. n.a. 1.6 0.2 2.5 0.6 1.5 0.5 2.0 0.5 2.4 0.6 2.7 0.7
1.6 0.5 2.1 0.5 1.7 0.7 2.3 0.6 1.6 0.5 2.1 0.8 2.0 0.7 3.0 2.2 2.4 2.8 3.3 n.a. n.a. n.a. n.a. n.a. 2.4 0.7 2.7 0.6 1.7 1.9 2.3 2.7 n.a. n.a. n.a. n.a. n.a. n.a. 2.4 0.8 2.6 0.8 2.3 0.7 3.0 0.9 n.a. n.a. n.a. n.a. 2.4 0.3 2.8 0.4 1.5 0.4 2.0 0.5 2.1 0.5 2.4 0.6
646 302 742 253 718 384 819 308 611 240 733 296 632 290 935 910 1,053 1,224 1,286 425 107 807 240 833 238 845 247 905 240 828 273 973 323 554 639 726 835 824 307 823 301 899 335 938 362 963 402 960 403 612 264 777 365 797 220 862 283 684 215 914 339 933 497 1,104 426 897 67 983 164 651 255 723 260 745 231 803 285
n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1,384 1,143 1,345 1,612 1,704 n.a. n.a. n.a. n.a. n.a. 1,047 279 1,225 319 797 939 1,088 1,252 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1,101 281 1,348 363 n.a. n.a. n.a. n.a. 1,201 151 1,453 198 757 223 933 256 1,014 244 1,140 294
200 73 243 55 241 94 292 82 192 56 297 125 240 103 n.a. 228 252 288 324 n.a. n.a. n.a. n.a. n.a. 199 48 237 51 206 244 291 338 n.a. n.a. n.a. n.a. n.a. n.a. 321 97 365 127 163 45 222 62 n.a. n.a. n.a. n.a. 227 27 283 46 140 38 175 46 194 47 220 61
8.6 2.8 11.5 2.7 10.0 4.2 12.0 3.6 8.9 2.6 12.6 3.7 11.3 4.8 10.4 6.7 7.9 9.9 11.1 7.5 1.7 6.4 1.8 7.0 2.2 7.8 2.5 8.8 3.1 8.4 3.2 10.2 3.1 7.7 9.2 11.1 12.9 7.7 4.7 8.6 4.7 9.6 3.9 10.2 4.6 11.0 5.1 11.9 6.1 9.7 3.0 10.3 3.1 8.9 3.2 12.5 4.4 6.8 2.2 9.3 3.0 10.2 4.3 n.a. 10.3 14.0 2.0 5.7 2.3 8.3 2.6 9.7 2.7 10.9 3.2
6.5 2.1 8.1 1.6 7.7 2.8 10.5 3 7.6 2.7 11.1 3.8 10.1 3.6 n.a. 7.5 9.1 11.5 12.7 4.1 1.3 6.2 1.7 6.6 1.6 7.0 1.6 7.6 1.7 7.6 1.9 8.9 2.1 6.4 7.5 8.7 10.1 n.a. n.a. n.a. n.a. n.a. n.a. 7.7 2.5 9.0 2.9 8.7 2.8 12.3 3.4 n.a. n.a. n.a. n.a. n.a. n.a. 4.5 1.4 5.6 1.8 6.1 1.6 7.2 2.1
67 24 102 39 90 55 96 41 85 33 100 50 99 27 n.a. 58 69 84 82 n.a. n.a. n.a. n.a. n.a. 250 95 299 133 48 56 68 86 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1.1 1.4 1.7 1.9 n.a. n.a. n.a. n.a. n.a. n.a. 1.5 1.6 1.4 1.2 0.9 0.4 1.4 0.5 n.a. n.a. n.a. n.a. n.a. n.a. 0.5 0.2 0.7 0.4 0.8 0.2 0.9 0.4
n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2.6 3.3 3.9 4.5 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 24 30 39 42 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 30.4 13.3 41.6 16.2 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
0.8/1.1/ 2.0/3.1
400/450/ 550/1,000
300/350/ 450/775
85/120/ 200/280
4/4/6/10
4/6/7/9
70/90/ 100/120
0.4/0.6/ 0.7/0.8
1–10
10/15/ 25/35
Eastern Austria, 2 Western Austria, 3 months, 4 boys and girls. SCF, 1993; reference values refer to age groups 1–3 years/4–6 years/7–10 years/11–14 years; n.a. not available.
Table 9b. Mineral intake (mean SD) in children of European countries (girls)
Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark
Finland4
Germany
Greece
Hungary Italy4 Norway
Portugal Spain UK
Reference values*
1
*
Age (years)
N
Sodium (g)
Potassium (g)
Calcium (mg)
Phosphorous (mg)
Magnesium (mg)
Iron (mg)
Zinc (mg)
Iodine (g)
Copper (mg)
Manganese (mg)
Selenium (g)
3–6 7–91 7–92 10–121 10–122 13–141 13–142 6–12 1–3 4–6 7–10 11–14 83 133 2 3 4 1–3 4–7 4–6 7–9 10–12 13–14 2–3 4–5 6–7 8–9 10–11 12–14 12–13 14–15 1–9 10–14 4 9 13 7–9 2–5 6–13 1–4 4–6 7–10 11–14
85 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 149 137 191 172 215 449 433 398 359 30 47 528 627 600 381 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 185 411 517 2,113 175 448 827 172 225 238
1.5 0.5 n.a. n.a. n.a. n.a. n.a. n.a. 1.8 1.9 2.2 2.9 2.7 0.7 0.3 1.6 0.5 1.8 0.5 2.0 0.5 2.1 0.5 n.a. n.a. 1.2 1.7 2.0 2.1 n.a. n.a. n.a. n.a. n.a. n.a. 5.4 1.5 5.0 1.4 3.3 1.5 5.0 1.8 n.a. n.a. n.a. n.a. 1.6 0.1 2.1 0.4 1.5 0.5 1.8 0.5 2.2 0.5 2.3 0.6
1.6 0.5 1.9 0.5 1.6 0.4 2.0 0.7 1.7 0.4 2.0 0.6 1.7 0.6 2.8 2.1 2.1 2.6 2.7 n.a. n.a. n.a. n.a. n.a. 2.4 0.7 2.7 0.6 1.7 1.9 2.2 2.4 n.a. n.a. n.a. n.a. n.a. n.a. 2.3 0.7 2.3 0.6 2.3 0.7 3.0 0.9 n.a. n.a. n.a. n.a. 2.2 0.5 2.5 0.3 1.5 0.4 1.8 0.5 2.0 0.4 2.1 0.6
663 259 664 214 560 215 667 254 628 172 688 276 645 303 848 996 890 1,093 1,061 425 107 807 240 833 238 845 247 905 240 828 273 973 323 594 582 667 746 782 301 754 306 819 323 822 334 851 395 748 321 596 264 667 267 797 220 862 283 667 208 751 271 785 359 1,049 414 876 214 866 0.1 624 253 658 220 668 194 658 247
n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1,182 1,168 1,152 1,426 1,419 n.a. n.a. n.a. n.a. n.a. 1,047 279 1,225 319 786 855 986 1,067 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1,101 281 1,348 363 n.a. n.a. n.a. n.a. 1,170 201 1,288 138 726 226 949 196 924 196 949 251
193 56 224 52 186 58 255 83 202 64 255 85 200 67 n.a. 214 217 264 263 n.a. n.a. n.a. n.a. n.a. 199 48 237 51 205 219 259 290 n.a. n.a. n.a. n.a. n.a. n.a. 309 94 305 87 163 45 222 62 n.a. n.a. n.a. n.a. 213 37 251 29 133 38 155 40 179 41 185 49
7.9 2.4 10.1 2.6 8.4 2.7 10.4 3.7 9.5 3.8 10.7 3.4 8.4 2.8 10.0 6.0 6.8 8.5 8.9 7.5 1.7 6.4 1.8 7.0 2.2 7.8 2.5 8.8 3.1 8.4 3.2 10.2 3.1 7.7 8.7 10.1 10.7 7.2 3.7 8.3 4.5 8.8 3.8 9.3 4.3 10.0 4.9 10.1 4.8 9.3 3.0 9.0 2.4 8.9 3.2 12.5 4.4 6.4 2.0 8.2 3.5 8.7 3.3 n.a. 9.0 1.6 12.1 1.4 5.4 2.5 7.3 2.2 8.6 2.5 9.2 3.3
6.2 1.6 7.9 1.7 6.6 1.8 8.5 3.1 7.5 2.6 9.1 3.4 7.4 2.7 n.a. 7.4 7.7 10.4 10.7 4.1 1.3 6.2 1.7 6.6 1.6 7.0 1.6 7.6 1.7 7.6 1.9 8.9 2.1 6.0 6.9 8.0 8.5 n.a. n.a. n.a. n.a. n.a. n.a. 7.0 2.3 7.2 2.2 8.7 2.8 12.3 3.4 n.a. n.a. n.a. n.a. n.a. n.a. 4.3 1.4 5.0 1.4 5.8 1.4 6.1 1.8
69 25 98 36 84 32 88 45 87 26 91 39 89 46 n.a. 61 59 75 65 n.a. n.a. n.a. n.a. n.a. 250 95 299 133 51 54 66 73 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1.1 1.2 1.5 1.7 n.a. n.a. n.a. n.a. n.a. n.a. 1.5 1.6 1.3 1.3 0.9 0.4 1.4 0.5 n.a. n.a. n.a. n.a. n.a. n.a. 0.5 0.2 0.7 0.4 0.8 0.3 0.8 0.3
n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2.3 2.7 3.4 3.9 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 25 26 35 34 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 30 13 42 16 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
0.8/1.1/ 2.0/3.1
400/450/ 550/1,000
300/350/ 450/625
85/120/ 200/280
4/4/6/18
4/6/7/9
70/90/ 100/120
0.4/0.6/ 0.7/0.8
1–10
Eastern Austria, 2 Western Austria, 3 months, 4 boys and girls. SCF, 1993; reference values refer to age groups 1–3 years/4–6 years/7–10 years/11–14 years; n.a. not available.
10/15/ 25/35
27
Table 10. Method and period of dietary assessment in adolescents of European countries
Country
Age group
Method
Year of survey
Austria
15–18 years (apprentices) 13–18 years 15–18 years 15–18 years 17 years 16–19 years 14–24 years 15–18 years
3-day-weighed record
2001
3-day-record, FFQ 7-day-record, personal interview HBS FFQ FFQ 24-hour-recall 7-day-weighed record
1998 1995 1998 2003 1997 1998–2000 1997
Belgium Denmark Germany Italy Norway Spain UK
carbohydrates. The lowest mean intake of carbohydrates was found in Spanish adolescents with only 42 %E (excl. alcohol). The average proportion of sucrose in total energy intake was above the level proposed by the WHO (2003) in all countries with data from adolescents. Sugar-sweetened beverages make a considerable contribution to total sucrose intake, not only in adolescents. A study carried out in young and middle-aged American women showed that a higher consumption of sugarsweetened beverages was associated with a greater magnitude of weight gain and an increased risk for development of type 2 diabetes [Schulze et al., 2004]. The lowest proportion was found in female adolescents of Norway and Denmark, the highest in Austrian female adolescents. Beside a high proportion of carbohydrates and a low share of sucrose, adolescents in Norway and Germany had the highest intake of dietary fibre. In Austrian and Spanish adolescents, both male and female, as well as in Belgian and Danish female adolescents the mean intake of dietary fibre was clearly below 20 g/day. The upper level of fat intake of Eurodiet (30 %E) was on average exceeded by adolescents of nearly all countries. Only Norwegian female adolescents were with 29 %E below this upper level. Norwegian and Austrian male adolescents had a mean intake which was only slightly above the upper level. The highest proportion of fat in total energy intake was found in Spain (40 %E, excl. alcohol) and Italy (39–40 %E), but also in Belgium, Denmark, the UK and Germany, as well as in Austrian female adolescents the proportion of fat was high. Beside this high fat intake, the proportion of SFA in the diet of adolescents was high as well. The lowest proportion was found in Spanish and UK adolescents (13 %E excl. alcohol) and in Norwegian female adolescents with only 12 %E. In all other countries it was between 14 and 16 %E. The upper level of Eurodiet
28
Energy and Nutrient Intake in the European Union
(2000) was exceeded by male and female adolescents of all countries. The mean proportion of MUFA in total energy intake was particularly high in Spanish adolescents. The highest proportion of PUFA was found in German adolescents with 7 %E in both males and females. The mean intake of cholesterol was generally higher in male than in female adolescents. In Denmark, both male and female adolescents exceeded on average the upper intake level (300 mg/day) as proposed by the WHO (2003), in Austria and Norway the intake was only too high in the male group. The proportion of alcohol in total energy intake was on average between 1 and 2% in adolescents of the participating countries. Only in Austrian male adolescents it was higher with 4 %E. Vitamins Apart from Spain, the vitamin A intake can on average be regarded as sufficient in these European adolescents. Table 12 shows that Spanish adolescents had a mean intake of 0.5 mg RE/day, which was below the population reference intake of the SCF (1993). The -carotene intake was only assessed in Austrian, Danish, UK and German adolescents. German and Austrian male adolescents, as well as UK male and female adolescents had the lowest average intakes of -carotene with only 1.6 mg/day. The highest average intake was found in Danish female adolescents. The mean vitamin D intake was particularly low in Austrian male and female adolescents and in Spanish female adolescents with less than 2 g/day. The highest average intakes were observed in Norwegian adolescents with 5.4 g/day in the male and 3.4 g/day in the female group. The mean riboflavin intake was below the recommended level in Austrian and German male adolescents. In female adolescents of these countries the average
Table 11. Intake of energy and macronutrients (mean SD) in adolescents of European countries (male and female) Age (years)
N
Energy (MJ) Protein %E
Carbohydrates %E Total
Sucrose
Dietary fib. (g)
Fat %E
SFA %E
MUFA %E
PUFA %E
Cholesterol (mg)
Alcohol %E
Energy and Nutrient Intake in the European Union
Male Austria Belgium Denmark Germany Italy*** Norway Spain UK
15–18 13–18 15–18 15–18 17 16–19 14–24 15–18
46 n.a. 68 796 125 n.a. 692 179
11.0 2.7 11.1 2.2 11.9 10.5 11.3 2.7 13.9 10.5 1.5 9.6 2.4
16 3 14 2 14 13 15 4 14 18 21 13 22
49 6 49 5 49 51 48 15 54 42 51 53 62
16 6 n.a. 134 15 14 6 16 n.a. n.a.
14 5 20 6 21 24 17 6 26 19 4 13 53
31 6 36 5 35 35 39 10 31 40 51 35 52
15 2 15 2 15 14 12 4 14 13 21 13 22
11 2 14 2 10 12 n.a. 11 17 21 12 22
52 62 5 7 n.a. 5 5 11 6 12
367 131 265 72 313 288 334 111 362 479 160 246 96
46 12 2 n.a. 0.8 1.3 1 28 n.a.
Female Austria Belgium Denmark Germany Italy*** Norway Spain UK
15–18 13–18 15–18 15–18 17 16–19 14–24 15–18
56 n.a. 84 772 108 n.a. 884 210
8.6 1.7 8.2 1.9 10.0 8.8 8.6 2.4 9.1 8.1 1.1 6.9 1.8
15 3 15 3 14 12 15 4 15 17 21 13 22
51 7 49 5 50 52 48 14 55 42 61 53 62
18 6 n.a. 134 16 15 6 12 n.a. n.a.
15 5 16 5 19 22 14 5 21 15 3 11 33
34 6 35 5 34 34 40 12 29 40 41 35 52
16 3 14 2 15 14 13 4 12 13 21 13 22
12 1 13 3 10 12 n.a. 10 16 21 11 22
62 61 4 7 n.a. 5 5 11 62
262 93 206 66 333 237 266 98 228 370 38 181 79
12 11 2 n.a. 0.3 0.3 1 16 n.a.
10–15**
55
10**
25
30
10
6–10
300**
Reference values* 1
*
Excl. alcohol, 2 % of total food energy (excl. alcohol), 3 Non-starchy polysaccharides, 4 Eurodiet, 2000; ** WHO; *** Rome, 2003; n.a. not available.
added sugar.
29
30
Table 12. Intake of vitamins and minerals (mean SD) in adolescents of European countries (male and female)
Energy and Nutrient Intake in the European Union
Age N (years)
Vitamin A1 -Caro(mg) tene(mg)
Male Austria
15–18
46
0.9 0.5
1.6 1.7 1.3 0.7
9.9 4.3
Denmark
15–18
68
1.4
2.1
3.0
9.1
Vitamin D Vitamin E2 Thiamine (g) (mg) (mg)
Riboflavin Niacin3 (mg) Vitamin B6 (mg) (mg)
Folate4 (g)
Cobalamin Ascorbic acid (g) (mg)
1.4 0.4
1.4 0.5
38 16
2.0 1.0
175 61
5.2 1.9
88 56
1.5
2.3
30
1.7
295
7.1
65
Germany
15–18
796 1.0
1.6
2.7
15.5
1.4
1.5
26
1.6
199
4.9
98
Norway
16–19
n.a. 1.6
n.a.
5.4
n.a.
1.9
2.4
20
n.a.
n.a.
n.a.
129
Spain
14–24
692 0.5 0.1
n.a.
2.3 0.5
8.2 1.6
1.6 0.2
1.9 0.3
27 2
1.9 0.2
180 44
9.1 1.4
79 33
UK
15–18
179 0.4 0.35
1.6 1.3 3.3 1.8
10.4 4.4
2.0 0.8
2.0 0.9
37 11
2.7 1.1
312 127 5.1 2.1
89 69
0.7
–
–
1.1
1.6
18
1.5
200/400** 1.4
40
Reference values*
0–15
Female Austria
15–18
56
0.9 0.5
2.1 2.2 1.5 1.0
10.9 4.6
1.1 0.4
1.3 0.5
25 6
1.6 0.9
164 62
3.5 1.4
109 80
Denmark
15–18
84
1.3
3.6
2.7
7.4
1.2
1.8
25
1.5
266
5.5
79
Germany
15–18
772 0.9
2.4
2.3
13.0
1.2
1.3
22
1.4
190
3.5
106
Norway
16–19
n.a. 1.3
n.a.
3.4
n.a.
1.3
1.7
15
n.a.
n.a.
n.a.
119
Spain
14–24
884 0.5 0.1
n.a.
1.7 0.5
6.8 1.6
1.3 0.2
1.6 0.2
22 3
1.6 0.3
161 29
71
81 33
UK
15–18
210 0.3 0.35
1.6 1.8 2.2 1.3
8.7 7.3
1.4 0.9
1.3 0.7
26 8
2.0 2.0
215 85
3.4 1.7
82 78
–
–
0.9
1.3
14
1.1
200/400** 1.4
Reference values*
0.6
0–15
40
Table 12 continued
Energy and Nutrient Intake in the European Union
Age (years)
N
Sodium (g)
Potassium Calcium (g) (mg)
Phosphorous (mg)
Magnesium Iron (mg) (mg)
Zinc (mg)
Male Austria
15–18
46
n.a.
2.3 0.7
675 277
n.a.
289 102
12.2 3.2
Denmark
15–18
68
4.1
3.5
1,362
1,848
360
11.8
Iodine (g)
Copper (mg)
Manganese Selenium (mg) (g)
11.0 2.8 106 32
n.a.
n.a.
n.a.
14.2
113
n.a.
n.a.
43
Germany
15–18
796
2.4
2.8
920
1,341
353
13.2
11.0
93
2.0
4.8
Norway
16–19
n.a.
n.a.
n.a.
1,400
n.a.
n.a.
13.7
n.a.
n.a.
n.a.
n.a.
n.a.
Spain
14–24
692
3.0 0.5
3.1 0.4
1,006 223 1,656 224
316 45
16.3 2.5
n.a.
n.a.
n.a.
n.a.
n.a.
UK
15–18
179
3.3 0.9
2.9 0.8
883 300
1,344 349
259 73
13 4
93
n.a.
1.1 .3
n.a.
n.a.
–
3.1
1,000/ 800**
775
300
13
9.5
130/150** 1.0
1–10
45
Reference values* Female Austria
15–18
56
n.a.
2.1 0.7
718 276
n.a.
245 73
10.0 2.5
9.0 2.1
106 37
n.a.
n.a.
n.a.
Denmark
15–18
84
3.2
3.0
1,121
1,492
292
9.4
11.0
90
n.a.
n.a.
37
Germany
15–18
772
2.4
2.6
813
1,172
326
11.8
9.2
78
1.8
4.4
Norway
16–19
n.a.
n.a.
n.a.
1,000
n.a.
n.a.
9.8
n.a.
n.a.
n.a.
n.a.
n.a.
Spain
14–24
884
2.2 0.4
2.6 0.4
838 146
1,341 167
264 36
12.8 1.8
n.a.
n.a.
n.a.
n.a.
n.a.
UK
15–18
210
2.3 0.6
2.2 0.6
659 256
969 281
192 59
8.9 3.8
6.2 2.1
n.a.
0.8 0.3 n.a.
n.a.
–
3.1
1,000/ 800**
625
300
17/15**
7.0
130/150** 1.0
Reference values*
1–10
45
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR- -Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals), 5 preformed-retinol. * SCF, 1993; reference values refer to age group 15–17 years; ** Eurodiet, 2000; n.a. not available. 1
31
corresponded to the guidelines. Adolescents of all other countries had a mean intake above the population reference intakes recommended by the SCF (1993). Apart from Denmark and the UK, the mean folate intake was below the recommended level of the SCF (1993) in both male and female adolescents. Compared to the reference values of Eurodiet (400 g/day) the average folate intake was insufficient in adolescents of all countries. Minerals The sodium intake in adolescents was only assessed in Denmark, Germany, the UK and Spain. Denmark had in the male as well as in the female group the highest average estimated intake. In the male group it was higher than 4 g/day (table 12). The average potassium intake was not sufficient in female adolescents of all countries, in male adolescents it was below the recommended level in Austria, Germany and the UK. Norway did not have intake data for potassium. The supply of calcium was on average very good in adolescents of the participating countries. Apart from Austrian male and female adolescents and female adolescents of the UK, the mean intake of this nutrient was above the recommended level of Eurodiet (2000) at least 800 mg/day, and in some of these countries it was even above the recommendation of the SCF of 1,000 mg/day. An insufficient average intake of magnesium was found in both male and female adolescents in Austria and the UK. In Danish and Spanish female adolescents it was below the recommended level as well. The average iron intake was not sufficient in females of all countries. In the male group it was too low in Austria and Denmark. The intake of iodine was examined in Austrian, Danish and German adolescents. In all these countries the mean intake of iodine was insufficient.
Energy and Nutrient Intake in European Adults All of the participating countries had energy and nutrient intake data of adults (table 13). The age categorisation in the countries was not uniform and also the methods used were not consistent among the countries. The assessment of most of the presented data was accomplished in the preceding decade and the current decade. Only the data of Belgium was from the early 1980s and has to be treated cautiously when making comparisons between the countries. 32
Energy and Nutrient Intake in the European Union
Energy and Macronutrients The energy intake was on average higher in men than in women and usually decreased with increasing age or stayed at a relatively consistent level (tables 14a and 14b). Only in German adults and in Portuguese men the opposite tendency was observed. The average share of protein in total energy intake in European men was comparable to that in women of the same age classes. The highest average proportion of protein in women was found in Portugal (18–19 %E) and France (18%). Also in Finnish and Spanish women, as well as in Austrian women aged 65 years or more, and in women of the UK older than 34, the average intake of protein was with 17 %E relatively high. In men, the highest proportions of protein intake were found in Portugal, the UK (older than 34 years), France and Austria (older than 64 years). The average carbohydrate intake in European adults was low. Apart from Norway, European men of all age groups had a mean carbohydrate intake below 50 %E. An intake of at least 55 %E is recommended [Eurodiet, 2000]. In Belgium, France and Greece they even had a proportion below 40 %E. On average, women had a slightly higher share of carbohydrates in their daily diet. Again, the lowest carbohydrate intake was found in Greece, Belgium and France (38–41 %E) and the highest intake in Norwegian women. The mean proportion of sucrose in total energy intake was relatively low in European men. In Austria, Denmark, Finland and Sweden it did not on average exceed the upper level proposed by the WHO (2003). The highest mean proportion in men was found in young Hungarian men (15 %E) and in young men of the UK (17 %E). It has, however, to be considered that in the UK the proportion of macronutrients was based on total food energy (excl. alcohol). Apart from the UK, the mean share of sucrose in energy intake was higher in European women than in men of the same age groups. The highest average sucrose intake was found in Hungarian women with 16–18 %E. As a consequence of the low proportion of carbohydrates, the average intake of dietary fibre was low in European adults, especially in women. The highest mean intakes of dietary fibre in women were found in Germany (22–26 g/day) and Portugal (22–25 g/day). European men had on average a higher intake of dietary fibre than women. In most countries the mean intake was above 20 g/day, but still below the recommended 25 g/day. The highest intakes were found in German men of the last age group, as well as in Norwegian and Portuguese men. The average intake in adults of the UK
Table 13. Method and period of dietary assessment in adults of European countries
Country
Age group
Method
Year of survey
Austria
18– 65 years
24-hour-recall
1998–2001
Belgium
25–75 years
24-hour-recall
1979–1984
Denmark
19–64 years
7-day-record, personal interview
1995
Finland
25–64 years
48-hour-recall (using personal interview)
2002
France
45–60 years (m) 35–60 years (f)
24-hour-recalls (6/year)
1994–2002
Germany
19–64 years
HBS
1998
Greece
25–64 years
Semi-quantitative FFQ
1994–1999 (EPIC data collected at national level)
Hungary
18–34 years 35–59 years (m) 35–54 years (f)
3 24-hour-records
1992–1994
Italy
18–64 years
7-day-record, personal interview
1994–1996
Norway
20–59 years
FFQ
1997
Portugal
18–29 years
4-day-record semiquantitative FFQ 7-day-record semiquantitative FFQ
2001
40 years
1995–1998
Spain1
25–60 years
Repeated 24-hour-recalls 3-day-record FFQ
1990–1998
Sweden
18–74 years
7-day-record
1997–1998
UK
19–64 years
7-day-record
2000–2001
1
The data for Spain was derived from different studies, where different methods were used.
was indicated as non-starch polysaccharides (NSP) and can thus not be directly compared to that of the other countries. The WHO (2003) recommends an intake of NSP of at least 20 mg/day. This level was not reached in men and women of any age groups. In most of the participating countries the average fat intake was high. In men it was only below the upper level of 30 %E of Eurodiet (2000) in Portuguese older than 40 years. The highest proportion of fat in total energy intake was found in Greek men (44–46 %E). In European women the average fat intake was relatively high as well. The lowest intakes were found in Norwegian and Portuguese women, the highest again in Greece with 46–48 %E followed by Belgium (42 %E), and France and Spain with 39 %E. The high fat intake in Greece is mainly a result of the general high olive oil consumption. In addition to this high total fat intake in European countries, the relative proportion of SFA was
Energy and Nutrient Intake in the European Union
considerable in this population group as well. The highest proportions were found, in both men and women, in Austrian and Belgian adults. In Italian adults, as well as in Portuguese adults the mean SFA intake was relatively low. Despite a large proportion of SFA, the mean intake of PUFA was within the normal range in Austrian and Belgian adults. Belgian adults even had the highest proportion of PUFA in total energy intake, followed by German men and UK women (19–34 years). The lowest proportion was found in Hungarian men and women. The high average intake of fat in European adults was accompanied by a high cholesterol intake, especially in men. The highest intakes were found in Hungarian young men and French men with an average of more than 600 mg/day, but also in the older age group of Hungarian men it was relatively high with around 33
34
Table 14a. Intake of energy and macronutrients (mean SD) in adults of European countries (men) Age (years)
N
Energy (MJ)
Protein %E
Carbohydrates %E Total
Sucrose
Dietary fib. (g)
Fat %E
SFA %E
MUFA %E
PUFA %E
Cholesterol (mg)
Alcohol %E
Energy and Nutrient Intake in the European Union
Austria
18–24 25–50 51–64 65
188 511 263 51
11.3 4.7 10.7 3.9 10.6 3.7 8.0 2.9
15 5 15 5 15 5 18 7
45 11 43 10 41 9 41 11
10 7 10 7 96 65
19 9 20 9 21 9 19 9
36 10 37 10 39 9 35 11
17 5 17 5 18 4 16 6
13 4 14 4 15 4 13 5
64 63 65 62
411 286 436 383 440 257 366 181
47 56 56 67
Belgium
25–75
3,596
11.9 3.9
14 4
39 8
n.a.
23 10
41 9
16 5
15 4
85
411 273
98
4
Denmark
19–24 25–34 35–44 45–54 55–64
86 142 135 147 140
12.4 12.1 11.2 11.0 11.1
14 14 15 14 14
45 42 43 41 42
10 94 74 74 74
22 21 23 22 22
35 36 36 37 38
15 14 15 16 16
11 11 11 12 11
5 5 5 5 5
391 422 414 416 467
6 8 6 7 6
Finland
25–34 35–44 45–54 55–64
190 215 232 275
10.0 2.8 9.3 3.1 8.9 2.6 8.7 2.8
16 4 16 4 16 4 16 3
47 8 45 7 45 10 45 8
95 96 95 95
21 10 22 10 23 11 22 10
34 7 35 7 35 8 36 8
15 4 14 5 15 5 14 4
12 3 12 3 12 3 12 3
52 52 52 52
270 138 266 141 276 167 275 151
36 37 48 36
France
45–60
3,323
9.5 2.3
17 4
39 12
n.a.
20 8
37 11
15 7
14 4
52
609 316
77
Germany
19–24 25–50 51–64
926 5,037 2,785
9.7 10.2 11.4
13 14 14
49 44 43
13 12 12
22 22 26
36 36 36
14 14 14
12 13 13
7 7 7
274 300 345
1 5 7
Greece
25–34 35–44 45–54 55–64
794 2,776 2,683 2,353
11.3 3.2 10.8 3.1 10.4 3.0 9.6 2.8
14 2 14 2 14 2 14 2
38 6 38 6 38 6 38 6
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
45 6 46 5 45 6 44 6
14 3 13 3 13 3 12 3
22 4 22 4 22 4 21 4
62 62 63 73
n.a. n.a. n.a. n.a.
55 56 56 67
Hungary
18–34 35–59
338 730
14.8 3.9 13.2 3.2
15 2 15 2
45 6 43 6
15 6 13 6
n.a. n.a.
38 6 38 6
14 5 14 4
15 5 15 5
42 42
655 297 556 235
34 45
Italy1
18–64
n.a.
9.2 2.0
16 4
46 12
15 6
20 7
34 10
10 3
13 4
52
341 122
45
Norway
20–29 30–59
248 748
12.6 10.6
15 16
51 50
12 8
24 25
32 31
13 12
11 11
6 6
358 334
2 3
Portugal
18–29 40
159 310
10.9 1.9 11.1 2.8
18 3 17 5
48 10 45 13
n.a. n.a.
23 7 26 9
33 6 28 9
11 2 93
14 3 12 4
61 52
444 91 364 132
11 10 9
Spain
25–60
4,728
10.5
16
42
n.a.
20
37
12
16
5
450
5
Sweden
18–74
589
9.9
16
46
9
18
34
15
13
5
350
4
UK
19–24 25–34 35–49 50–64
108 219 253 253
9.4 2.2 9.8 2.5 9.9 2.6 9.6 2.4
15 32 16 52 17 32 17 32
49 62 48 62 47 62 47 62
17 72 14 72 13 72 12 62
12 43 15 63 16 63 16 63
36 62 36 52 36 62 36 62
14 32 13 32 14 32 13 32
12 22 12 22 12 22 12 22
62 62 62 62
269 134 298 120 309 130 319 127
68 77 77 68
10–15**
55
10**
25
30
10
6–10
300**
Reference values* 1
*
Men and women, 2 % of total food energy (excl. alcohol), 3 Eurodiet, 2000; ** WHO, 2003; n.a. not available.
Non-starchy polysaccharides, 4 added sugar.
Table 14b. Intake of energy and macronutrients (mean SD) in adults of European countries (women) Age (years)
N
Energy (MJ)
Protein %E
Carbohydrates %E Total
Sucrose
Energy and Nutrient Intake in the European Union
Dietary fib. (g)
Fat %E
SFA %E
MUFA %E
PUFA %E
Cholesterol (mg)
Alcohol %E
19 8 19 9 19 8 17 8
36 10 36 10 38 9 37 9
16 5 17 5 17 3 18 5
14 5 13 4 15 3 13 3
63 63 63 64
323 212 306 204 333 187 338 218
25 45 35 25
Austria
18–24 25–50 51–64 65
372 777 357 62
8.8 2.9 8.4 2.9 8.5 2.7 6.7 2.4
14 5 15 5 15 5 17 5
48 11 45 11 44 10 44 10
12 7 11 6 10 6 74
Belgium
25–75
3,274
8.8 2.7
15 4
40 8
n.a.
21 8
42 9
17 5
15 4
95
331 220
55
Denmark
19–24 25–34 35–44 45–54 55–64
100 161 158 155 128
9.0 9.2 8.5 8.4 8.3
13 14 15 15 15
48 47 44 43 43
124 104 94 84 8
17 19 16 18 17
36 36 36 37 35
15 15 15 16 15
10 11 11 11 11
5 5 5 5 5
292 344 332 349 344
3 3 5 5 6
Finland
25–34 35–44 45–54 55–64
263 266 275 291
7.1 2.2 6.7 2.0 6.6 2.0 6.2 1.9
16 4 17 3 17 4 17 4
51 8 49 8 48 8 50 8
12 5 11 5 10 5 10 5
17 6 19 7 19 8 20 8
32 7 34 7 33 7 31 7
13 4 14 4 14 4 13 4
10 3 11 3 11 3 10 3
52 52 52 52
187 103 197 108 187 86 182 98
14 14 24 14
France
35–60
4,879
7.1 1.9
18 5
40 13
n.a.
17 6
39 13
16 6
14 5
52
497 268
35
Germany
19–24 25–50 51–64
786 5,845 2,867
8.7 9.7 10.3
13 14 14
51 47 45
15 12 13
22 24 26
34 35 37
14 14 16
11 12 13
6 6 6
226 280 344
1 4 3
Greece
25–34 35–44 45–54 55–64
1,161 3,380 3,775 4,020
9.0 2.7 8.8 2.4 8.4 2.4 7.6 2.2
15 2 14 2 14 2 14 2
38 5 39 5 39 5 41 5
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
48 5 48 5 47 5 46 5
14 2 14 2 13 3 13 3
23 4 23 4 23 4 22 4
62 73 73 73
n.a. n.a. n.a. n.a.
12 12 12 12
Hungary
18–34 35–54
343 938
9.9 2.7 10.0 2.8
14 2 15 2
47 7 46 6
18 8 16 6
n.a. n.a.
37 6 38 5
14 5 14 5
15 5 15 5
42 42
407 170 415 181
12 12
Italy1
18–64
n.a.
9.2 2.0
16 4
46 12
15 6
20 7
34 10
10 3
13 4
52
341 122
45
Norway
20–29 30–59
268 774
8.7 7.8
15 16
53 51
13 9
20 21
30 31
13 13
11 11
6 6
239 260
2 2
Portugal
18–29 40
87 416
8.9 1.4 8.8 2.3
19 3 18 5
48 9 50 14
n.a. n.a.
22 7 25 10
33 7 30 10
11 3 94
14 3 13 6
6 1.3 52
382 85 303 120
0.3 1 24
Spain
25–60
5,480
7.8
17
43
n.a.
17
39
12
16
6
350
1
Sweden
18–74
626
7.8
16
47
9
16
34
14
12
5
292
3
UK
19–24 25–34 35–49 50–64
104 210 318 259
7.0 1.9 6.6 1.6 6.7 1.8 6.9 1.7
15 42 16 42 17 32 17 32
49 82 49 62 49 72 48 72
14 82 12 62 12 72 11 62
11 43 12 53 13 53 14 53
36 82 35 62 34 62 35 72
13 42 13 32 13 32 13 42
12 32 12 22 11 32 11 32
72 72 62 62
196 112 188 83 214 92 239 93
56 45 45 45
10–15**
55
10**
25
30
10
6–10
300**
Reference values* 1
35
Men and women, 2 % of total food energy (excl. alcohol), 3 * Eurodiet, 2000; ** WHO, 2003; n.a. not available.
Non-starchy polysaccharides, 4
added sugar.
550 mg/day. In most countries, the mean cholesterol intake of men was between 300 and 470 mg/day. Only in Finnish men and in young men of the UK (19–34 years) it was below the upper level of 300 mg/day indicated by the WHO (2003). In women the cholesterol intake was on average lower than in men. The highest intake was found in France with about 500 mg/day, followed by Hungary with a mean intake slightly above 400 mg/day. A particularly low cholesterol intake was observed in Finnish women. Also in adults of the UK, Norway and in German young women it was clearly below the upper level of the WHO (2003). The mean proportion of alcohol was higher in men than in women. On average it was between 1 and 6 %E in women, and between 1 and 10 %E in men. The highest alcohol intake in men was found in Portuguese older than 40 years, followed by Belgian men. In women the mean alcohol intake was relatively high in Denmark as well as in the UK. Vitamins Tables 15a and 15b show that the supply of vitamins in European adults was in general relatively good. The average vitamin A intake was above the recommendation of the SCF (1993) in both men and women. Also the supply of -carotene was relatively good in most of the examined European adults. An average intake below 2 mg/day was found in men and women in Sweden and the UK, as well as in Spanish men, Finnish men of the last age group (55–64 years) and German young men (19–14 years). For vitamin D, the SCF does not indicate any exact recommendation, but a range of 1–10 g/day. On average, the vitamin D intake was higher in men than in women. The lowest intakes in women were found in the UK and in Sweden, with an average of less than 2 g/day. Compared to Swedish women, the mean intake was relatively high in their male compatriots with 6.3 g/day. In Finnish men aged 45–64 years it was even higher with 6.1–7.3 g/day. Also in Norwegian men and in Austrian men older than 64 years the mean vitamin D intake was relatively high with more than 5 g/day. The intake of vitamin E was on average higher in European men than in women as well, but there was no noticeable difference between the age groups. The lowest average intakes in men and women were found in Denmark, Hungary, Portugal and Spain. The supply of riboflavin was relatively good in European adults. A mean intake below the reference values of the SCF was only found in Austrian men and women older than 64 and in young German men (19–24 36
Energy and Nutrient Intake in the European Union
years). The mean intake of thiamine, niacin, vitamin B6 and cobalamin was above the recommended level in adults of all participating countries. The mean folate intake was in general above the recommended minimum level of 200 g/day indicated by the SCF (1993). However, comparing the average intake data of this vitamin with the recommendation of Eurodiet (400 g/day) shows that the supply of folate has to be considered as insufficient in men and women of all countries and age groups. The mean supply of vitamin C can – on the basis of the recommendation of the SCF (1993) – be regarded as sufficient as well. Minerals The relatively high estimated sodium intake among the participants, especially among men, is typical for the average diet in industrialised countries. The highest mean estimated intakes were found in Hungary with 8.8–9.5 g/day in men and 6.1–6.4 g/day in women. Also in Italian adults the average estimated sodium intake was relatively high with 5.3 g/day. Apart from Hungary, the women of all participating countries had a mean intake which was within the acceptable range of intake indicated by the SCF (1993) (tables 16a and 16b). The mean intake of potassium in men was sufficient and on average higher than in women. It was only below the recommended level of the SCF (1993) in Austrian men, and in the youngest age group in men of Germany and the UK (19–24 years). In women an insufficient intake was more prevalent than in men and was observed in Austria, Denmark, Hungary, Spain and the UK, as well as in the youngest age group of German women (19–24 years). The highest intake was found in Portuguese young women, followed by German women older than 25 years. The mean supply of calcium was relatively good in European adults. The average intake of this nutrient was below the recommended level of at least 800 mg/day [Eurodiet, 2000] in Austrian men and women older than 64 years, in Hungarian women of both age groups and Hungarian men older than 35 years, as well as in women of the UK aged 19–34 years. Men had on average a higher calcium intake than women. Apart from Germany and the UK, the mean intake decreased with increasing age. The mean supply of iron can be regarded as sufficient in men. There was no age group of any country which had an intake below the population reference intake of 9 mg/day [SCF, 1993]. Women have higher requirements than men, but had on average lower intakes. Apart from
Table 15a. Vitamin intake (mean SD) in adults of European countries (men)
Energy and Nutrient Intake in the European Union
Age (years)
N
Vitamin A1 (mg)
-Carotene (mg)
Vitamin D (g)
Vitamin E2 (mg)
Thiamine (mg)
Riboflavin (mg)
Niacin3 (mg)
Vitamin B6 (mg)
Folate4 (g)
Cobalamin (g)
Ascorbic acid (mg)
Austria
18–24 25–50 51–64 65
188 511 263 51
1.4 1.5 1.3 1.0 1.4 1.2 1.3 2.0
3.1 2.8 3.5 3.5 3.9 4.0 2.7 2.6
3.3 4.1 4.1 5.7 4.9 6.5 5.4 7.0
14.3 10.3 14.1 9.2 13.8 8.7 9.0 4.6
1.7 0.9 1.6 1.1 1.5 0.7 1.1 0.5
2.1 1.5 2.0 1.2 1.9 1.1 1.3 0.6
42 21 39 17 36 15 30 9
2.6 2.3 2.3 1.6 2.0 1.0 1.5 0.5
286 152 294 138 277 123 217 115
89 78 77 8 10
161 154 156 130 142 123 108 107
Denmark
19–24 25–34 35–44 45–54 55–64
86 142 135 147 140
1.3 1.4 1.9 1.5 1.8
2.6 3.2 4.4 3.3 2.9
3.2 3.2 3.2 3.7 3.9
8.4 9.1 8.8 9.0 9.7
1.5 1.4 1.5 1.3 1.4
2.3 2.0 2.0 1.9 2.1
34 37 38 35 35
1.9 1.8 1.8 1.7 1.6
313 282 329 291 313
7.0 6.3 7.1 6.6 7.7
65 65 77 88 82
Finland
25–34 35–44 45–54 55–64
190 215 232 275
1.0 1.0 1.1 2.4 1.0 1.2 1.0 1.2
2.3 2.2 2.1 1.9 2.3 2.4 1.9 2.0
4.2 3.2 4.9 4.8 6.1 6.8 7.3 7.6
12.1 5.6 11.5 5.2 11.5 4.9 12.1 6.4
1.4 0.5 1.4 0.6 1.3 0.5 1.4 0.6
2.2 0.9 2.0 0.9 2.0 0.8 1.9 0.7
34 15 32 12 30 10 29 11
2.4 2.9 2.0 0.8 2.0 0.8 1.9 0.8
281 100 275 164 274 108 267 108
6.9 5.1 6.8 11 7.0 5.9 7.2 6.1
104 87 95 82 87 67 83 71
France
45–60
3,323
0.9 1.4
3.6 2.8
2.9 2.4
11.2 4.6
1.8 0.7
1.8 0.6
n.a.
2.0 0.5
320 101
8.2 6.8
92 50
Germany
19–24 25–50 51–64
926 5,037 2,785
1.0 1.2 1.5
1.8 2.2 2.7
2.3 3.5 4.5
15.2 14.8 16.6
1.3 1.4 1.6
1.5 1.6 1.8
26 32 38
1.6 1.8 2.1
195 210 254
4.8 6.2 7.7
101 96 120
Hungary
18–34 35–59
338 730
1.2 1.4 1.0 1.2
2.6 1.8 2.7 1.8
n.a. n.a.
9.0 5.1 7.8 4.2
1.5 0.5 1.3 0.7
1.9 0.8 1.6 0.7
26 10 25 8
2.4 0.7 2.3 0.6
n.a. n.a.
7.9 9.3 6.3 6.9
101 70 104 76
Italy5
18–64
n.a.
1.2 1.2
3.0 1.9
3.1 2.1
11.2 5.1
1.1 0.3
1.6 0.5
19 5
2.0 0.6
297 98
n.a.
117 62
Norway
20–29 30–59
248 748
1.6 1.6
n.a. n.a.
5.6 5.9
n.a. n.a.
1.7 1.6
2.3 1.9
21 20
n.a. n.a.
n.a. n.a.
n.a. n.a.
124 120
Portugal
18–29 40
159 310
1.5 0.8 1.5 0.8
n.a. n.a.
4.8 1.8 n.a.
8.2 2.2 8.7 2.4
2.1 0.4 n.a.
2.4 0.6 n.a.
27 5 n.a.
2.4 0.5 n.a.
305 93 296 90
10.6 4.1 n.a.
125 48 n.a.
Spain
25–60
4,728
0.7 0.5
1.8 1.5
2.4 2.6
9.1 6.1
1.8 0.8
1.8 1.0
40 15
2.3 0.9
267 108
9.5 8.5
123 85
6
Sweden
18–74
589
1.3
1.7
6.2
7.8
1.6
1.9
39
2.2
232
6.9
80
UK
19–24 25–34 35–49 50–64
108 219 253 253
0.6 0.47 0.9 0.77 1.1 1.47 1.3 1.37
1.3 0.9 1.6 1.1 1.9 1.1 2.3 1.8
3.0 1.6 4.1 3.2 4.2 3.1 4.9 3.3
10.1 4.3 11.9 7.2 14.4 27.4 15.2 27.7
1.6 0.6 2.3 2.6 2.3 2.6 2.4 3.1
1.7 0.8 2.4 2.2 2.4 1.8 2.5 3.7
40 12 49 30 47 16 46 16
2.7 1.0 3.3 2.2 3.5 5.1 3.4 4.6
305 114 376 224 355 171 373 151
4.5 1.7 6.2 4.3 7.4 7.3 7.6 6.6
67 55 84 66 108 208 125 142
0.7
–
0–10
–
1.1
1.6
18
1.5
200/400**
1.4
45
Reference values*
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR- -Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals), 5 men and women, 6 -tocopherol, 7preformed-retinol. * SCF, 1993; ** Eurodiet, 2000; n.a. not available. 1
37
38
Table 15b. Vitamin intake (mean SD) in adults of European countries (women)
Energy and Nutrient Intake in the European Union
Age (years)
N
Vitamin A1 (mg)
-Carotene (mg)
Vitamin D (g)
Vitamin E2 (mg)
Thiamine (mg)
Riboflavin (mg)
Niacin3 (mg)
Vitamin B6 (mg)
Folate4 (g)
Cobalamin (g)
Ascorbic acid (mg)
Austria
18–24 25–50 51–64 65
372 777 357 62
1.2 0.9 1.3 1.2 1.3 1.3 0.9 0.7
3.3 3.3 3.8 4.1 3.5 3.6 2.6 2.1
3.3 4.0 3.7 5.1 4.1 5.8 2.6 2.5
12.7 8.1 12.9 8.5 12.3 7.6 8.2 4.6
1.3 0.9 1.3 0.8 1.2 0.7 0.9 0.4
1.7 1.1 1.7 0.9 1.6 0.9 1.2 0.5
29 14 30 14 29 12 25 11
1.9 1.6 1.9 1.5 1.7 0.9 1.3 0.6
256 110 264 120 247 112 199 91
55 54 57 43
127 106 138 114 126 111 98 84
Denmark
19–24 25–34 35–44 45–54 55–64
100 161 158 155 128
1.1 1.2 1.2 1.2 1.4
2.9 3.2 3.3 3.4 3.7
2.4 2.7 2.8 3.6 4.0
6.7 8.0 6.9 7.0 6.9
1.1 1.1 1.1 1.0 1.0
1.7 1.6 1.5 1.6 1.6
24 27 28 28 27
1.3 1.3 1.3 1.3 1.3
244 266 234 248 241
4.9 5.0 4.8 5.3 5.7
72 82 76 78 82
Finland
25–34 35–44 45–54 55–64
263 266 275 291
0.8 0.5 0.9 0.8 1.1 1.6 1.0 1.3
2.5 2.2 2.8 2.9 2.7 3.0 2.7 2.6
2.9 2.6 3.5 3.8 3.7 3.9 4.8 5.3
8.9 3.5 8.6 3.5 8.8 3.9 9.5 5.8
1.0 0.5 1.0 0.4 1.0 0.4 1.1 0.4
1.6 0.6 1.5 0.6 1.5 0.6 1.6 0.7
23 8 22 7 22 7 21 7
1.7 0.7 1.5 0.5 1.5 0.6 1.5 0.6
214 73 219 86 233 115 229 110
4.3 2.7 4.7 3.2 5.2 6.7 5.2 5.5
104 69 98 72 106 69 112 71
France
35–60
4,879
0.7 1.0
3.4 2.8
2.4 2.1
9.5 4.0
1.5 0.6
1.5 0.5
n.a.
1.6 0.5
272 93
6.1 5.2
88 46
Germany
19–24 25–50 51–64
786 5,845 2,867
1.0 1.4 1.7
2.8 3.4 4.0
2.1 2.5 3.0
11.9 12.7 14.8
1.2 1.4 1.4
1.3 1.5 1.7
23 32 34
1.4 1.7 1.9
194 227 266
3.6 5.3 6.1
116 129 157
Hungary
18–34 35–54
343 938
0.9 0.8 1.0 1.0
2.4 1.7 2.8 2.1
n.a. n.a.
7.3 3.9 7.4 4.0
1.0 0.4 1.0 0.3
1.3 0.5 1.3 0.5
17 6 18 6
1.7 0.6 1.8 0.6
n.a. n.a.
4.3 4.3 4.8 6.5
97 64 95 56
Italy5
18–64
n.a.
1.2 1.2
3.0 1.9
3.1 2.1
11.2 5.1
1.1 0.3
1.6 0.5
19 5
2.0 0.6
297 98
n.a.
117 62
Norway
20–29 30–59
268 774
1.3 1.5
n.a. n.a.
3.4 4.2
n.a. n.a.
1.2 1.2
1.6 1.5
14 14
n.a. n.a.
n.a. n.a.
n.a. n.a.
111 119
Portugal
18–29 40
87 416
1.7 1.0 1.7 1.0
n.a. n.a.
4.6 1.6 n.a.
7.8 2.2 8.2 2.8
1.8 0.3 n.a.
2.1 0.5 n.a.
23 4 n.a.
2.1 0.5 n.a.
277 96 282 106
9.2 3.8 –
133 53 –
Spain
25–60
5,480
0.7 0.5
2.0 1.8
2.0 2.3
8.3 5.2
1.5 0.6
1.7 0.8
33 13
2.0 0.8
252 103
7.1 7.1
136 88
Sweden
18–74
626
1.1
1.9
4.9
6.86
1.3
1.6
31
1.9
217
6.0
93
UK
19–24 25–34 35–49 50–64
104 210 318 259
0.6 0.67 0.6 0.77 0.8 0.67 1.0 0.87
1.4 1.9 1.6 1.2 1.8 1.5 2.0 1.2
2.9 2.5 2.7 2.0 3.5 2.9 5.1 4.1
9.4 9.2 8.6 4.7 14.3 40.1 23.2 60.5
1.6 1.0 1.6 1.3 2.0 5.7 2.3 6.6
1.5 0.8 1.5 0.6 2.1 5.5 2.5 6.6
31 10 29 9 34 12 35 12
2.1 0.9 2.3 3.2 3.4 9.8 3.3 8.3
248 109 249 113 280 123 359 917
4.1 2.1 4.0 2.2 5.5 6.4 6.1 3.7
96 134 85 85 123 299 127 161
0.6
–
0–10
–
0.9
1.3
14
1.1
200/400**
1.4
45
Reference values*
1 Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR- -Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrieno l0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals), 5 men and women, 6 -tocopherol, 7 preformed-retinol. * SCF, 1993; ** Eurodiet, 2000; n.a not available.
Table16a. Mineral intake (mean SD) in adults of European countries (men)
Energy and Nutrient Intake in the European Union
Age N (years)
Sodium (g)
Potassium Calcium (g) (mg)
Phosphorous Magnesium (mg) (mg)
Iron (mg)
Zinc (mg)
Iodine (g)
Copper (mg)
Manganese Selenium (mg) (g)
Austria
18–24 25–50 51–64 65
188 511 263 51
n.a. n.a. n.a. n.a.
3.0 1.4 3.1 1.7 3.0 1.1 2.4 0.8
1,045 588 1,000 582 981 528 661 504
n.a. n.a. n.a. n.a.
385 169 379 154 362 129 286 95
15.6 6.7 15.5 7.8 15.6 6.4 12.9 4.4
13.3 5.5 12.5 4.9 12.8 4.9 11.7 4.0
160 234 165 254 135 74 109 59
2.3 0.8 2.3 0.8 2.2 0.8 2.1 0.8
4.5 2.6 4.6 2.3 4.7 2.3 4.8 2.4
n.a. n.a. n.a. n.a.
Denmark
19–24 25–34 35–44 45–54 55–64
86 142 135 147 140
4.6 4.2 3.9 3.8 3.4
3.6 3.7 4 3.8 3.8
1,379 1,121 1,027 983 1,051
1,893 1,747 1,708 1,614 1,674
396 403 408 394 383
12.3 12.1 12.6 11.8 11.6
15 14.6 14.9 13.9 13.8
110 166 161 160 147
n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a.
46 47 48 47 48
Finland
25–34 35–44 45–54 55–64
190 215 232 275
4.1 1.2 3.9 1.4 3.8 1.4 3.9 1.5
4.1 1.2 4.0 1.3 4.1 1.2 3.9 1.1
1,391 1,203 1,137 1,075
410 148 409 148 411 124 392 120
13.3 5.2 13.1 5.8 13.0 5.5 13.4 5.8
12.7 7.1 12.5 3.9 11.8 3.3 9.1 3.3
320 116 284 112 270 107 275 108
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
83 30 81 28 78 27 75 31
France
45–60
3,323 3.5 1.1 n.a.
936 336
n.a.
322 86
14 4
n.a.
n.a.
n.a.
n.a.
n.a.
Germany
19–24 25–50 51–64
926 2.8 5,037 3.4 2,785 4.2
880 889 965
1,284 1,385 1,555
336 384 443
12.3 13.5 16
10.6 11.1 12.6
86 97 117
1.9 2.2 2.5
4.2 4.4 5.2
n.a. n.a. n.a.
Hungary
18–34 35–59
338 730
9.5 3.0 3.5 1.0 8.8 2.8 3.2 0.9
868 452 659 348
n.a. n.a.
482 133 429 114
16.2 6.6 14.4 4.7
13.5 4.7 n.a. 11.9 3.7 n.a.
2.9 2.5 n.a. 2.9 2.8 n.a.
n.a. n.a.
Italy1
18–64
n.a.
5.2 2.2 3.1 0.8
893 288
1,326 316
212 57
13.1 3.9
11.7 3.2 n.a.
1.5 0.6 n.a.
43 18
Norway
20–29 30–59
248 748
n.a. n.a.
1,300 1,000
n.a. n.a.
n.a. n.a.
13.0 12.1
n.a. n.a.
n.a. n.a.
n.a. n.a.
Portugal
18–29 40
159 310
2.5 0.6 3.6 0.8 n.a. n.a.
998 318 862 337
1,689 339 363 74 n.a. n.a.
15.6 3.4 19 5
15.2 3.0 104 53 n.a. n.a.
1.8 0.5 n.a. n.a. n.a.
151 92 n.a.
Spain
25–60
4,728 2.9
867
1,441
15.2
n.a.
n.a.
n.a.
2.8 3.2 3.9
n.a. n.a.
3.3
623 607 535 509
1,878 1,761 1,754 1,733
Sweden
18–74
589
3.6
3.5
1,070
1,570
UK
19–24 25–34 35–49 50–64
108 219 253 253
3.3 1.1 3.4 1.1 3.3 1.0 3.2 1.0
2.8 0.7 3.3 1.0 3.5 0.9 3.6 1.0
867 325 1,030 606 1,049 359 1,035 331
1,341 1,550 1,524 1,508
0.6–3.5
3.1
700/ 800**
550
Reference values* 1
*
Men and women. SCF, 1993; ** Eurodiet, 2000; n.a. not available.
600 643 573 603
319 319 727 429 403
n.a. n.a.
n.a.
n.a. n.a.
n.a.
345
12.3
12.6
n.a.
n.a.
n.a.
36
260 73 311 105 322 106 320 103
11.5 4.6 13.9 7.5 14.1 12.9 15.2 13.2
9.2 2.5 10.7 4.4 11.4 8.4 10.8 4.2
167 70 223 122 226 93 235 85
1.2 0.3 1.4 0.7 1.6 1.0 1.6 0.9
2.5 0.8 3.2 1.3 3.6 3.1 3.8 1.5
n.a. n.a. n.a. n.a.
150–500
9
9.5
130/ 150**
1.1
1–10
55
39
40
Table 16b. Mineral intake (mean SD) in adults of European countries (women)
Energy and Nutrient Intake in the European Union
Age N (years)
Sodium (g)
Potassium Calcium (g) (mg)
Phosphorous Magnesium Iron (mg) (mg) (mg)
Zinc (mg)
Iodine (g)
Copper (mg)
Manganese Selenium (mg) (g)
Austria
18–24 25–50 51–64 65
188 511 263 51
n.a. n.a. n.a. n.a.
2.5 0.9 2.7 1.0 2.6 0.9 2.3 0.9
938 461 900 474 844 467 727 433
n.a. n.a. n.a. n.a.
313 110 323 117 307 100 268 104
13.1 7.2 13.7 7.0 13.0 5.5 11.1 4.5
10.3 3.6 10.2 3.8 10.3 3.7 9.8 3.7
127 73 137 80 128 70 103 68
2.0 0.7 2.1 0.7 2.1 0.7 1.8 0.7
4.5 2.5 4.6 2.4 4.5 2.3 5.1 2.9
n.a. n.a. n.a. n.a.
Denmark
19–24 25–34 35–44 45–54 55–64
86 142 135 147 140
3.1 3.3 2.9 2.8 2.5
2.8 3 3.1 3.1 3
1,100 1,015 901 947 885
1,380 1,403 1,292 1,332 1,287
290 316 310 313 295
8.5 9.5 8.7 8.9 8.9
10.3 11 10.6 10.9 10.6
102 117 134 150 158
n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a.
34 39 36 38 39
Finland
25–34 35–44 45–54 55–64
190 215 232 275
2.7 0.9 2.7 0.9 2.7 0.9 2.7 1.0
3.1 0.9 3.2 0.9 3.2 0.9 3.3 0.9
1,001 455 986 404 954 397 946 419
1,314 450 1,315 426 1,309 439 1,349 482
299 88 311 93 311 88 315 92
10.0 3.5 10.0 3.5 9.9 3.4 10.2 4.8
10.4 3.3 10.3 3.7 10.1 3.1 9.2 3.4
215 80 218 121 203 75 214 77
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
55 20 58 19 56 18 55 20
France
35–60
3,323 2.6 0.9 n.a.
Germany
19–24 25–50 51–64
926 2.2 5,037 2.6 2,785 3.2
821 303
n.a.
251 73
10 3
n.a.
n.a.
n.a.
n.a.
n.a.
838 925 989
1,173 1,352 1,420
340 415 417
12.2 15.1 15.4
9.2 11 11.6
80 94 101
1.8 2.3 2.3
4.4 5.5 5.4
n.a. n.a. n.a.
Hungary
18–34 35–59
338 730
6.1 2.1 2.7 0.8 6.4 2.0 2.7 0.7
631 298 579 276
n.a. n.a.
331 93 328 91
10.8 3.3 11.1 3.8
8.6 3.0 8.8 2.9
n.a. n.a.
1.7 1.7 n.a. 1.9 1.8 n.a.
n.a. n.a.
Italy1
18–64
Norway
20–29 30–59
n.a.
5.2 2.2 3.1 0.8
893 288
1,326 316
212 57
13.1 3.9
11.7 3.2 n.a.
1.5 0.6 n.a.
43 18
248 748
n.a. n.a.
900 800
n.a. n.a.
n.a. n.a.
9.7 9.6
n.a. n.a.
n.a. n.a.
n.a. n.a.
Portugal
18–29 40
159 310
2.1 0.4 4.0 0.9 n.a. n.a.
897 269 896 399
1,467 277 n.a.
317 69 n.a.
18.0 3.7 15 5
12.8 2.4 92 43 n.a. n.a.
Spain
25–60
4,728 2.0
2.9
800
1,206
266
11.7
n.a.
n.a.
n.a.
n.a.
n.a.
Sweden
18–74
589
2.9
3.1
925
1,290
295
10.4
9.9
n.a.
n.a.
n.a.
32
UK
19–24 25–34 35–49 50–64
108 219 253 253
2.3 0.7 2.3 0.7 2.3 0.7 2.3 0.7
2.4 0.7 2.4 0.7 2.7 0.8 2.9 0.7
706 264 736 233 814 293 903 382
1,050 299 1,045 279 1,134 296 1,180 309
260 73 311 105 322 106 320 103
10.0 4.9 9.8 6.0 12.9 23.3 12.3 8.0
7.1 3.2 7.1 2.9 8.2 3.8 8.6 3.7
167 70 223 122 226 93 235 85
1.0 0.4 1.0 0.4 1.1 0.5 1.1 0.4
2.2 1.0 2.5 1.0 2.9 1.2 3.1 1.5
n.a. n.a. n.a. n.a.
0.6–3.5
3.1
700/ 800**
550
150–500
16/15**
7
130/ 150**
1.1
1–10
55
Reference values* 1
*
2.8 3.5 3.7
n.a. n.a.
Men and women. SCF, 1993; ** Eurodiet, 2000; n.a. not available.
n.a. n.a.
n.a. n.a.
1.6 0.4 n.a. n.a. n.a.
135 27 n.a.
Portuguese women, the average intake in women of all age groups and countries was clearly below the guideline of 15 mg/day [Eurodiet, 2000]. The average iodine intake was particularly high and clearly above the indicated requirement of 150 g/day [Eurodiet, 2000] in Finnish and UK adults. An insufficient average intake of iodine was observed in Austrian men older than 50 years and in Austrian women of all age groups, in Portuguese and German adults, as well as in some age groups of Danish women and men. The average supply of zinc was relatively good. There were only a few age groups in Finland and the UK which had an intake below the recommendation of the SCF (1993). The mean selenium intake was too low in Denmark, Italy and Sweden, but only five countries assessed this nutrient. The average supply of magnesium, copper and manganese can be regarded as sufficient.
Energy and Nutrient Intake in European Elderly More than half of the participating countries had data of energy and nutrient intake in elderly (table 17). Here again, the age groups are not homogeneous, and also the methods used for the assessment of dietary intake data
Table 17. Method and period of dietary assessment in elderly of European countries
were different among the participating countries (table 17). Data from Belgian elderly as well as Hungarian elderly aged 70–75 years have to be interpreted with caution, as they are limited only to these population groups of the elderly and are more than 12 years old. The SCF (1993) does not indicate specified recommendations for elderly. Thus, in this report, the intake data of European elderly is compared to the recommendations for adults. Energy and Macronutrients On average, the energy intake was lower in elderly than in adults of the same countries. The mean proportion of protein in total energy intake was within the recommended range of the WHO (2003) in elderly of most countries, or slightly above it (table 18). The highest average proportion was found in Spanish men and women, but also in Norwegian women it was relatively high. Like in European adults, the mean share of carbohydrates was low in European elderly as well. Only in Norwegian and Portuguese elderly and in Hungarian women aged 70–75 years the average carbohydrate intake was higher than 50 %E. In UK elderly it was on average 50 %E and higher as well, but it has to be considered that it is the percentage of food energy only. This means that considering the energy intake from alcohol,
Country
Age group
Method
Year of survey
Austria
55– 85 years
24-hour-recall
2002
Belgium
70–75 years
24-hour-recall
1988
Denmark
65–80 years
7-day-record, personal interview
1995
Germany
65 years
HBS
1998
Greece
65– 75
Semiquantitative FFQ
1994–1999 (EPIC data collected at the national level)
Hungary
60 years (m) 55 years (f) 70–75 years
3 24-hour-records
1992–1994
FFQ
1988
Italy
65 years
7-day-record, personal interview
1994–1996
Norway
60–79 years
FFQ
1997
Portugal
70–75 years
FFQ
1993
Spain
65–75
24-hour-recall
1990–1998
UK
65
4-day-weighed record
1995
Energy and Nutrient Intake in the European Union
41
42
Table 18. Intake of energy and macronutrients (mean SD) in elderly of European countries (men and women) Age (years)
Male Austria
Energy and Nutrient Intake in the European Union
Belgium Denmark Germany Greece Hungary Italy1 Norway Portugal Spain UK
Female Austria
Belgium Denmark Germany Greece Hungary Italy1 Norway Portugal Spain UK
Reference values* 1
*
N
Energy (MJ)
Protein %E
Carbohydrates %E Total
Sucrose
Dietary fib. (g)
Fat %E
SFA %E
MUFA %E
PUFA %E
Cholesterol (mg)
Alcohol %E
55–64 65–74 75–84 85 70–75 65–74 75–80 65 65–74 75 60 70–75 65 60–79 70–75 65–75 65–74 75–84 85
21 22 22 22 120 122 64 1,509 2,377 340 55 21 n.a. n.a. 77 382 313 360 178
9.0 3.2 8.7 2.3 8.7 2.3 7.4 2.4 10.4 2.9 10.9 10.5 12.3 8.5 2.5 7.9 2.3 11.8 3.5 11.2 4.7 8.2 2.0 8.8 8.0 2.5 7.8 8.2 2.0 7.8 1.9 7.5 2.0
16 5 16 5 16 4 14 5 13 3 14 13 13 14 2 14 2 15 2 12 2 16 4 16 16.4 2.9 17 15 32 15 32 14 32
45 9 45 10 42 6 44 11 41 7 41 41 45 40 6 41 6 44 6 49 12 46 13 52 52.4 9.4 46 49 72 51 72 51 72
85 84 73 11 15 n.a. 74 74 12 n.a. n.a. 14 6 n.a. 14 5 8 n.a. n.a. 13 72 15 82 17 82
20 7 23 9 22 9 15 5 n.a. 25 20 31 n.a. n.a. n.a. n.a. 20 7 25 n.a. 19 20 83 18 73 16 63
36 6 36 7 40 6 40 8 41 7 39 38 36 44 5 44 6 39 6 32 8 32 10 30 25.7 5.7 33 35 72 35 62 36 52
16 2 17 3 20 3 20 3 16 4 17 16 14 12 3 12 3 15 6 12 3 10 3 12 8.4 2.6 10 14 42 15 32 16 32
15 2 14 2 15 2 15 2 15 5 12 11 12 21 4 21 4 16 7 12 3 13 5 11 10.5 2.6 15 11 22 11 22 11 22
52 52 52 52 95 5 6 7 73 63 42 53 53 5 3.8 1.3 5 6 22 5 22 5 22
466 232 323 113 377 119 354 155 318 140 466 415 358 n.a. n.a. 474 212 333 200 291 115 292 223 85 343 302 122 288 130 283 119
35 24 23 23 56 6 8 6 56 45 23 79 57 2 6.5 8.7 4 n.a. n.a. n.a.
55–64 65–74 75–84 84 70–75 65–74 75–80 65 65–74 75 55 70–75 65 60–79 70–75 65–75 65–74 75–84 85
180 121 160 93 100 103 44 1,690 3,439 344 105 26 n.a. n.a. 80 429 278 303 301
7.5 2.3 7.5 2.0 7.4 1.9 7.1 2.0 8.4 1.9 8.5 8.2 9.6 6.8 2.0 6.4 2.2 9.7 2.6 9.7 2.9 8.2 2.0 7.1 5.5 1.6 6.5 6.1 1.5 6.1 1.6 6.1 1.6
16 4 16 5 16 5 16 4 14 3 16 14 13 14 2 14 2 15 2 14 2 16 4 17 17.0 3.0 18 16 42 16 32 14 32
47 9 46 8 45 9 43 9 43 8 43 45 46 42 6 42 6 47 7 51 7 46 13 53 56.2 7.3 47 50 72 51 62 52 72
95 95 95 95 n.a. 84 94 15 n.a. n.a. 17 6 n.a. 14 5 8 n.a. n.a. 12 62 14 72 16 82
21 8 20 7 18 7 16 6 n.a. 19 18 23 n.a. n.a. n.a. n.a. 20 7 22 n.a. 16 17 63 15 53 14 53
36 9 37 7 38 8 40 8 42 8 39 38 38 45 5 45 5 37 6 35 7 32 10 29 27.7 6.2 34 36 62 36 62 37 62
17 4 17 3 19 4 20 3 17 5 17 17 16 12 3 12 3 14 5 13 3 10 3 12 9.2 2.8 11 15 42 15 42 16 42
14 3 14 2 14 2 15 2 15 4 11 11 13 22 4 21 4 15 6 12 3 13 5 11 11.1 3.1 15 11 22 11 22 11 22
53 62 52 52 84 5 5 6 73 73 42 62 53 5 4.4 1.5 4 6 22 6 22 5 22
299 172 325 222 300 130 337 225 273 107 382 387 328 n.a. n.a. 375 169 328 108 291 115 222 178 87 304 224 95 230 96 228 102
14 12 12 12 23 2 3 2 12 12 12 12 57 1 0.3 1.8 1 n.a. n.a. n.a.
10–15**
55
10**
25
30
10
6–10
300**
Men and women, 2 % of total food energy (excl. alcohol), 3 Non-starchy polysaccharides, 4 added sucrose. Eurodiet, 2000; ** WHO, 2003; n.a. not available.
this level would probably be lower. The recommended level of at least 55 %E [Eurodiet, 2000] was not reached by elderly of any country. The proportion of this nutrient in total energy intake was particularly low in Belgian, and Danish elderly men, and in Greek elderly of both sexes. On average the carbohydrate intake was in elderly women higher than in elderly men. The mean sucrose intake in European elderly was generally below the upper level of 10 %E [WHO, 2003]. In German, Hungarian and UK elderly men and women it was however clearly above this recommended upper level. Especially in Hungarian elderly women it was very high with 17 %E. The mean dietary fibre intake varied in elderly people among the participating countries. In Austrian men and women older than 84 years, as well as in Spanish elderly women it was very low. Only in German and Norwegian elderly men, as well as in Danish men aged 65–74 years, the recommendation of Eurodiet (2000) was reached. As a consequence of the low intake of carbohydrates, the proportion of fat was rather high in European elderly. The highest intakes were found in Greek men and women, but also in Belgium, Austria, Denmark, Germany, and Hungary the proportion was considerable. The lowest average fat intake was observed in Norwegian elderly. Apart from Greece, countries with a high total fat intake had a high average intake of SFA as well. In Austrian elderly men older than 74 years and women older than 84 years it was 20 %E, which was the 2-fold of the recommended upper level Eurodiet (2000). In Spain, Italy, Greece and Norway the mean SFA intake was low compared to the other countries. The PUFA intake was in general too low in European elderly. The highest mean intake was found in Belgian elderly. In German and Greek elderly it was on average sufficient as well. Due to the generally high fat intake in European elderly, the mean cholesterol intake was high as well. Especially in men it was generally above the upper level of 300 mg/day indicated by the WHO (2003). Also in Danish and Hungarian women, as well as in women of some other countries this upper level was exceeded. The lowest mean cholesterol intakes were found in Norway, Italy and the UK. Despite the high proportion of fat in total energy intake in Belgian elderly, the mean cholesterol intake was not as high as in most other countries, in women it was even below the recommended upper level. The highest mean proportion of alcohol in total energy intake was found in Danish, German and Hungarian men, but also in Italian adults it was considerable.
Energy and Nutrient Intake in the European Union
Vitamins According to table 19, the vitamin A intake in elderly people of the participating countries was on average above the population reference intake of the SCF (1993). Only in Hungarian elderly men and women aged 70–75 years the mean vitamin A intake was with 0.3 and 0.4 mg/day, respectively, clearly below these recommendations. The mean vitamin D intake was below the recommended intake of 10 g/day [Eurodiet, 2000] in elderly men and women of all countries. The highest mean intake was found in Norwegian men with 5.8 g/day, followed by Austrian men aged 55–74 years with 5.0–5.1 g/day. For vitamin E intake the SCF does not give any absolute recommendations. In general, the average vitamin E intake was clearly lower in European elderly than in adults of the same countries, and it was higher in elderly men than in elderly women. The thiamine intake was on average sufficient in the European population. Only in Hungarian men and women aged 70–75 years, as well as in Italian elderly and Austrian elderly men older than 84 years the mean intake was below the recommended value. Apart from Hungary, the average riboflavin intake was above the population reference intake in elderly women of the participating countries. In men a low intake of riboflavin was more prevalent. A sufficient mean intake was only observed in Denmark, Germany and Norway. The mean niacin supply was good in European elderly. Only in Norwegian men it was below the population reference intake of the SCF (1993). A low vitamin B6 intake was found in Austrian and Hungarian men. In all other countries it can on average be regarded as sufficient. The mean food folate intake was among women and men of all countries below the recommended level of 400 g/day [Eurodiet, 2000]. The supply of cobalamin and ascorbic acid in European elderly can on average be regarded as sufficient. Minerals The mean estimated sodium intake was relatively high in European elderly, especially in men. The highest intake was found in Hungarian elderly men (7.4 g/day) and women (6.2 g/day), followed by Italian elderly (5.4 g/day) (table 20). The mean supply of potassium was not sufficient in elderly of most of the participating countries. Only in Danish men and in German men and women the average intake of this nutrient can be regarded as sufficient. The mean calcium intake was 43
44
Table 19. Vitamin intake (mean SD) in elderly of European countries (men and women)
Male Austria
Energy and Nutrient Intake in the European Union
Denmark Germany Hungary Italy5 Norway Portugal6 Spain UK
Age (years)
N
Vitamin A1 (mg)
-Carotene (mg)
Vitamin D (g)
Vitamin E2 (mg)
Thiamine (mg)
Riboflavin (mg)
Niacin3 (mg)
Vitamin B6 (mg)
Folate4 (g)
Cobalamin (g)
Ascorbic acid (mg)
55–64 65–74 75–84 85 65–74 75–80 65 60 70–75 65 60–79 70–79 65–75 65–74 75–84 85
21 22 22 22 122 64 1,509 55 21 n.a. n.a. 77 382 313 360 178
1.5 1.6 1.3 1.1 1.2 0.8 0.9 0.4 1.6 1.4 1.7 0.8 0.6 0.3 0.1 1.2 1.2 1.6 0.64 1.2 0.9 1.65 0.8 1.65 0.8 1.15
2.9 2.1 2.8 2.5 3.0 2.1 2.2 1.9 3.2 2.8 3.5 2.5 2.1 1.7 0.8 3.0 2.0 n.a. 1.95 n.a. 2.0 1.5 1.9 1.4 2.0 1.5
5.0 5.7 5.1 5.3 3.4 2.2 3.4 3.1 4.1 3.7 4.9 n.a. n.a. 2.5 1.8 5.8 n.a. 4.1 4.6 3.7 4.1 2.9 3.7 2.4
9.9 4.2 9.0 3.1 9.3 4.1 6.2 2.9 9.2 10.8 19.2 7.2 3.4 n.a. 10.9 4.4 n.a. n.a. 7.9 10.2 9.8 8.7 5.1 7.9 9.1
1.4 0.7 1.2 0.4 1.2 0.4 1.0 0.4 1.3 1.2 1.7 1.1 0.4 0.6 0.5 1.0 0.3 1.5 1.08 1.1 1.6 0.6 1.4 0.6 1.4 0.5
1.5 0.8 1.5 0.4 1.4 0.3 1.3 0.5 1.9 1.7 1.9 1.4 0.5 0.9 0.4 1.5 0.5 1.7 1.65 1.5 1.8 0.8 1.7 0.8 1.8 0.8
31 13 27 7 28 8 23 9 36 29 39 19 8 n.a. 18 5 17 n.a. 19 33 9 30 9 28 9
1.6 0.6 1.4 0.4 1.5 0.5 1.1 0.4 1.7 1.5 2.4 2.0 0.7 1.3 0.8 1.9 0.5 n.a. 1.38 1.8 2.2 0.8 2.0 0.7 1.8 0.7
234 92 232 70 232 80 174 61 301 259 286 n.a. n.a. 295 166 n.a. n.a. 311 283 108 248 103 238 96
5.3 3.4 4.9 2.6 5.3 3.2 4.0 1.8 6.8 5.7 7.7 n.a. n.a. n.a. n.a. n.a. 7.4 6.3 5.7 5.3 5.8 5.0 4.3
97 85 113 104 109 86 93 133 79 69 144 91 64 66 31 109 60 117 87 124 74 62 61 51 59 80
0.7
–
10**
–
1.1
1.6
18
1.5
200/400**
1.4
45
1.1 0.9 1.2 1.2 1.1 1.1 1.0 1.0 1.6 1.6 1.5 0.8 0.6 0.4 0.2 1.2 1.2 1.6 0.51 1.1 0.8 1.25 0.8 1.25 0.7 1.45
3.2 2.7 2.7 3.1 2.9 3.5 2.3 2.6 3.4 2.8 3.0 2.9 1.8 2.0 0.8 3.0 2.0 n.a. 1.43 n.a. 1.8 1.5 1.6 1.3 1.6 1.2
3.4 4.4 4.7 6.2 3.6 6.1 3.1 3.5 3.3 3.2 3.1 n.a. n.a. 2.5 1.8 4.0 n.a. 2.9 3.4 2.7 3.4 2.7 3.0 2.1
8.6 5.2 9.3 5.5 7.2 3.2 6.3 2.7 7.8 7.8 13.1 7.1 3.7 n.a. 10.9 4.4 n.a. n.a. n.a. 11.1 37.6 9.1 35.6 7.1 10.6
1.2 0.5 1.1 0.5 1.0 0.4 0.9 0.4 1.1 1.0 1.2 1.0 0.4 0.8 0.5 1.0 0.3 1.2 0.62 1.0 1.7 6.0 1.3 0.7 1.1 0.4
1.4 0.6 1.5 0.6 1.4 0.5 1.3 0.6 1.6 1.6 1.6 1.2 0.4 1.2 0.7 1.5 0.5 1.5 1.24 1.6 1.9 6.1 1.6 0.9 1.4 0.6
25 8 25 10 24 8 23 8 29 24 30 17 6 n.a. 18 5 14 n.a. 17 27 10 25 10 23 8
1.4 0.6 1.4 0.6 1.3 0.5 1.2 0.5 1.4 1.3 1.6 1.8 0.6 n.a. n.a. n.a. 0.93 1.5 2.3 6.9 1.7 0.9 1.5 0.7
223 88 210 68 189 67 166 60 261 273 231 n.a. n.a. n.a. n.a. n.a. 272 226 92 213 114 189 86
3.9 2.1 4.4 2.9 4.1 2.5 3.9 2.3 6.1 6.2 5.5 3.8 4.8 n.a. n.a. n.a. n.a. 6.2 4.6 4.2 3.9 3.3 4.3 3.9
109 73 98 66 87 63 71 62 79 77 123 94 62 56 34 109 60 123 62 118 73 58 58 53 52 63
0.6
–
10**
–
0.9
1.3
14
1.1
200/400**
1.4
45
Reference values* Female Austria
Denmark Germany Hungary Italy5 Norway Portugal6 Spain UK
Reference values*
55–64 65–74 75–84 84 65–74 75–80 65 55 70–75 65 60–79 70–79 65–75 65–74 75–84 85
180 121 160 93 103 44 1,690 105 26 n.a. n.a. 80 429 278 303 301
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR- -Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals), 5 Preformend retinol; 6 values correspond to the median (P50). * SCF, 1993; ** Eurodiet, 2000; n.a. not available. 1
Table 20. Mineral intake (mean SD) in elderly of European countries (men and women) Age (years)
N
Sodium (g)
Potassium (g)
Calcium (mg)
Phosphorous (mg)
Magnesium (mg)
Iron (mg)
Zinc (mg)
Iodine (g)
Copper (mg)
Manganese (mg)
Selenium (g)
55–64 65–74 75–84 85
21 22 22 22
n.a. n.a. n.a. n.a.
2.6 1.2 2.8 1.0 2.5 0.8 1.9 1.9
635 402 959 400 695 266 642 642
n.a. n.a. n.a. n.a.
311 152 341 98 281 85 233 84
14.2 5.4 14.7 4.3 14.4 6.0 10.0 2.9
12.7 7.1 12.5 3.9 11.8 3.3 9.1 3.3
123 52 136 54 119 23 102 34
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
Denmark
65–74 75–80
122 64
3.6 3.4
3.8 3.3
954 822
1,641 1,404
380 334
11.9 9.7
13.5 11.1
143 101
n.a. n.a.
n.a. n.a.
49 41
Germany
65
1,509
4.3
4.2
1,031
1,657
474
17.8
13.5
127
2.7
6.0
n.a.
Hungary
60 70–75
55 21
7.4 1.9 n.a.
2.9 0.8 n.a.
699 365 638 220
n.a. n.a.
381 112 n.a.
12.4 3.8 9.7 2.8
n.a. n.a.
n.a. n.a.
n.a. n.a.
n.a. n.a.
n.a. n.a.
Italy1
65
n.a.
5.4 2.9
3.0 0.8
845 263
1,242 295
199 56
12.6 4.0
10.7 3.1
n.a.
n.a.
n.a.
n.a.
Norway
60–79
n.a.
n.a.
n.a.
900
n.a.
n.a.
11.0
n.a.
n.a.
n.a.
n.a.
n.a.
Portugal2
70–79
77
n.a.
n.a.
766
n.a.
n.a.
12.8
n.a.
n.a.
n.a.
n.a.
n.a.
Male Austria
Energy and Nutrient Intake in the European Union
Spain
65–75
382
1.7
3.0
714
1,218
295
12.5
n.a.
n.a.
n.a.
n.a.
n.a.
UK
65–74 75–84 85
313 360 178
2.8 0.9 2.7 0.9 2.6 0.9
2.8 0.8 2.5 0.7 2.3 0.6
856 290 840 302 847 285
1,261 340 1,179 331 1,134 308
258 79 233 77 214 69
11.5 6.6 10.6 3.9 10.1 4.1
9.0 2.7 8.4 2.8 8.0 2.6
193 82 185 80 177 73
1.1 0.7 1.0 0.6 0.9 0.4
n.a. n.a. n.a.
n.a. n.a. n.a.
0.6–3.5
3.1
700/ 800**
550
150–500
9
9.5
130/ 150**
1.1
1–10
55
Reference values* Female Austria
55–64 65–74 75–84 84
180 121 160 93
n.a. n.a. n.a. n.a.
2.6 0.9 2.6 0.9 2.3 0.8 2.1 0.8
831 409 799 402 780 361 649 351
n.a. n.a. n.a. n.a.
286 98 288 101 271 110 235 86
12.6 6.6 12.3 5.0 11.0 4.1 11.1 7.3
10.4 3.3 10.3 3.7 10.1 3.1 9.2 3.4
130 56 135 55 122 56 111 42
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a.
Denmark
65–74 75–80
103 44
2.8 2.5
3.2 2.8
912 864
1,366 1,264
307 276
9.0 8.5
11.2 9.8
111 115
n.a. n.a.
n.a. n.a.
41 39
Germany
65
1,690
3.0
3.5
886
1,276
377
13.4
10.1
91
2.1
4.6
Hungary
55 70–75
105 26
6.2 1.8 n.a.
2.7 0.8 n.a.
613 264 838 527
n.a. n.a.
328 96 n.a.
10.8 3.3 9.8 5.1
n.a. n.a.
n.a. n.a.
1.4 1.3 n.a.
n.a. n.a.
n.a. n.a.
Italy1
65
n.a.
5.4 2.9
3.0 0.8
845 263
1,242 295
199 56
12.6 4.0
10.7 3.1
n.a.
1.3 0.5
n.a.
39 17
Norway
60–79
n.a.
n.a.
n.a.
800
n.a.
n.a.
9.0
n.a.
n.a.
n.a.
n.a.
n.a.
2
Portugal
70–79
80
n.a.
n.a.
548
n.a.
n.a.
7.0
n.a.
n.a.
n.a.
n.a.
n.a.
Spain
65–75
429
1.5
2.9
759
1,133
250
10.1
n.a.
n.a.
n.a.
n.a.
n.a.
UK
65–74 75–84 85
278 303 301
2.1 0.7 2.1 0.6 2.0 0.7
2.3 0.6 2.1 0.5 2.0 0.6
720 251 729 270 718 273
1,032 275 983 268 940 278
208 61 188 60 178 55
9.4 3.5 8.4 3.0 7.9 2.9
7.2 2.2 7.0 2.8 6.5 2.3
154 62 151 63 149 67
0.9 0.5 0.9 0.6 0.8 0.5
n.a. n.a. n.a.
n.a. n.a. n.a.
0.6–3.5
3.1
700/ 800**
550
150–500
9
7
130/ 150**
1.1
1–10
55
Reference values* 1
45
Male and female, 2 values correspond to the median (P50). * SCF, 1993; n.a. not available.
below the recommended level of at least 800 mg/day [Eurodiet, 2000] in Austrian men and women of nearly all age groups, in Hungarian and Spanish men and women, and in female elderly of the UK. Also the supply of iron was on average relatively good. As postmenopausal women do not have higher requirements than men, the average intake was compared to the recommendation of the SCF (1993) for male adults. According to this recommendation, the mean intake was too low in Danish women aged 75–80 years, and in UK women aged 75 years and older. A low zinc intake was observed
46
Energy and Nutrient Intake in the European Union
in Austrian men older than 84 years, in women of the UK older than 84 years, and in elderly UK men of all age groups. The iodine intake was assessed in Austria, Denmark, Germany and the UK. Apart from the UK, the average iodine intake was below the recommended level of 150 g/day [Eurodiet, 2000] in both elderly men and women of these countries. The supply of magnesium, copper and manganese in European countries can on average be regarded as sufficient. Only in UK elderly the intake of copper was below the recommended level.
Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 2004. Forum Nutr. Basel, Karger, 2005, vol 58, pp 47–61
Health Indicators and Status in the European Union
Prevalence of Overweight and Obesity Overweight and obesity are one of the major health problems in developed countries. An excessive energy intake – this means that it is higher than the energy expenditure of a person – leads to an increase in overweight and obesity. However, in some countries the average energy intake shows a decreasing trend, whereas the prevalence of overweight and obesity shows an increasing trend. Thus, a general low and decreasing amount of physical activity among people living in industrial countries is further responsible for this negative trend. An increased prevalence of non-communicable diseases, such as diabetes mellitus, cardiovascular disease and an increased incidence of cancer, is one of the most important outcomes of the typical lifestyle in developed countries. This not only affects the amount of healthy life years, but also causes high costs for the health care system. Children The onset of overweight and obesity can often already be found in childhood. Thus, the prevention of this profound public health problem has to be taken up in this early life stage. Only four of the participating countries – Austria, Spain, Germany and Belgium – have data about body weight and height of children, which were in Belgium and in parts in Austria (age 7–10 years) selfreported. In these countries the description of body weight was done based on BMI categories. The BMI was calculated according to the formula BMI ⫽ body weight in kg divided by body height in m2. The prevalence of overweight and obesity was especially high in Spanish and also in German and Greek children (fig. 22). However, it has to be considered that Spain used the 85th percentile as borderline of
overweight, whereas Germany and Austria used the 90th percentile. Further, different reference data sets were used. The cut-off point for obesity was the same in Spain, Germany and Austria (97th percentile). For Belgium no cut-off points are given. The same trend for boys and girls was found in these four countries. The highest prevalence of overweight and obesity was found in German and Spanish children. In all countries the prevalence of overweight and obesity was lower in girls than in boys. Adults Figure 23 shows that the prevalence of overweight and obesity in adults of European countries is considerable. In men the prevalence of overweight was on average between 35 (Austria) and 53% (Greece). The highest rate of obese male adults was found in Greece with 26% and the UK with 25%, the lowest in Austria with only 6%. However, these data have to be treated cautiously as the data set of Austria for example were based on selfreporting, whereas that of the UK relies on measured weight and height. Studies show that there can be a considerable difference in the prevalence of overweight and obesity calculated from self-reported or measured data. In the National Nutrition Survey 1995 in Australia for example the BMI based on self-reported data classified 52% of males and 36% of females as overweight, compared with 64 and 47%, respectively, from measured data [NSW Centre for Public Health Nutrition, 2000a]. In female adults the prevalence of overweight persons (BMI ⫽ 25–29.9 kg/m2) was – apart from Greece – clearly lower than in male adults of the presented European countries. The prevalence of obesity was, however, comparable to that in men. The lowest prevalence
20
Spain (10–13 years), 1998–2000*, M 16
Spain (6–9 years), 1998–2000*, M Spain (2–5 years), 1998–2000*, M
10.8 16.6
3.6
19.1
Portugal (7–9 years), 2002****, M
10.3
12.7
Greece (7–12), 2004***, M
10 18.5
Greece (7–12 years), 2004**, M
9.4
7.6
15.5
10.9
Greece (1–6 years), 2004**, M
Boys
9.2
12.5
Germanyears (6–16 years), 1999, M Belgium (11–18 years), 2002, S
21.7
9.3
Portugal (11–15 years), 2002*****, M
Greece (1–6 years), 2004***, M
22
8.6
13.9 1.8
11
Austria (7–10 years), 2001, S
5
10
Austria (3–6 years), 2001, S
6 % of boys
Spain (10–13), 1998–2000*, M
9.1
10.9
11.5
10.4
Spain (2–5 years), 1998–2000*, M
2.7
12.9
Portugal (11–15 years), 2002*****, M Portugal (7–9 years), 2002****, M
14.5
Greece (1–6 years), 2004***, M
6.4
Greece (1–6 years), 2004**, M
8
Belgium (11–18 years), 2002, S
7.2
11.1
Greece (7–12 years), 2004**, M
Germany (6–16 years), 1999, M
12.3
21.4
Greece (7–12 years), 2004***, M
Obesity
9.8
13.1
Spain (6–9 years), 1998–2000*, M
Overweight
3.7 14.4 3.3
Girls
10.2 7.4
Austria (7–10 years), 2001, S
10
Austria (3–6 years), 2001, S
10
11.7 1.5 4 3 % of girls
Fig. 22. Prevalence of overweight and obesity in children of European countries (boys and girls). Overweight: ⬎90th–97th percentile (* ⬎85th–97th percentile); Obesity: ⬎97th percentile. M ⫽ BMI calculated from measured height and weight; S ⫽ BMI calculated from self-indicated height and weight. The Greek data was derived from two different studies [** Chiotis et al., 2004; *** Kapantais et al., 2004]. The Portuguese data was derived from two different studies [**** Padez et al., 2002; ***** HBSC-Portugal, 2002].
of overweight women was again found in Austrian women with 20% of all female adults followed by French women with 21%. The highest prevalence of obesity in women was observed in Greece with 31%. Also the lowest proportion of obese women was found in Austria (6%) and France (7%). As mentioned before, the differences between the participating countries could be due to different methods of data collection and assessment. 48
Health Indicators and Status in the European Union
Table 21 shows the mean BMI of adults in different countries and population groups. Eurodiet (2000) indicates a BMI 21–22 as the optimum population mean BMI which both limits the likelihood of underweight and of obesity. Male and female adults of the below presented European countries had mean BMI which were above this recommended range in all age groups. The mean BMI was in women lower than in men.
UK, 2001, M
41
Spain, 1990–2000, M
25
45
13
Portugal, 2000, M
41
13
Italy, 2002, S
42
9
Hungary, 1992–1994, M
42
21
Greece, 2002, M
52
Germany-East, 1990–1992, M
26
45
21
Germany-West, 1990–1992, M
49
18
Finland, 2003**, n.i.
49
19
France, 1994–2003, M
47
Denmark, 2002*, S
10
44
Belgium, 2001, S
9
40
Austria, 1998–2001, S
10
35
6 % of men
UK, 2001, M
33
Spain, 1990–2000, M
32
Portugal, 2000, M
31
Italy, 2002, S
21 37
Germany-East, 1990–1992, M
32
Germany-West, 1990–1992, M
31
35 25 21
33
18
21
Denmark, 2002*, S
8
26 20
Women
7 29
Belgium, 2001, S Austria, 1998–2001, S
15 9
Greece, 2002, M
France, 1994–2003, M
Obesity
16
28
Finland, 2003**, n.i.
Overweight
20
26
Hungary, 1992–1994, M
Men
12 6 % of women
Fig. 23. Prevalence of overweight and obesity in male female adults of European countries. Overweight: BMI ⫽ 25–29.9 kg/m2; Obesity: BMI: ⱖ30 kg/m2. M ⫽ BMI calculated from measured height and weight; S ⫽ BMI calculated from self indicated height and weight; n.i. ⫽ method used not indicated. * Mean prevalence of overweight/obesity (%) calculated from the prevalence in different age groups (16–24 years: 22.7/5.4 and 16.0/3.0 (male and female, respectively), 25–44 years: 45.5/7.8 and 29.7/9.1, 45–66 years: 62.3/13.8 and 40.4/10.6). ** Mean prevalence of overweight/obesity (%) calculated from the prevalence in 5 different Finnish regions (North Karelia: 50/18 and 31/20 (male and female, respectively), Kuopio province: 46/23 and 36/17, South-West Finland: 53/18 and 36/18, capital area: 44/17 and 29/18, Oulu province: 51/18 and 32/18).
It has to be considered, that the mean BMI of these countries is given for adults of different age groups and are thus not directly comparable. The same categorisation of age group can be seen for Austria and the UK, Finland and Greece, and Germany and Norway.
Health Indicators and Status in the European Union
Blood Lipids Apart from Austrian elderly men, Greek men aged 25–34 years and Greek women aged 25–44 years, the average total plasma cholesterol level in European adults 49
Table 21. Mean BMI in adults of European countries Country/Study
Men
Austria 1998–2001 N Age group, years Mean BMI
407 25–34 23.9 ⫾ 3.7
439 35–49 25.3 ⫾ 3.6
205 50–64 26.5 ⫾ 3.4
813 25–34 22.8 ⫾ 3.7
1,092 35–49 23.5 ⫾ 3.6
245 50–64 24.7 ⫾ 3.7
UK 2000–2001 N Age group, years Mean BMI
227 25–34 26.4 ⫾ 4.1
263 35–49 27.4 ⫾ 4.2
264 50–64 28.4 ⫾ 4.8
213 25–34 25.4 ⫾ 5.0
331 35–49 26.7 ⫾ 5.8
269 50–64 27.4 ⫾ 5.5
Finland 2002 N Age group, years Mean BMI*
734 25–34 25.7–26.1
856 35–44 25.9–27.2
924 45–54 27.0–27.9
1,066 55–64 27.4–28.2
991 25–34 23.1–25.3
1,057 33–44 24.7–26.3
1,076 45–54 25.7–27.5
1,125 55–64 27.5–29.4
Greece 1994–1999 N Age group, years Mean BMI
n.a. 25–34 27.3 ⫾ 3.7
n.a. 35–44 27.8 ⫾ 3.9
n.a. 45–54 28.6 ⫾ 6.5
n.a. 55–64 28.7 ⫾ 3.9
n.a. 25–34 25.4 ⫾ 5.0
n.a. 35–44 27.0 ⫾ 5.1
n.a. 45–54 29.0 ⫾ 5.2
n.a. 55–64 30.3 ⫾ 5.1
Spain 2000 N Age group, years Mean BMI
n.a. 25–34 24.9 ⫾ 3.4
n.a. 35–44 26.1 ⫾ 3.4
n.a. 45–54 26.8 ⫾ 3.7
n.a. 55–60 27.1 ⫾ 3.4
n.a. 25–34 23.2 ⫾ 3.6
n.a. 35–44 25.1 ⫾ 4.2
n.a. 45–54 27.5 ⫾ 4.6
n.a. 55–60 28.4 ⫾ 4.7
Germany 1998 N Age group, years Mean BMI
n.a. 20–29 25.0 ⫾ 3.6
n.a. 30–39 26.4 ⫾ 3.8
n.a. 40–49 27.5 ⫾ 3.7
n.a. 50–59 28.0 ⫾ 3.8
n.a. 20–29 23.7 ⫾ 4.2
n.a. 30–39 24.8 ⫾ 4.7
n.a. 40–49 26.2 ⫾ 5.0
n.a. 50–59 27.6 ⫾ 5.3
Norway 1997 N Age group, years Mean BMI
242 20–29 24.2
263 30–39 25.3
249 40–49 25.5
183 50–59 25.9
263 20–29 22.7
286 30–39 23.5
278 40–49 24.1
188 50–59 24.6
Portugal 2001 N Age group, years Mean BMI
Women
665 ⱖ18 27.3 ⫾ 4.1
853 ⱖ18 26.5 ⫾ 4.7
* Range of BMI from five different Finnish regions (North Karelia, Kuopio province, South-West Finland, capital area, Oulu province); n.a. ⫽ not available.
was above the upper level of 5.2 mmol/l (⫽ 200 mg/dl; table 22) [Beck et al., 2002]. There was no notable difference between men and women. The mean HDL-cholesterol status in European adults was relatively good. 50
Health Indicators and Status in the European Union
Only in Austrian and Greek men, and in men and women of the UK the mean plasma HDL-cholesterol concentration was below the lower level of 1.3 mmol/l (⫽ 50 mg/dl) indicated by Beck et al. (2002). Apart from Greek men aged 45–54 years, the proportion total
Table 22. Blood lipid status (mean ⫾ SD) in European adults Men
Age group (years)
Year of survey
N
Total cholesterol mmol/l plasma
HDL-cholesterol mmol/l plasma
Total cholesterol/HDLcholesterol
LDL-cholesterol mmol/l plasma
Triglycerides mmol/l plasma
Austria Finland France Germany Greece
53–93 25–64 45–60 18–65 25–34 35–44 45–54 55–64 18–ⱖ60 ⱖ18
2002 2002 1994 1979–1991 1994–1999
1992–1994 2001
31 3,543 3,287 16,288 n.a. n.a. n.a. n.a. 1,173 665
5.2 ⫾ 0.9 5.6 ⫾ 1.1 6.2 ⫾ 1.0 5.5 ⫾ 1.2 5.0 ⫾ 1.0 5.3 ⫾ 1.1 5.5 ⫾ 1.1 5.5 ⫾ 1.0 5.7 ⫾ 1.2 5.5
1.1 ⫾ 0.3 1.3–1.4* n.a. 1.2 ⫾ 0.3 1.0 ⫾ 0.3 1.1 ⫾ 0.7 1.0 ⫾ 0.3 1.1 ⫾ 0.4 1.4 ⫾ 0.4 1.2
4.6 n.a. n.a. 4.6 5.0 4.8 5.5 5.0 4.1 4.6
3.4 ⫾ 0.8 n.a. n.a. 3.6 ⫾ 1.0 n.a. n.a. n.a. n.a. 3.6 ⫾ 1.1 3.6
1.4 ⫾ 0.6 1.6–1.8* 1.4 ⫾ 0.9 1.4 ⫾ 0.9 n.a. n.a. n.a. n.a. 2.1 ⫾ 2.2 1.9
25–60 18–75 25–60 18–75 19–64
1990 1992/93 1997 1997/98 2000/01
410 893 394 782 618
5.4 5.3 5.3 5.6 5.2 ⫾ 1.2
1.5 1.4 1.5 1.4 1.1 ⫾ 0.3
3.7 3.6 3.6 4.1 4.9
3.3 3.3 3.5 3.6 4.2 ⫾ 1.2
1.4 1.2 1.4 1.4 –
53–93 25–64 35–60 18–65 25–34 35–44 45–54 55–64 18–ⱖ55 ⱖ18
2002 2002 1994 1979–1991 1994–1999
1992–1994 2001
195 4,223 4,796 7,328 n.a. n.a. n.a. n.a. 1,386 853
5.7 ⫾ 1.0 5.4 ⫾ 1.0 5.9 ⫾ 1.0 5.3 ⫾ 1.1 4.8 ⫾ 1.0 5.1 ⫾ 1.0 5.6 ⫾ 1.1 5.9 ⫾ 1.1 5.6 ⫾ 1.2 5.5
1.4 ⫾ 0.4 1.6–1.7* n.a. 1.5 ⫾ 0.4 1.3 ⫾ 0.3 1.3 ⫾ 0.3 1.3 ⫾ 0.3 1.3 ⫾ 0.3 1.6 ⫾ 0.4 1.5
4.2 n.a. n.a. 3.6 3.7 3.9 4.3 4.5 3.5 3.7
3.6 ⫾ 0.9 n.a. n.a. 3.3 ⫾ 1.0 n.a. n.a. n.a. n.a. 3.6 ⫾ 1.1 3.6
1.4 ⫾ 0.6 0.6–0.7* 0.9 ⫾ 0.5 1.0 ⫾ 0.5 n.a. n.a. n.a. n.a. 1.3 ⫾ 1.3 1.2
25–60 18–75 25–60 18–75 19–64
1990 1992/93 1997 1997/98 2000/01
410 893 394 782 659
5.4 5.3 5.3 5.6 5.3 ⫾ 1.2
1.5 1.4 1.5 1.4 1.3 ⫾ 0.4
3.7 3.7 3.6 4.1 4.1
3.3 3.3 3.5 3.6 4.0 ⫾ 1.2
1.4 1.2 1.4 1.4 n.a.
⬍5.2
⬎1.3
3–5
⬍3.4
⬍2.3
Hungary Portugal Spain** Basque Country Catalonia Andalusia Canary Islands UK Women Austria Finland France Germany Greece
Hungary Portugal Spain** Basque Country Catalonia Andalusia Canary Islands UK Reference value***
* Range of serum HDL and serum triglyceride levels from six different Finnish regions (North Karelia, Kuopio province, South-West Finland, capital area, Oulu province, Lapland); ** men and women; *** ACCC 2002 [Beck et al., 2002]; n.a. ⫽ not available.
cholesterol to HDL-cholesterol was within the recommended normal range in all countries. The plasma LDLcholesterol concentration was on average above the recommended upper level of 3.4 mmol/l (⫽ 130 mg/dl) in European adults. On average, elevated mean levels of triglycerides in the plasma were not found in European adults of any of the countries below.
Health Indicators and Status in the European Union
Mortality The data about mortality of different diseases in the participating countries were taken from the WHO database [WHO, 2003b]. In order to compare mortality rates between the countries, data from 1996 were chosen as this was the only year where data was available for all 51
participants. The mortality rates are indicated in deaths/100,000 persons alive (of the same population group, crude death rates; table 23). Cardiovascular diseases (CVD) are the leading cause of death in industrial countries. The highest rate of deaths in men due to CVD was found in Hungary with 706 deaths/100,000 men alive, followed by Sweden, Greece, Austria and the UK (fig. 24). The lowest mortality in men from CVD was observed in France. In women, the highest mortality rate due to CVD was again
found in Hungary (744 deaths/100,000 women alive), and was followed by Austria, Germany, Sweden and Greece. Apart from Sweden, the mortality rate of cardiovascular disease was higher in women than in men. Figure 24 shows, that this difference is particularly meaningful in Austria and Germany. Cardiac heart disease (CHD) constituted in all countries the biggest part of all CVD. Here again the highest mortality rate in men was observed in Hungary with 425 deaths/100,000 alive, followed by Sweden, Austria,
Table 23. Causes and number of deaths in 1996 in European countries, indicated as deaths/100,000 persons alive (crude death rate) Cause of Death (ICD*)
Total (001–999)
CVD (390–459)
CHD (390 –398, 402, 404, 410–429)
Cerebrovascular disease (430–438)
Diabetes mellitus (250)
Malignant neoplasms (140–208)
Chronic liver disease and cirrhosis (571)
Country Austria
M F
953 1,049
457 624
336 422
94 161
16 25
246 222
37 17
Belgium
M F
1,058 999
357 413
252 279
78 110
11 20
322 224
15 9
Denmark
M F
1,160 1,148
425 431
305 276
88 119
12 12
300 279
19 9
Finland
M F
972 947
413 446
311 298
78 127
9 14
215 178
18 7
France
M F
974 865
280 313
189 202
64 85
10 12
307 189
23 10
Germany
M F
1,023 1,130
440 596
322 399
89 152
22 37
272 248
32 15
Greece
M F
1,030 895
482 503
321 296
147 198
8 10
265 163
8 4
Hungary
M F
1,535 1,284
706 744
425 405
183 211
15 21
388 274
100 34
Italy
M F
1,020 916
396 440
268 279
99 135
26 38
314 213
27 17
Norway
M F
1,022 984
446 445
314 286
101 137
11 12
260 226
8 4
Portugal
M F
1,181 987
428 470
190 183
216 259
26 34
249 164
36 13
Spain
M F
973 820
316 363
208 224
83 114
17 28
282 163
24 11
Sweden
M F
1,075 1,048
521 516
374 333
96 132
18 18
248 222
8 4
UK
M F
1,058 1,104
450 472
326 297
88 144
11 11
281 251
10 6
* International Classification of Diseases, 9th and 10th revision. Source: WHO, 2003b.
52
Health Indicators and Status in the European Union
706
Hungary Sweden
596 516
Sweden
457
Austria
624
Germany
482
Greece
744
Hungary Austria
521
UK
450
Greece
Norway
446
Average*
503 484
Germany
440
UK
472
Average*
437
Portugal
470
Portugal
428
Finland
446
Denmark
425
Norway
445
413
Finland
396
Italy
357
Belgium
280
France 0
440 431 413
Belgium
316
Spain
Italy Denmark
363
Spain Men
100 200 300 400 500 600 700 800
313
France 0
Women
100 200 300 400 500 600 700 800
Deaths/100,000 alive
Deaths/100,000 alive
Fig. 24. Mortality rate (deaths/100,000 alive) from cardiovascular disease in 1996 in European countries. * Average of participating countries. Source of raw data: WHO, 2003b.
the UK and Germany. In women the highest proportion of those dying of CHD was again found in Austria (422 deaths/100,000 alive), followed by Hungary, Germany and Sweden. The mortality rate due to cerebrovascular disease was higher in women than in men in all participating countries. The highest mortality rate in women was found in Portugal (259 deaths/100,000 alive), followed by Hungary, Greece and Germany, the lowest rate in France (85 deaths/100,000 alive). Also in men the highest mortality rate from cerebrovascular disease was found in Portugal (216 deaths/100,000 alive), followed by Hungary and Greece. The lowest rate was again found in France (64 deaths/100,000 alive). Concerning mortality from diabetes mellitus it has to be considered that this issue is very complicated and the results are not always reliable. Diabetes as a cause of death may confer misclassification errors, since the disease is associated to other causes of death. Except for Denmark, the mortality from diabetes mellitus was in the participating countries higher in women than in men. The highest death rates were found in Italy and Germany (38 and 37 deaths/100,000 alive, respectively), the lowest was observed in Greece (10 deaths/ 100,000 alive). In men the highest death rate from
diabetes was found in Italy and Portugal (both 28 deaths/100,000 alive) and the lowest in men was found in Greece and Finland with less than 10 deaths/100,000 alive. Cancer is the second most prevalent cause of death in industrial countries. Many cases of cancer could be prevented by a change of lifestyle, such as quitting smoking, drinking less alcohol and healthy nutrition. In all participating countries the mortality rate due to malignant neoplasms was higher in the male population than in the female population (fig. 25). The highest death rate in men was found in Hungarian men (388 deaths/100,000 alive), followed by Belgium, Italy, France and Denmark. The lowest mortality rate from malignant neoplasm was observed in Finnish men. In women the highest rate was found in Denmark (279 death/100,000 alive), followed by Hungary and the UK, the lowest was found in Spain and Portugal (162 and 163 deaths/100,000 alive, respectively). The lowest mortality rate from chronic liver disease and cirrhosis in both men and women was found in Greece, Norway and Sweden with only 8 and 4 deaths/100,000 people alive, respectively, the highest rate was found in Hungary, also in both men (100 deaths/100,000 alive) and women (34 deaths/100,000 alive).
Health Indicators and Status in the European Union
53
388
Hungary 322
Belgium
279
Denmark
274
Hungary
Italy
314
UK
251
France
307
Germany
248
Norway
226
Average*
282
300
Belgium
224
Spain
282
Austria
222
281
Denmark
Sweden
222
Germany
272
Average*
215
Greece
265
Italy
213
260
France
UK
Norway
189
Portugal
249
Finland
Sweden
248
Portugal
164
Austria
246
Greece
163
Spain
163
Men
215
Finland 0
100
200
300
400
500
178
0
Deaths/100,000 alive
100
200
Women 300
400
500
Deaths/100,000 alive
Fig. 25. Mortality rate (deaths/100,000 alive) from malignant neoplasms in 1996 in European countries. * Average of participating countries. Source of raw data: WHO, 2003b.
Morbidity Incidence of Malignant Neoplasms
More than 10 million people worldwide are diagnosed with cancer each year and it is estimated that there will be 15 million new cases every year by 2020. Cancer causes 6 million deaths every year which is 12% of deaths worldwide. Lung, colorectal and stomach cancer are among the most prevalent cancers worldwide [WHO, 2004]. In the following figures data from the International Agency for Research on Cancer is presented. These data can be found in the publication GLOBOCAN 2000 in which the most recent data on cancer incidence is included. Figure 26 shows that in the participating countries the incidence of malignant neoplasms was higher in men than in women. Further, the order of countries in men and women was different. In men the highest incidence rate of cancer was found in Hungary (577 new cases/100,000 inhabitants), followed by Belgium, France and Italy (532, 517 and 510 new cases/100,000 inhabitants, respectively). The lowest incidence of cancer was found in Finland and Austria (390 and 399 new cases/100,000 inhabitants, respectively). In women Denmark, Hungary, Sweden and 54
Health Indicators and Status in the European Union
Germany (496, 473, 450 and 440 new cases/100,000 inhabitants, respectively) had the highest rates, and Greece and Spain (284 and 290 new cases/100,000 inhabitants, respectively) the lowest ones. Especially in women, a north-south decline can be observed. The highest incidences of stomach cancer were found in men and women of Portugal (47 and 29 new cases/100,000 inhabitants, respectively), followed by Hungary (37 and 25 new cases/100,000 inhabitants, respectively) and Italy (37 and 24 new cases/100,000 inhabitants, respectively; fig. 27). The lowest incidence was observed in Denmark (13 and 8 new cases/100,000 inhabitants, respectively), Sweden and France (both 17 and 10 new cases/ 100,000 inhabitants, respectively). In all countries the proportions of new cases were higher in men than in women. The highest incidence of colorectal cancer was observed in Hungarian and German men (88 and 75 new cases/100,000 inhabitants, respectively) and women (70 and 73 new cases/100,000 inhabitants, respectively). The lowest incidence was found in Greek men (33 new cases/100,000 inhabitants) and women (29 new cases/ 100,000 inhabitants; fig. 28). In general, the proportion
577
Hungary Belgium France
496
Denmark
532
Hungary
473
517
Sweden
Italy
510
Germany
Germany
502
Belgium
414 414
450 440
Sweden
467
UK
Average*
461
Norway
412 404
Norway
446
Italy
Spain
437
Average*
Denmark
434
Finland
429
Austria
UK Portugal
413
France
Greece
402
Portugal
Austria
399
Finland
Men
390 0
100
200
300
400
500
600
393 377 373 357 322
Spain
290
Greece
284
700
0
New cases/100,000 inhabitants
100
200
300
Women 400
500
600
700
New cases/100,000 inhabitants
Fig. 26. Incidence of malignant neoplasms (excl. skin) in European countries indicated as new cases/100,000 inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN 2000 [Ferlay et al., 2001].
Hungary
37
Hungary
Italy
37
Italy
18 16
Average*
23
Greece
21
Greece
UK
21
Belgium
14 13 13
Finland
20
Belgium
21 19
Spain
25
Austria
24
Austria
27
Average*
25
Germany
29
Spain Germany
29
Portugal
47
Portugal
12
Norway
19
UK
Finland
18
Norway
11 10
France
17
France
Sweden
17
Sweden
Men
13
Denmark 0
10
10 Women 8
Denmark 20
30
40
50
60
0
New cases/100,000 inhabitants
10
20
30
40
50
60
New cases/100,000 inhabitants
Fig. 27. Incidence of malignant neoplasm of stomach in European countries indicated as new cases/100,000 inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN 2000 [Ferlay et al., 2001].
Health Indicators and Status in the European Union
55
88
Hungary
73
Germany Hungary
75
Germany
70
Portugal
65
Norway
Denmark
64
Denmark
France
64
Belgium
Italy
64
Sweden
55
Norway
64
Average*
54
Austria
63
France
54
Belgium
63
Austria
53
67 62 59
Sweden
62
UK
53
Average*
61
Italy
52
60
Portugal
UK
33
Greece 0
43
Finland
38
Finland
47
Spain
54
Spain
Men
10 20 30 40 50 60 70 80 90 100 New cases/100,000 inhabitants
41 29
Greece 0
Women
10 20 30 40 50 60 70 80 90 100 New cases/100,000 inhabitants
Fig. 28. Incidence of malignant neoplasm of colon and rectum in European countries indicated as new cases/100,000 inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN 2000 [Ferlay et al., 2001].
of new cases was higher in men than in women, although the difference was not as meaningful as it was in lung or stomach cancer. The highest rates of new cases of breast cancer were found in Germany and Hungary (73 and 70 new cases/100,000 inhabitants, respectively). The difference in lung cancer incidence between men and women was particularly large. The main reason for this probably was the higher amount of smokers in men during the past decades compared to women. However, the amount of smokers in women has noticeably increased during the past years. It is in some regions already approximately as high as in men, or even higher. As the consequences of smoking usually appear several years after starting smoking, the outcome of this high proportion of female smokers will probably be seen in the future. The highest incidence of lung cancer in men was found in Hungary and Belgium (136 and 126 new cases/100,000 inhabitants, respectively), and in women in Denmark and the UK (50 and 45 new cases/100,000 inhabitants, respectively; fig. 29). Sweden (39 new cases/100,000 inhabitants) had the lowest incidence in men, and Spain and Portugal (8 and 10 new cases/ 100,000 inhabitants, respectively) in women. The prevalence of prostate cancer was particularly high in Swedish men with 139 new cases/100,000 inhabitants (fig. 30). 56
Health Indicators and Status in the European Union
In Greece and Spain the lowest incidences of prostate cancer were observed (43 and 46 new cases/100,000 inhabitants, respectively), but also of breast cancer in women (79 and 84 new cases/100,000 inhabitants, respectively). Prevalence of Diabetes The data from the International Diabetes Federation presented in figure 31 shows the prevalence of diabetes (type 1 and 2) in adults of the participating countries. It was derived from the year 2000 and is not separated for men and women. The highest prevalence of diabetes was found in Italy with 7.1% of the total adult population, followed by Hungary (6.6%), and Sweden and Denmark (both 6.1%). The lowest prevalence of diabetes mellitus was observed in the UK with only 3.5% of the total adult population suffering from this metabolic disease, followed by Norway and Austria with 3.5% both.
Physical Activity Physical activity is defined as ‘any bodily movement produced by skeletal muscles that results in energy expenditure’. In order to quantify habitual physical activity different aspects of daily life (domains) in which physical
136
Hungary
126
Belgium
Greece
45 40 29
Norway
101
24
Average*
87
Spain
50
UK Hungary
108
Italy
Denmark
Germany
83
Sweden
24
Average*
82
Germany
22
UK
82
Austria
21
80
Belgium
20
Italy
19 17
France
76
Denmark Austria
60
Finland
Finland
57
Greece
Norway
56
France
52
Portugal
0
20
40
10
Portugal Men
39
Sweden
17 13
60
0
80 100 120 140 160
Women
8
Spain
New cases/100,000 inhabitants
20
40
60
80 100 120 140 160
New cases/100,000 inhabitants
Fig. 29. Incidence of malignant neoplasm of the lung in European countries indicated as new cases/100,000 inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN 2000 [Ferlay et al., 2001].
139
Sweden Finland
116 111
Norway
France
98
Germany
94 81
Average*
61
Denmark
20
40
60
123 116 111 109
Hungary
106
Austria
105 104 84
Greece Prostate
43 0
Germany
Portugal
46
Spain Greece
123
Norway
54 51
Italy
123
France
Italy
65
Hungary
Finland
Average*
74
UK Portugal
131
UK
77
Austria
134
Sweden Belgium
103
Belgium
136
Denmark
80
100 120 140 160
79
Spain
Breast
74 0
New cases/100,000 inhabitants
20
40
60
80
100 120 140 160
New cases/100,000 inhabitants
Fig. 30. Incidence of malignant neoplasm of the prostate and breast in European countries indicated as new cases/100,000 inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN 2000 [Ferlay et al., 2001].
activity takes place need to be recognised. These domains usually include: occupational physical activity, transport or moving from place to place, household chores, gardening, and leisure time and recreational physical activity,
which includes exercise. Exercise is defined as ‘a subset of physical activity that is planned, structured, and repetitive bodily movements done to improve or maintain one or more components of physical fitness’.
Health Indicators and Status in the European Union
57
7.1
Italy Hungary
6.6 6.4
Sweden* Denmark*
6.1
Spain*
6.1 5.9
Greece Finland*
5.5 5.4
Portugal Germany
4.2 4.1
Belgium
4
Austria
3.8
Norway
3.8 3.5
UK 0
1
2
60 50 40 30 20 10 0
5
35 16
6
7
21
33
8
9
10
16
22 20
38
37
23 14
2 3
Men–Vienna
Exercise Habits In some participating countries, data about exercise habits (only) were available. The methods used for the assessment of physical activity or exercise and the way of data presentation were not comparable between these countries. The data will thus not directly be compared to each other, but a general overview about the level of physical activity will be given. The Eurobarometer 58.2 (EU DG PRESS, 2002) included physical activity. It used the International Physical Activity Questionnaire (IPAQ), which is an international measure for the total amount and pattern of physical activity, but the data analyses are not yet finalised and reported. In Austria the frequency of exercise was asked in a survey among adults. The sample was divided into adults 58
4
50
Daily
Fig. 32. Frequency of physical activity in Austrian adults (rounded values).
3
% of total population
% of adult population
Fig. 31. Prevalence of Diabetes in adults of European countries (male and female). * Crude value. Source: International Diabetes Federation, 2004.
France
Health Indicators and Status in the European Union
12
20 17 15 8 0
3–5x/week Men–Federal states
1–2x/week Women–Vienna
1–2x/month
Less/Never
Women–Federal states
living in Vienna, and adults from all other Austrian federal states. Viennese men seemed to be physically more active than those of the federal states (fig. 32). 34.7% of those living in Vienna indicated exercising 3–5 times per week and 49.7% 1–2 times per week, compared to only 16.3 and 23.1%, respectively, of those living in the federal states. About 20% of men of the federal states indicated doing exercise less than 1–2 times per months or not at all. The physical activity data for Finland were assessed in the course of a health behaviour study carried out in 2003 [Helakorpi et al., 2003]. The proportion of people doing regular exercise (at least twice a week) is relatively high in Finland. Apart from the first age group (15–24 years) the proportion of women doing regular exercise is higher than in men (fig. 33).
% of population group
Men
% of total sample
Fig. 33. Proportion of Finnish adolescents and adults practicing physical exercise in their leisure time at least twice a week.
60 50 40 30 20 10 0
Men
Irregular
Walks⬎1hour/day (or equivalent activity)
Fig. 34. Amount of physical activity in a non-representative sample of French adults (rounded values).
Fig. 35. Frequency of physical activity in Norwegian adolescents and adults.
% of adolescent and adult population
In France, the physical activity of adults was asked in the SU.VI.MAX Study, an intervention study performed with a non-representative sample. The results show that the exercise level of this sample was on average higher in men than in women (fig. 34). About 24% of the examined men and 27% of the women indicated not doing regular physical exercise. Results of the National Health Survey 1998 (BundesGesundheitssurvey 1998) in German adults aged 18–79 years show that 43.8% of the male and 49.5% of the female population did not do any exercise in their spare time at all. Only 10.5% of men and 5.1% of women were physically active for more than 4 hours a week, 13 and 10.3%, respectively, did between 2 and 4 hours of exercise a week. The proportion of inactive people
40 35 30 25 20 15 10 5 0
Health Indicators and Status in the European Union
68
64 55
25–34 years
60
Women
64
68
55
49
35–44 years
45–54 years
55–64 years
significantly increased with increasing age [Mensink, 1999]. Compared to other European countries, Norwegian women aged 16–79 years were physically more active than their male compatriots of the same age (fig. 35). 62% of the examined sample was physically active at least two times a week, in men it was 53%. Only 5% of the Norwegian women and 12% of the Norwegian men were not regularly exercising. In Portugal the proportion of inactive individuals among adolescents and adults was high, especially in women of whom 70% indicated not doing any physical exercise at all, also about half of the male sample was physically inactive (fig. 36). Those who were doing sports seemed, however, to be fairly active. Most of them started doing more than 3.5 hours of physical exercise a week. Especially in men this proportion was with 40% high. In the UK more than two thirds of the adult population was fairly or very physically active (fig. 37). Only 5% of men and 6% of women were not at all physically active. About one quarter of men and women were not very physically active. Apart from the category very physically active there was hardly any difference between men and women. According to figure 38, only a limited minority of men and women in the Greek population are regularly
25
Walks⬍1hour/day (or equivalent activity)
62
15–24 years
38
36 24
69
52
Women 27
80 70 60 50 40 30 20 10 0
35
Men
Women
28 17 12
18 19 14
13
15
12 12
5 Never
⬍1x/week
1x/week
2–3x/week
4–6x/week
Every day
59
% of adolescent and adult population
80 70 60 50 40 30 20 10 0
70
Men
Women
50 40 21 3
8
3
⬍1.5 hours/ week
0 hours/ week
7 ⬎3.5 hours/ week
1.5–3.5 hours/ week
% of adult population
Fig. 36. Weekly hours spent on physical activity in Portuguese adults and adolescents (rounded values).
60 50 40 30 20 10 0
Men
51
Women 23
Smoking
52
24
21
17
6
5
Not at all Not very physically active physically active
Fairly physically active
Very physically active
% of population group
Fig. 37. Level of physical activity in adults of the UK [Henderson et al., 2003c].
Men (total) Men RIAA
25 20 15
20 13
11,545 1,147
Women (total) 16,469 Women RIAA 1,235
13 10
12 11
10
7 5
5
7
5 2
3
65–74 years
75 ⫹ years
0 25–34 years
35–44 years
45–54 years Men
55–64 years Women
% of adult population
Fig. 38. Percentage of Greek men and women regularly involved in some athletic activity (RIAA) by age group. Source: EPIC Newsletter Issue 3, 2002.
100
Men
80
66
Women
73
60 40 20
17
18
17
9
0 Insufficiently active
Sufficiently active
Highly active
Fig. 39. Level of physical activity in Spanish adults (Catalonia).
60
involved in some athletic activity. The higher levels of RIIA observed in the eldest group of the EPIC cohort may be due to the selected survival of persons regularly involved in some athletic activity Figure 39 shows that 17% of Catalan men and 18% of Catalan women were insufficiently physically active. 66% of men and 73% of women were sufficiently active, and 17 and 9%, respectively, were highly active. According to this table, the Catalan population was fairly active.
Health Indicators and Status in the European Union
Some of the participating countries had available data on smoking habits. These data show a high proportion of smokers in the examined populations. It was particularly high in Spain and Greece (men), as well as in adults and adolescents of Vienna (Austria; fig. 40). The lowest percentage of smokers was observed in a French study. It has however to be considered that these data were derived from an intervention study and was not representative for the French population. Also the proportion of ex-smokers was considerable in the participating countries, here again particularly in the sample of the intervention study in France. Apart from Norway and France, the proportion of smokers was clearly lower in women compared to men (fig. 40). The highest proportion of women smokers was found in Norwegian and Austrian (Vienna) women with more than 36%, the lowest in women of the French study sample. The amount of ex-smokers in women was particularly high in the French sample, but also in Austrian women living in Vienna. When comparing these data it has to be considered that it was acquired in different years. Figure 41 shows that the proportion of smokers in the European Union increased from 33.9% in 1995 to 39.4% in 2002. Only three countries (Denmark, the Netherlands and Belgium) observed a decrease in the percentage of smokers. These countries were three of the four countries with the highest share of smokers in the population in 1995 [46.4, 43.4, 39.9 (Greece) and 38.3%, respectively]. The top four countries in 2002 were the UK, France, Denmark and Greece. The overall EU average increase in the proportion of smokers was 4.8% from 1995 to 2002 [Eurobarometer, 2003].
Men 29
27
25 47
25
** *
7
01
w ay ,1
Sp ai
N or
(e G
G
re
re
ec
ec
e
e
99
00 Ita
ld er
du l (a
4
ry
ly ,2
ga
02
H un
ly ),
20
20
02
8 99 y, 1 an
er G
Fi
Fr
nl
an
an
ce
d* *,
*, 1
), (2 a st ri
Au
20
99
4
02 20
20 ), (1 a st ri Au
42
38
30
23
03
14
50
48
37
26
ts ),
36
m
44
20
51
n,
28
01
% of men
90 80 70 60 50 40 30 20 10 0
90 Women
80 % of women
70 60 50
22
40
15 30 26
28
19
14
* 01 **
ai
ec
Sp
e
N
(e
or
ld
w
n,
ay
20
,1
,2
99
00
7
4
ry ly
ly er
Ita
20 ),
), lts du (a e
ec G
re
re G
02
02 20
98
m er G
an nl Fi
19 an
*, d*
ce an Fr
y,
20
99 *, 1
20 ), (2 ria st
Au
03
4
02
01 20 ), (1 ria
27
23
4 3
0
st
36
30
24
ga
33
10
Au
Fig. 40. Proportion of smokers and ex-smokers in European men and women. Austria: (1) ⫽ Viennese adults, source: Freidl et al., 2001; (2) ⫽ Austrian adults. * Data was derived from an intervention study and is not representative for the whole France. ** Daily smokers. *** Adults and elderly.
9
11
9
un
20
H
30
Smokers
Ex-smokers
50.0 Smoke 1995 Smoke 2002
45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0
Health Indicators and Status in the European Union
P
S
L
I IR L
D
To ta W l es t B
A D
F EU N 15
R N D L O st E
G
K
F DK
0 U
Fig. 41. Comparison of smoking habits in the European Union 1995 and 2002 (% of population). Source: Eurobarometer, 2003.
61
Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 2004. Forum Nutr. Basel, Karger, 2005, vol 58, pp 62–65
General Discussion
The major challenge of the European Nutrition and Health Report was to bring a diversity of data into a consistent form. Due to the low comparability of national data of the participating countries, other sources of nutritional data were taken as well. In the chapter ‘Trends of Average Food Supply in the European Union’, food supply data from the food balance sheets (FBS) of the FAO is presented. One problem of FBS is that only supply can be shown, the per capita consumption cannot be calculated from these data. Further, these data are based on the population level, compared to the household budget surveys (HBS) which are used in the DAFNE project (see chapter ‘Food Availability at the Household Level in the European Union’) and which are based on the household level, and national intake data which are generally based on an individual level. This means that data of the FBS do not show differences between men and women, people of different socioeconomic classes or between different regions. However, a major advantage of the FBS is that the data are comparable between countries for which FBS are available, as uniform methods for their assessment were used by the FAO. Further, trends in food supply can be shown as they have been carried out annually since 1961. As mentioned before, the data used for the chapter ‘Food Availability at the Household Level in the European Union’ were derived from HBS conducted in the countries participating in the DAFNE project. HBS are useful tools for the assessment of food availability at the household level. Differences between households from different socioeconomic classes as well as regional differences can be observed and described by this method. Time trends during the past 20 years can be shown for most but not all participating countries. For this reason only the most recent data were taken from the
participating countries in the current report which also participate in the DAFNE project. This project produces useful data, especially in regard to the ability of showing differences not only between countries, but within different population groups in one country. The supply data gained by FBS and the availability data by household consumption surveys differ from each other. The reason for this difference lies in the nature of the assessment methods. HBS mainly assess the food and beverage available in the household and it is difficult to assess the out-of-house consumption. Agricultural statistics like the FBS of the FAO rely on data from production, imports, stock changes and exports, also considering feed, seed, losses occurring during processing, storage and transportation, and waste and other use [FAO, 2001]. Due to the different nature of these two assessment methods, the average per capita supply calculated from FBS is higher than the average availability of the HBS. The following example on fruit and vegetable availability should highlight another problem. The proportion of availability of some food groups seems to be different from the proportion of their supply according to FBS. Figure 42 shows how much the fruit supply/availability differs from the average vegetable supply/availability (data of the countries was taken from the same survey years). Here we can see that in some countries, for example Austria and Finland, this difference is comparable between data from FBS and HBS. However, some countries – especially those from South Europe – show very different trends, depending on the assessment method. In Spain for example the average per capita fruit supply calculated from FBS is 40% lower than the average per capita vegetable supply, whereas based on the HBS the availability is 61% higher. The reasons for this might be various (e.g. different definitions of food
80
63 36 35
40
17
3
Availability2
Intake3
353 262
192 142
183 148
Supply data derived from the FAO Food Balance Sheets data, for Austria 2000. Availability at the household level; data derived from DAFNE database, for Austria 1999–2000. Intake data at the individual level, data derived from nutritional assessments accomplished in Austrian adults (19–60 years) 1998– 2001.
groups, different assessment methods etc.). Further, in HBS the vegetable and fruit consumed outside the household might be difficult to assess. Table 24 highlights again that the data about fruit and vegetable supply for example, which are very approximate, do reflect neither the real availability at household level nor the real intake of these food groups (this example was made for Austria). This table makes clear that, although the average supply of fruit and vegetables was above the recommended intake of 400 g fruit and vegetables per day [Eurodiet, 2000; WHO, 2003], it does not automatically indicate a sufficient intake. In Austria for example, the intake was still too low, although the average supply was relatively high. Thus the supply data of the FAO have to be treated cautiously. Although an increasing trend in fruit and vegetable supply was observed, it cannot be regarded as sufficient. The availability data at the household level from the DAFNE database do not notably differ from the intake data at the individual level.
19
U K
l ga rtu
⫺29
Po
w ay
ly
⫺28
N or
ga
ec re
ry
e
⫺21 ⫺28 ⫺33
H un
d G
an nl
ce an Fr
Sp ai
m er G
Supply1
General Discussion
an
st ri Au
Table 24. Fruit and vegetable supply, availability and intake in Austria
2
y
a
⫺80
⫺39
⫺40
n
⫺40
⫺60
1
24
⫺2
⫺16
⫺40
Fruits g/day Vegetables g/day
27 13
Ita
0 ⫺20
Fig. 42. Average deviation of fruit and vegetable supply (FBS, FAO) and availability (HBS, DAFNE project).
28
HBS
1
Fi
%
20
FBS
63
61
60
The data from chapters ‘Trends of Average Food Supply in Europe’ and ‘Food Availability at the Household level in the European Union’ are based on standardised methods. Thus, between countries comparability is given in general. In contrast, the data used in the chapter ‘Energy and Nutrient Intake in the European Union’ derived from national assessments made in the participating countries. There are some reasons why it is difficult to directly compare these data. First of all, different methods for the assessment of dietary data was used (e.g. 3-day-record, 7-day-record, 24-hour-recall, HBS, food frequency questionnaire etc.). These methods have in general different sources of error and lead to more or less exact data. The method used depends in general on the sample size and the amount of money available. Also the exactness of each single method depends on the sample size, on the staff carrying out the assessment, and also on the period of assessment. In general, an assessment should take place during a whole year, in order to consider seasonal fluctuations. Another reason for a limited comparability of the presented nutrient intake data is the fact that the national surveys were carried out during different years. The diet of a population can considerably change during one decade. This means that differences in nutrient intake between two countries with data from the early 1990s and from recent years, respectively, can be due to the various times of assessment. Further, for the presentation of assessed nutrient intake data, different age groups were used in different countries. If the raw data is available, the age group is not necessarily a problem. In the case of the European Nutrition and Health Report, raw data were not available from most of the participating countries. Thus, intake data of predetermined age groups had to be taken. Especially in children, 63
the dietary intake changes considerably with increasing age, thus nutrient intake data of countries which used different age groups cannot be directly compared. The sample representativeness was not always given, which can influence the comparability as well. Further, different databases for the calculation of nutrient intake data were used. In order to obtain comparable data between European countries… – … a standardised dietary assessment method should be used (e.g. repeated 24-h-recall) among all countries. – … the assessment should be carried out in a given time period in all participating countries. – … the assessment should take place during a whole year in order to avoid seasonal fluctuations. – … uniform age groups should be used. – … the sampling method should be standardised between all countries. – … a standardised database for the calculation of nutrient intake should be used among all countries. – … the data should be representative for the target population. Another problem about the national data was that not all data from the participating countries were representative. Some data (e.g. of France) were even derived from intervention studies. The representativeness is important in order to be able to characterise the nutritional habits of a population or population group. For the description of health and nutrition status in Europe (see chapter Health Indicators and Status in the European Union) different data sources were used. For the description of prevalence of overweight and obesity in this report, nationally assessed data from the participating countries – where available – were used. The body mass index (BMI ⫽ kg body weight/m2 body height) was taken as a measure of overweight and obesity, calculated from height and weight of the participants. One major problem of the here presented data was, that some countries used BMI data calculated from self-reported height and weight, whereas in other countries measurements were accomplished. Studies show that there can be a considerable difference in the prevalence of overweight and obesity calculated from selfreported or measured data. In the National Nutrition Survey 1995 in Australia for example the BMI based on 64
General Discussion
self-reported data classified 52% of males and 36% of females as overweight, compared with 64 and 47%, respectively, from measured data [NSW Centre for Public Health Nutrition, 2000a]. Another problem was that the cut-off points used were partly not uniform either. For example Spain used as cut-off point for overweight in children the 85th percentile, whereas most other countries chose the 90th percentile as borderline between normal and overweight.
– For the assessment of prevalence of overweight and obesity in European countries, a standardised method should be used (whether self-reported or measured height and weight). – Data from measured height and weight are more accurate (presuming the use of standardised instruments), but their assessment is more expensive and time-consuming than calculated from self-reported data. – Uniform cut-off points should be chosen. The mortality and morbidity data were taken from sources which have comparable data between countries, such as the WHO (2003b) and GLOBOCAN 2000 [Ferlay et al., 2001]. Only some of the participating countries had data about physical activity. None of these data were comparable due to different assessment methods and different way of presentation (see chapter Health Indicators and Status in the European Union, section Physical Activity). This means that a conclusion concerning physical activity in the participating countries cannot be made. In future projects a standardised method for assessing physical activity among a population group has to be used, in order to allow a description of amount and degree of physical activity and a between-countries comparison.
– In order to allow a between-countries comparison of the amount of physical activity, a standardised method for its assessment has to be used. An example of a standardised questionnaire is the IPAQ (International Physical Activity Questionnaire) of which a short and a long form exists, and which is also being used outside the EU [Public Health Information Development Unit, 2000].
Also the data about smoking were hardly comparable, as they were from different years and the assessment method was on general not indicated. Most of the smoking data were assessed in the course of a nutritional survey or were taken from statistical offices. Also for the assessment of smoking habits standardised methods should be used, which can be included in a nutritional survey.
– A standardised method for the assessment of smoking habits of a population should be used in order to obtain comparable data. The assessment of smoking habits can be made in the course of a nutritional survey.
General Discussion
Many data about nutrition and health issues exist in the participating countries. However, a main goal for the future would be to accomplish standardised assessments in order to obtain comparable data. Therefore it would be important, that professionals in the field of nutrition and health should work on the development of such standardised methods, and that those methods would be used for future surveys by all European countries. Different projects are being developed, for example by the ECHI project (2004) or the EFCOSUM group [EFCOSUM, 2002]. Still, there is a lot to be done. Finally it has to be mentioned that some data were only available for few countries and were thus not included in the general part but only in the national reports (such as vitamin status, blood pressure etc.).
65
Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 2004. Forum Nutr. Basel, Karger, 2005, vol 58, pp 66–212
Annexes
Illustrations of Food Supply Data, Based on FBS Data Legend for the figures on the following pages: EU
(European Union)
A
(Austria)
BL
(Belgium/Luxembourg)
D
(Germany)
DK
(Denmark)
E
(Spain)
F
(France)
FIN (Finland) GR
(Greece)
H
(Hungary)
I
(Italy)
N
(Norway)
P
(Portugal)
S
(Sweden)
UK
(United Kingdom)
200 180 160 GR I P A E, D EU N S
Fruits (kg/capita/year)
140 120 100
F, DK FIN, UK BL
80
H
60 40 20 0 1961
1996
1971
1976
1981
1986
1991
Year
Fig. 43. Average per capita supply of fruits in the participating countries. Source of raw data: FAO, 2003.
1996
2001
400 350
Vegetables (kg/capita/year)
300 GR
250 200
P I E
150
BL F, EU H DK, A D, UK S, FIN N
100 50 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 44. Average per capita supply of vegetables in the participating countries. Source of raw data: FAO, 2003.
160
140
P
Potatoes (kg/capita/year)
120
BL UK
100
E, DK EU, D GR FIN, N A, H, F
80
60
S
40
I
20
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 45. Average per capita supply of potatoes in the participating countries. Source of raw data: FAO, 2003.
Annexes
67
200 180 I
Cereals (kg/capita/year)
160
GR
140 P N, DK, H
120
A, F, EU FIN BL S, UK, D, E
100 80 60 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 46. Average per capita supply of cereals in the participating countries. Source of raw data: FAO, 2003.
70
Sugar and sweeteners (kg/capita/year)
60 BL DK, H, A S N, D
50
F EU, UK FIN GR, P E I
40
30
20
10
0 1961
1966
1971
1976
1981
1986
1991
1996
Year
Fig. 47. Average per capita supply of sugar and sugar products in the participating countries. Source of raw data: FAO, 2003.
68
Annexes
2001
10
Pulses (kg/capita/year)
8
UK
6
E I GR P EU
4
H BL
2
0 1961
F S, D FIN DK, N A
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 48. Average per capita supply of pulses in the participating countries. Source of raw data: FAO, 2003.
18 16 GR
Oilcrops (kg/capita/year)
14 12 10 8 6
E UK EU, D, A I, BL, S F, P DK N, H, FIN
4 2 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 49. Average per capita supply of oilcrops in the participating countries. Source of raw data: FAO, 2003.
Annexes
69
35
30
Vegetable oils (kg/capita/year)
E, GR I
25
BL D EU
20 UK F A, S, P H N
15
FIN
10
DK
5
0 1961
1966
1971
1976
1981 Year
1986
1991
1996
2001
Fig. 50. Average per capita supply of vegetable oils in the participating countries. Source of raw data: FAO, 2003.
50
40 Animal fats (kg/capita/year)
H
30 DK BL D
20
F A S N EU P FIN, I
10
UK E GR
0 1961
1966
1971
1976
1981
1986
1991
Year
Fig. 51. Average per capita supply of animal fats in the participating countries. Source of raw data: FAO, 2003.
70
Annexes
1996
2001
120
Red meat (kg/capita/year)
100
DK A E
80 GR, F I, EU D, BL P S FIN N, H, UK
60
40
20
0 1961
1966
1971
1976
1981 Year
1986
1991
1996
2001
Fig. 52. Average per capita supply of red meat in the participating countries. Source of raw data: FAO, 2003.
40
Bovine meat (kg/capita/year)
30 F DK I GR BL N, S A, EU FIN UK
20
E, P D
10
H
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 53. Average per capita supply of bovine meat in the participating countries. Source of raw data: FAO, 2003.
Annexes
71
100
80
Pork (kg/capita/year)
A DK E
60 D EU, H I, P BL F S, GR FIN
40
UK N
20
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 54. Average per capita supply of pork in the participating countries. Source of raw data: FAO, 2003.
Mutton and goat meat (kg/capita/year)
20
15 GR
10
E P UK
5
F P, EU
0 1961
BL, I A, DK D, S, H FIN
1966
1971
1976
1981
1986
1991
1996
Year
Fig. 55. Average per capita supply of mutton and goat meat in the participating countries. Source of raw data: FAO, 2003.
72
Annexes
2001
40
35 H
Poultry (kg/capita/year)
30
UK P, F E
25 BL EU DK GR I, A
20
15
D FIN S
10 N
5
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 56. Average per capita supply of poultry in the participating countries. Source of raw data: FAO, 2003.
90 80
Fish and seafood (kg/capita/year)
P
70 60 N
50
E
40 FIN F, S
30
DK, EU GR, FIN BL, UK
20
D, A
10 H
0 1961
1966
1971
1976
1981 Year
1986
1991
1996
2001
Fig. 57. Average per capita supply of fish and seafood in the participating countries. Source of raw data: FAO, 2003.
Annexes
73
450 400 S, FIN
Milk excl. butter (kg/capita/year)
350 300
A F, N DK I, EU, GR, D BL, UK, P
250 200
H E
150 100 50 0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 58. Average per capita supply of milk (excluding butter) in the participating countries. Source of raw data: FAO, 2003.
25
Eggs (kg/capita/year)
20 H DK F
15
BL, A, S, EU D, I, E P, UK N GR FIN
10
5
0 1961
1966
1971
1976
1981
1986
1991
Year
Fig. 59. Average per capita supply of eggs in the participating countries. Source of raw data: FAO, 2003.
74
Annexes
1996
2001
160
Beer (kg/capita/year)
140
120
DK A D
100
BL UK FIN EU H E P S
80
60
N
40
GR F I
20
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 60. Average per capita supply of beer in the participating countries. Source of raw data: FAO, 2003.
140
120
Wine (kg/capita/year)
100
80
60 I, F P
40
E DK, EU, H A GR, BL D UK, S N FIN
20
0 1961
1966
1971
1976
1981
1986
1991
1996
2001
Year
Fig. 61. Average per capita supply of wine in the participating countries. Source of raw data: FAO, 2003.
Annexes
75
Annex DAFNE Project The DAFNE Project Antonia Trichopoulou1, Androniki Naska1, 1 1 1 Economou E , Foukas V , Tsiotas K and Chloptsios Y1 on behalf of the DAFNE network*. * Participants of the DAFNE Network (only for the countries and datasets presented in this report) Austria Institute of Nutritional Sciences, University of Vienna I. Elmadfa, H. Freisling, A. Suchomel Belgium University of Gent, Faculty of Agricultural and Applied Biological Sciences, Department of Food Technology and Nutrition A.M. Remaut – de Winter, A.P. Cueto Eulert National Institute of Statistics, Brussels Staff from the Household Budget Survey Unit. Finland Statistics Finland, Helsinki, Finland M.A. Berg, A. Pajunen National Public Health Institute, Helsinki, Finland T. Hirvonen France Unite Observatoire des Consommations Alimentaires, AFSSA J.L. Volatier, J. Maffre Germany Lehrstuhl für Wirtschaftslehre des Haushalts, Technische Universität München, TUM, Weihenstephan G. Karg, K. Gedrich, K. Wagner Greece (coordinating centre) Department of Hygiene and Epidemiology, School of Medicine, University of Athens A. Trichopoulou, A. Naska, E. Economou, V. Foukas, K. Tsiotas, Y. Chloptsios National Statistical Office, Athens Douros, I. Tsaousi 1
Department of Hygiene and Epidemiology, School of Medicine, University of Athens
76
Annexes
Hungary National Institute of Food Hygiene and Nutrition, Budapest Zajkas, M. Korom Central Statistical Office, Department of Living Standards and Human Resources Statistics, Budapest Szivos Italy National Research Institute for Food and Nutrition A. Turrini, S. Martines Italian Statistical Office (ISTAT) S. Barcherini Norway Institute of Nutrition Research, University of Oslo K. Trygg, K. Lund-Iversen Statistics Norway, Oslo E. Mork Portugal Faculty of Nutrition and Food Sciences University of Porto M.D. Vaz de Almeida, S. Rodrigues Spain Departamento de Nutricion y Bromatologia, Facultat de Farmacia, Universidad Complutense de Madrid O. Moreiras, C. Cuadrado Instituto Nacional de Estadistica, Madrid M.L. Boned, P. Seoane Spiegelberg United Kingdom King’s College London, Department of Nutrition and Dietetics, London Nelson, S. Burr Ministry of Agriculture, Fisheries and Food, National Food Survey Branch, London D. Rimmer Monitoring the nutritional status of the population, tracking dietary patterns and trends in food habits, and developing ways to translate knowledge into plans for action are integral parts of the policymaking cycle. At both the national and international level, a nutrition policy aims at formulating dietary guidance; pursuing progress toward nutrition and health targets; applying the principles of food quality and safety in daily nutrition practice and at setting nutrition research priorities.
International nutrition surveillance programmes should rely on data collected through dietary surveys undertaken at regular time intervals, among nation-representative population samples and with the same methodology or with methodologies similar enough to allow comparisons. Nevertheless, recent efforts to evaluate the comparability of food intake data in Europe have agreed upon a lack of internationally comparable data. Various dietary assessment and quantification methods are used to collect data at an individual level, whereas differences in age groups’ definitions and in statistical methods further reduce the potential of collating the findings [JH Brussaard et al., 2001]. Countries interested in comparing their national nutrition patterns with those of other populations and countries with no routine food intake survey have traditionally used the Food and Agriculture Organisation assembled food balance sheets, which describe the current and developing structure of the national dietary patterns, in terms of the major food commodities that disappear from the national markets (www.fao.org). Comparable between-countries information on food availability can also be provided by data collected in the household budget surveys (HBS). The HBS can be thought of occupying a position between the food balance sheets and the specially designed individual nutrition surveys. Like food balance sheets, the HBS allow between-country comparisons at a regular basis but, moving from total population to household level, the HBS can provide a more detailed and valid description of the dietary choices of the population, as well as of population sub-groups defined on account of their demographic and socioeconomic characteristics. In Europe, there is a need for collaborating efforts on standardising and collecting comparable dietary data. The establishment of a framework for monitoring dietary trends and for defining public health nutrition priorities is accentuated as an objective of the Health and Consumers Protection Directorate of the European Commission (EC). In this context, a series of EC funded projects have been implemented aiming at the development of an efficient way of using food and related data already collected in the aforementioned HBS.
The Data Food Networking (DAFNE) Initiative The exploitation of the HBS-derived data for nutritional purposes has been evaluated and implemented in the context of the DAFNE initiative. The DAFNE project
Annexes
is exploiting food, demographic and socioeconomic data collected in the national HBS, in order to develop a costeffective food databank that allows monitoring food availability within and between European populations, based on comparable information, also assuring continuity over time. The DAFNE initiative is coordinated by the Department of Hygiene and Epidemiology of the University of Athens Medical School and currently implicates 16 European countries (namely Austria, Belgium, Finland, France, Germany, Greece, Hungary, Italy, Ireland, Luxembourg, Norway, Poland, Portugal, Spain, Sweden and the UK). In December 2004, a new phase of the project will be initiated aiming at integrating data from five new EU Member States (Cyprus, Latvia, Malta, the Slovak Republic and Slovenia); and, within the next year, data from three Balkan Countries (Albania, Bulgaria and Croatia) will be provided to the DAFNE coordinating centre for further analysis. Since the early results of the DAFNE initiative, it became evident that the post-harmonisation of the HBS data is both feasible and purposeful. Hence, the DAFNE databank has been acknowledged as a tool to track trends in dietary practices, to identify population subgroups whose dietary habits are not favourable according to the current scientific knowledge, and to outline preventive interventions in order to support consumer choices toward a healthy nutrition.
The DAFNE Methodology Data Collection in the National Household Budget Surveys Household budget surveys collect data on food availability among nationally representative samples of households. The members of the participating households are asked to record all food purchases, contributions from the household’s own production and the food items offered to members as gifts (often referred to as contribution in kind). Within the EU, the recording period for food acquisitions generally refers to fourteen days and data collection is accomplished within one year, with due attention to capture seasonal variation in food intake. Trained interviewers visit the households regularly to assure complete data recording. Moreover, the recording of information on the socioeconomic characteristics of the household members further allow exploratory analyses on social disparities in dietary choices [Trichopoulou A, 1992]. 77
Post-Harmonisation of the Food, Demographic and Socioeconomic Information The national datasets and their file descriptions are forwarded to the DAFNE coordinating centre in Athens. Data are cleaned, managed and stored following standard procedures [Trichopoulou A et al., 2003]. The postharmonisation process includes the establishment of operational criteria for the classification of food and socio-demographic variables, iterative cross-coding, as well as several working group meetings and bilateral sessions to address specific problems. The aftermath of the harmonisation procedure is the development of the DAFNE Food Classification System, which allows the categorisation of HBS-collected food data into 56, common between countries, detailed sub-groups, which can be further aggregated at various levels ending up at 15 main food groupings [Lagiou P et al., 2001]. With respect to demographic and socioeconomic factors, focus is, up to now, put on the locality of the dwelling (classified as rural, semi-urban and urban), the educational level of the household head (classified as elementary, secondary and higher education), the occupation of the household head (categorised as manual, non-manual, unemployed and retired), and on the household composition, defined on the basis of the number and the age of the members. Calculation of the Average, Daily Individual Food Availability Analyses are conducted separately for each of the participating countries. Food availability per person per day is calculated by dividing the household availability by the product of the referent time period and the household size. Individual availability was estimated without making allowances for the proportion of food that was edible and under the assumption of equal distribution of food within the household and during the survey period. Lastly, a weighting factor is incorporated in the formula, whenever necessary, to accommodate the sampling scheme. Descriptive statistics are calculated to depict the nutritional habits of the European populations and of population sub-groups, defined on the basis of their socioeconomic characteristics.
The DafneSoft Application Tool Results on the mean daily food availability, based on the DAFNE data, are currently accessible by any 78
Annexes
interested user through the DafneSoft (version 2.1, freely downloaded at: www.nut.uoa.gr). The DafneSoft is a window-environment software application tool, which allows the presentation of DAFNE data in various formats (tables, bars, pie charts, map presentations) and at various level of detail, ranging from the analytical national food codes to the common between-countries DAFNE food groups. The tool currently provides access to the DAFNE data of 46 HBS undertaken during the last 20 years in 13 European countries, allowing thus the follow-up of trends in food availability within and between populations. Lastly, all data retrieved can be exported for potential use. The DafneSoft is a non-static application tool with built-in mechanisms for continuity overtime, exploiting thus the core advantages of the DAFNE data on which it is based. An update of the current DafneSoft will take place in December 2004. In addition to more recent datasets from several participating countries, the new version will also include data from Austria, Finland and Sweden.
Discussion of Results Following the advice of the coordinators of the European Nutrition and Health Report project, the information presented in the chapter entitled Food availability at the household level in the European Union. On the Basis of Household Budget Surveys, Data Retrieved from the DAFNE Databank, refers only to countries that also participate in the project. Thus the data presented refer to 12 out of the 16 countries of the DAFNE network and results are only presented based on the most recent dataset available in the database. From these twelve countries, four are South European (Greece, Italy Portugal and Spain), five are Central European (Austria, Belgium, France, Germany and Hungary) and three are North European (Finland, Norway and the UK). It should however be borne in mind, that the DAFNE databank can provide information for additional European countries and, even more importantly when it comes to nutrition monitoring, the available data can be spanned over time. From the socioeconomic indicators available in the DAFNE databank, we have chosen to present the effect of the household head’s education on daily dietary practices. Education has been reported as the strongest and most consistent indicator in assessing socioeconomic differences [Liberatos, 1988]. Education expresses not
only the individual’s attainment and years of schooling, but it might also reflect occupation, income and, even more importantly, the way people perceive and apply current nutritional advice [Johansson et al., 1999]. Information on the educational level of the household head was available only for ten out of the twelve countries studied. Our findings on how education affects food availability agree well with recent observations that low educational level, and by extension low socioeconomic status, was generally associated with increased consumption of sugar products, potatoes, cereals (including bread), meat and meat products and lower consumption of fresh fruit [Hulshof et al., 1991; Smith and Baghurst, 1992; Roos et al., 1996; Johansson et al., 1999; IralaEstevez et al., 2002]. However, it was observed that lower educational levels were associated with higher availability of fresh fruit in Southern European countries. The observation that fresh vegetable and legume availability decreased with the educational level of the household head may reflect the adherence of less educated Southern households to traditional dietary choices. The data retrieved from the DAFNE databank supported previous findings on disparities in food habits among the various European regions. Household budget surveys, on which the DAFNE data are based, provide regularly updated dietary data that can be linked to socio-demographic indicators and are undertaken in nationally representative population samples. Since, however, they are not primarily designed to collect nutritional information, the food data have limitations which need to be taken into consideration [Southgate DAT, 1991;Trichopoulou A, 1992]. Thus in most cases, no records are collected on the type and quantity of food items and beverages consumed outside the home. With the exception of the UK where data on the out-of-home consumption have been recorded since 1992, the majority of the European countries collect data only on expenses related to this food occasion. Lastly, the HBS data are collected at household level and estimation of the individuals’ intake requires the application of nonparametric modelling. The DAFNE coordinating centre, in conjunction with maintaining and upgrading the database, has also been running a number of smaller projects in order to study the limitations of the HBS data and evaluate their effect in the interpretability of the findings. Hence the Athens coordinating centre has applied and validated a model for individualising the HBS data. The compatibility of the DAFNE individualised data with food intake data
Annexes
collected through specially designed individual dietary surveys was evaluated in four European countries (Belgium, Greece, Norway and the UK), in the context of the FAIR-3096 project. The results showed that both datasets, given the inconsistencies present in both, are compatible, when studying the food habits of the populations [Trichopoulou and Naska, 2002]. Currently the DAFNE participants are working towards the development of a methodology for estimating nutrient availability based on HBS data. A protocol has also been compiled on how to collect information on meals taken out of home. Bearing in mind the above conditions, the HBSderived data stored in the DAFNE databank offer a realistic option for monitoring diet in Europe and identifying important determinants of people’s dietary choices. The application of the DAFNE methodology in harmonising and standardising the HBS data can constitute a reasonable alternative to specially designed individual-based nutrition surveys. In addition, based on the potential of the DAFNE database, the EU may benefit from the nationally representative sample of the HBS, and conduct an individual dietary survey in a subsample of the population already participating in the HBS. Thus HBS data will provide the first overview of the population dietary habits, which will, at a second phase, be studied in more detail using the individual dietary survey data. This survey design has already been used at national level [Becker W, 2001; Szponar L et al., 2001] and proved useful in comparing two independent dietary measures, given current interests in both the household budget and individual dietary survey data.
Acknowledgment The DAFNE initiative has been supported by the European Commission, in the context of the ‘Cooperation in Science and Technology with Central and Eastern European Countries’, the ‘Agriculture and Agro-Industry, including Fisheries – AIR’, the ‘Agriculture and Fisheries – FAIR’, the ‘COST Action 99 – Food Consumption and Composition Data’ programmes and the Health Monitoring Programme of DG-SANCO. Thanks are due to the Statistical Offices of all countries presented in this report for providing the national household budget survey data and supporting documentation, and for their unreserved collaboration. 79
The British HBS data is Crown copyright. It has been made available by the Office for National Statistics (ONS) through the Data Archive, based in the University of Essex. Neither the ONS nor Data Archive bear any responsibility for the analysis or interpretation of the data reported here.
National Reports Austria In Austria nutrient intake data was gathered in the course of the Austrian Study on Nutritional Status (ASNS – Österreichische Studie zum Ernährungsstatus, ÖSES). This study started in 1991 and the first comprehensive results were presented in the Austrian Nutrition Report 1998. In order to be able to describe long-term trends of nutritional status and deliver internationally comparable data, follow-up studies have been carried out among several population groups. Updated evaluations were made in 3–6 years old preschoolers (for the first time on a national level), schoolchildren, adolescents (first evaluation), adults, hobby athletes (first evaluation), seniors and pregnant women. These data were presented in the Austrian Nutrition Report 2003. For the assessment of food intake the following methods of survey have been used (table 25). Children Preschoolers (3–6 years) and Pupils (7–14 years) The mean energy intake in Austrian preschoolers was below the recommended intake of the SCF for 3–6 years old children (table 26). Despite this low energy intake the proportion of overweight and obese children in this age group was 13% among girls and 16% among boys. Children of the higher age groups showed a mean intake which was far below the recommended average requirements of the SCF as well. However, looking at the BMI distribution, a sufficient supply of energy can be assumed in these age groups. On average the energy intake was higher in children of West Austria compared to those of the east. The share of protein in total energy intake was between 13 and 16% in children at the age of 3–14 years. An undersupply of protein is not to be expected in this age group. The intake of carbohydrates was below the recommended level of Eurodiet (2000) in children aged 80
Annexes
Table 25. Study collective and method of collection of food intake data Collective
Evaluation model
Participants (n)
Year of survey
Preschoolers (3–6 years) Elementary school students (7–10 years) Junior high school students (11–14 years) Adolescents (15–18 years) Adults (19–60 years) Elder people (55 years) Pregnant women Breastfeeding women Hobby athletes
3-day-weighed record 7-day-weighed record
151
2001
326
2000–2001
7-day-weighed record
209
2000–2001
3-day-weighed record 24-hour-recall
102
2001
2580
24-hour-recall
645
2002
24-hour-recall 3-day-weighed record 24-hour-recall
254 39
2002 1994–1995
198
2002
1998–2001
7–14 years. In preschoolers, the intake of carbohydrates was higher. However, it has to be considered that the proportion of sucrose was bigger in this age group compared to the 7–14 year old and thus responsible for the relatively high proportion of carbohydrates in total energy supply. The mean relative consumption of fat was above the recommended upper level of Eurodiet (2000) in all age groups. Considering the recommendations at national level (30–35 %E for children aged 4–15 years) the mean fat intake in children was within a normal range, except for 10–12 year old boys from West Austria and 7–9 year old girls from both regions. The proportion of SFA in total energy intake should not be higher than 10% (Eurodiet, 2000). This level was on average exceeded by children of all age groups. Consequently the proportion of unsaturated fatty acids was in general too low. Table 27 shows that in Austrian children the mean intake of vitamin D was low. In all age groups of both girls and boys it was below 2 g/day, which is probably too low for Austrian children especially during winter months. For children a sufficient supply of vitamin D is very important in order to allow a highest possible increase of bone mass. The intake of this vitamin should be optimised.
Table 26. Mean daily intake of energy and macronutrients (mean SD) in Austrian children (3–14 years) Boys
3–6 years (n 66)
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E n-6-FA %E n-3-FA %E Cholesterol (mg)
5.7 1.5 13 2 55 6 15 5 12 5 32 5 16 2 12 1 42 3.3 1.2 0.5 0.2 220 102
Girls
(n 85)
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E n-6-FA %E n-3-FA %E Cholesterol
5.6 1.1 13 3 54 6 15 5 12 4 33 5 17 2 12 1 42 3.4 1.5 0.5 0.2 206 89
7–9 years
10–12 years
13–14 years
SCF
East
West
East
West
East
West
7.8 1.4 15 3 50 7 13 4 14 4 35 6 17 2 13 1 52
6.3 1.8 15 3 51 7 10 4 13 5 34 5 16 2 13 1 51
8.8 2.3 15 3 52 6 11 3 17 5 33 5 15 2 12 1 52
6.7 1.6 15 3 49 7 11 3 11 3 36 6 17 1 13 2 63
8.9 2.5 16 4 53 6 14 5 15 5 31 6 15 2 11 2 52
8.0 2.8 16 4 47 5 94 16 7 37 6 17 2 14 2 62
350 142
242 96
350 119
223 94
409 371
233 94
7.2 1.2 14 3 50 6 13 4 14 3 36 6 17 2 13 2 62
4.9 1.6 14 2 50 2 11 5 84 36 5 18 2 13 1 62
7.4 2.4 15 3 54 7 13 5 16 6 31 5 15 2 11 2 52
6.7 1.5 15 3 50 7 10 4 13 5 35 5 16 2 13 1 62
7.5 2.3 15 3 51 6 11 4 15 5 34 6 17 2 12 2 52
6.7 2.5 14 2 52 6 12 6 13 6 34 6 17 3 12 2 53
314 205
212 115
293 149
245 139
299 128
234 140
6.7/8.4/9.6 10–15** 55* 10** 30* 10* 6–10* 2.5*** 0.5***
6.3/7.5/8.4 10–15** 55* 10** 30* 10* 6–10* 2.5*** 0.5***
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** D-A-CH (2000).
On average the intake of folate was – compared to the reference population intake of the SCF – too low in boys and girls of Western Austria at the age of 13 and 14 years. The national recommendations [DACH, 2000] of folate intake are for 4–9 year old children 300 g/day, and for 10–12 year olds 400 g/day. Compared to these recommendations the average intake in Austrian children of all age groups was too low. For -carotene no recommendation is given by the SFC. DACH (2000) indicates an estimated value of about 2–4 mg/day. Apart from girls of East Austria of the last age group, both male and female children were below this value. Also for vitamin E the SCF does not give absolute recommendations. If we compare the intake of this vitamin with the estimated values for Austrian, German and Swiss children
Annexes
indicated by DACH (2000), the intake has to be valuated as too low in all age groups. On the basis of the population reference intake of the SCF of 1,000 mg/day for 11–14 year old children, the average intake of calcium has to be valuated as too low in the group of 10–14 year old children, in both male and female (table 28). In this age group the magnesium intake was slightly below the recommendation of the SCF as well. Only boys from East Austria showed on average a sufficient intake. An insufficient intake of iron and zinc was observed in females at the age of 10–14 years. The mean intake of iodine was lower than the recommended level of the SCF in all age groups, in both boys and girls. However, it has to be considered that fortified salt plays a major role in iodine supply in Austria. It is 81
Table 27. Mean daily vitamin intake (mean SD) in Austrian children (3–14 years) Boys
3–6 years (n 66)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E² (mg) Thiamine (mg) Riboflavin (mg) Niacin³ (mg) Pantothenic a. (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
0.8 0.5 1.6 1.4 2.1 2.2 5.8 2.5 0.9 0.4 1.2 0.5 16 6 3.7 1.5 1.1 0.4 35 22 155 57 2.7 1.3 105 71
Girls
(n 85)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E² (mg) Thiamine (mg) Riboflavin (mg) Niacin³ (mg) Pantothenic a. (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
0.7 0.5 1.8 1.7 1.9 2.1 5.9 2.7 0.9 0.3 1.2 0.5 16 5 3.6 1.3 1.1 0.4 35 19 172 118 2.5 1.2 95 60
7–9 years
10–12 years
13–14 years
SCF
East
West
East
West
East
West
1.0 0.8 2.0 1.9 1.8 1.1 8.5 3.1 1.3 2.0 1.5 0.4 26 4 4.8 1.6 1.7 0.6 40 20 207 63 4.4 2.6 130 77
0.7 0.4 1.5 1.3 1.6 1.1 7.2 2.6 1.0 0.6 1.2 0.6 19 9 3.6 2.2 1.2 0.8 28 25 169 91 3.5 1.6 85 55
0.8 0.4 2.0 1.2 2.1 1.9 8.0 3.2 1.4 0.6 1.5 0.5 28 9 4.7 1.6 1.5 0.6 39 11 222 80 4.2 1.5 119 65
0.9 0.7 1.4 0.9 1.4 0.7 9.0 3.4 1.0 0.4 1.2 0.5 20 7 3.5 1.6 1.2 0.5 30 14 152 81 4.2 2.2 70 42
0.7 0.5 1.5 0.8 1.7 1.2 7.4 2.9 1.1 0.5 1.3 0.5 29 12 4.0 1.7 1.5 1.0 34 11 203 62 4.9 3.1 71 45
0.8 0.4 1.8 1.7 1.5 0.8 10.5 4.0 12. 0.5 1.2 0.6 25 8 3.9 1.4 1.4 0.7 33 13 152 61 4.5 1.7 81 45
0.4/0.5/0.6 2–4* 0–10/15 8/10/13/14* 0.7/0.8/1.0 1.0/1.2/1.3 11/13/15 3–12 0.9/1.1/1.3 15–100 130/150/180 0.9/1.0/1.3 25/20/35
0.8 0.7 1.8 1.7 1.9 1.2 8.0 3.0 1.1 0.4 1.3 0.4 23 6 4.2 1.4 1.5 0.5 37 17 189 51 4.1 3.1 115 66
0.7 0.5 1.3 1.2 1.3 0.8 5.9 3.0 0.8 0.4 0.9 0.4 14 6 2.9 1.3 1.0 0.4 23 10 132 68 2.9 1.6 63 33
0.7 0.5 1.9 1.1 1.5 1.1 7.1 2.9 1.1 0.5 1.3 0.5 25 15 4.1 2.9 1.6 2.6 33 12 196 73 3.8 4.5 102 66
0.7 0.3 1.5 1.0 1.4 1.0 9.9 3.4 1.1 0.5 1.2 0.5 20 7 3.5 1.2 1.3 0.6 32 16 169 86 3.2 1.4 77 35
0.8 0.6 2.1 2.0 1.5 0.8 6.5 2.3 1.1 0.5 1.2 0.5 24 10 3.7 1.4 1.3 0.6 33 11 183 60 3.9 2.5 99 73
0.6 0.3 1.4 1.2 1.3 0.8 9.2 5.9 0.9 0.3 1.0 0.3 18 7 3.1 1.1 1.1 0.5 29 12 151 61 2.8 1.0 85 50
0.4/0.5/0.6 2–4* 0–10/15 8/9/11/12* 0.7/0.8/0.9 1.0/1.2 11/13/14 3–12 0.9/1.1 15–100 130/150/180 0.9/1.0/1.3 25/20/35
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000). 1 2
difficult to assess the actual salt intake as it is hard to evaluate the salt which was added at the table. In many age groups the mean potassium intake has to be valuated as insufficient as well. Adolescents According to table 29 the mean energy intake among both male and female adolescents approximately corresponded to the average requirements indicated by the SCF. Looking at the prevalence of overweight and obesity in the male sample (13 and 11%, respectively) it is 82
Annexes
obvious that the energy intake among this group is in reality probably higher than their requirement. The mean proportion of protein in the daily energy supply shows a protein intake within the normal range recommended by the WHO in girls, in male adolescents it was slightly higher. The intake of carbohydrates was low in both males and females. Further, the average proportion of added sugar should be decreased, whereas the mean intake of dietary fibre should be increased in both male and female apprentices. As a result of the low proportion of carbohydrates, the mean fat intake was too
Table 28. Mean daily mineral intake (mean SD) in Austrian children (3–14 years) Boys
3–6 years (n 66)
Calcium (mg) Potassium (g) Magnesium (mg) Sodium (g) Iron (mg) Zinc (mg) Iodine (g)
646 302 1.6 0.5 200 73 1.5 0.6 8.6 2.8 6.5 2.1 67 24
Girls
(n 85)
Calcium (mg) Potassium (g) Magnesium (mg) Sodium (g) Iron (mg) Zinc (mg) Iodine (g)
663 259 1.6 0.5 193 56 1.5 0.5 7.9 2.4 6.2 1.6 69 25
7–9 years
10–12 years
Male (n 46)
West
East
West
East
West
742 253 2.1 0.5 243 55 – 11.5 2.7 8.1 1.6 102 39
718 384 1.7 0.7 241 94 – 10.0 4.2 7.7 2.8 90 55
819 308 2.3 0.6 292 82 – 12.0 3.6 10.5 3 96 41
611 240 1.6 0.5 192 56 – 8.9 2.6 7.6 2.7 85 33
733 296 2.1 0.8 297 125 – 12.6 3.7 11.1 3.8 100 50
632 290 2.0 0.7 240 103 – 11.3 4.8 10.1 3.6 99 27
450/550/1000 1.1/2.0/3.1 120/200/280 – 4/6/10 6/7/9 90/100/120
664 214 1.9 0.5 224 52 – 10.1 2.6 7.9 1.7 98 36
560 215 1.6 0.4 186 58 – 8.4 2.7 6.6 1.8 84 32
667 254 2.0 0.7 255 83 – 10.4 3.7 8.5 3.1 88 45
628 172 1.7 0.4 202 64 – 9.5 3.8 7.5 2.6 87 26
688 276 2.0 0.6 255 85 – 10.7 3.4 9.1 3.4 91 39
645 303 1.7 0.6 200 67 – 8.4 2.8 7.4 2.7 89 46
450/550/1000 1.1/2.0/3.1 120/200/280 – 4/6/18 6/7/9 90/100/120
Female (n 56)
SCF M
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Linoleic acid (n-6) %E a-Linolenic a. (n-3) %E Cholesterol Alcohol %E
F
11.0 2.7 16 3 49 6 16 6 14 5 31 6 15 2 11 2 52 3.4 1.3
8.6 1.7 15 3 51 7 18 6 15 5 34 6 16 3 12 1 62 4.0 1.3
11.7 8.8 10–15** 55* 10** 25* 30* 10*
0.42 0.21
0.45 0.17
0.5***
367 131 46
262 93 12
300** –
6–10* 2.5***
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** D-A-CH (2000).
high, especially that of SFA. The cholesterol intake should be decreased in male apprentices. Also the mean share of alcohol in total energy intake was with 4.5% relatively high in this group. Annexes
SCF
East
Table 29. Mean daily intake of energy and macronutrients (mean SD) in Austrian adolescents (15–18 years) Adolescents (15–18 years)
13–14 years
The supply of folate in Austrian adolescents has to be valuated as insufficient (table 30). It was on average far below the recommended level of Eurodiet (2000), and even lower than the recommendations of the SCF. Also the mean intake of vitamin D was low with 1.3 g/day in the male and 2.1 g/day in the female group. In regard of the amount of sun irradiation in Austria, Germany and Switzerland, DACH recommends an intake of 5 g/day for adolescents of these countries. Considering this recommendation the mean intake of vitamin D in Austrian adolescents has to be valuated as too low. Regarding the average vitamin E intake, a sufficient supply is not necessarily warranted. The average intake was in both sexes below the estimated value of DACH (2000). The mean supply of riboflavin was sufficient in the female sample but below the recommendation of the SCF in the male group who also had an average -carotene intake below the recommended level of at least 2 mg/day [DACH 2000]. Table 31 shows that the calcium intake in Austrian adolescents was too low. Neither the recommended intake of the SCF (1,000 mg/day) nor that of Eurodiet (800 mg/day) was reached. Also the mean intake of magnesium was too low. The mean iron intake was only slightly below the recommended level in male adolescents but far below the guidelines for women. Concerning the relatively low intake data for iodine it 83
Table 30. Mean daily vitamin intake (mean SD) in Austrian adolescents (15– 18 years)
Adolescents (15–18 years)
Male (n 46)
Female (n 56)
SCF M
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
0.9 0.5 1.6 1.7 1.3 0.7 9.9 4.3 1.4 0.4 1.4 0.5 38 16 5.7 3.4 2.0 1.0 41 23 175 61 5.2 1.9 88 56
0.9 0.5 2.1 2.2 1.5 1.0 10.9 4.6 1.1 0.4 1.3 0.5 25 6 4.3 1.8 1.6 0.9 42 38 164 62 3.5 1.4 109 80
F
0.7
0.6 2–4* 0–15
15* 1.1 1.6 18
12* 0.9 1.3 14 3–12
1.5
1.1 15–100 200/400** 1.4 40
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1 2
Table 31. Mean daily mineral intake (mean SD) in Austrian adolescents (15–18 years) Adolescents (15–18 years)
Male (n 46)
Female (n 56)
SCF M
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) *
F
675 277 718 276 1,000/800* 2.3 0.7 2.1 0.7 3.1 289 102 245 73 300 12.2 3.2 10.0 2.5 13 17/16* 11.0 2.8 9.0 2.1 9.5 7 106 32 106 37 130/150*
Eurodiet (2000).
has again to be considered that the actual salt intake and thus the actual intake of iodine cannot be examined adequately. Also the intake of potassium was below the population reference intake of the SCF in Austrian apprentices. Vitamin and Mineral Status in Austrian Children and Adolescents The average vitamin and mineral status in Austrian children in 1994 revealed a good supply of retinol, 84
Annexes
phyllochinon, thiamine and cobalamin, as well as of potassium and magnesium (tables 32 and 33). The tocopherol status was insufficient in 12% of the examined girls and 18% of the examined boys, with a serum tocopherol level below 0.7 mg/dl. Especially in the group of 13–18 year olds the prevalence of a slightly decreased tocopherol status was higher in the male group than in the female group. 25% of the female group and 20% of the male group had a vitamin D status below the normal level of at least 6 g 25-OH-calciferol/dl serum. 20% of the examined girls and 30% of the examined boys had an insufficient vitamin B2 status; in 12–15% of these children and adolescents it was even significantly decreased. A low vitamin B6 status was observed in 5–10% of the examined pupils. The valuation of folate status showed that about 20% had clearly too low serum folate levels. In boys the prevalence was higher than in girls. A high proportion of children and adolescents, both male and female, had low concentrations of calcium per g creatinine (13–34%). The valuation of the serum iron concentrations show that about 80% were adequately supplied with this nutrient. Only 6% were below the cut-off value of 40 g/dl. An iron deficiency (stage 3 of WHO classification) was only found in 3% of the examined persons.
Table 32. Vitamin status (mean SD) in Austrian children and adolescents (6–14 years), 1994 Male
6 years
7–9 years
10–12 years
13–14 years
15–18 years
Reference values*
Serum retinol (g/dl) Serum 25-OH-calciferol (g/dl) Serum -carotene (g/dl) Serum tocopherol (total) (mg/dl) Serum phyllochinon (g/dl) Urine thiamine (mol/l) Vitamin B2 (-EGR) Vitamin B6 (-EGOT) Serum folic acid (ng/ml) Serum vitamin B12 (pg/ml)
28.0 10.8 5.5 2.9 40.6 32.1 0.90 0.13 – 1.56 1.11 1.21 0.09 1.64 0.20 5.1 4.5 564 251
28.8 7.0 5.3 2.6 35.1 23.8 0.93 0.21 0.27 0.13 1.12 0.95 1.27 0.16 1.57 0.25 3.8 3.1 412 362
29.8 7.2 4.3 2.6 31.7 16.8 0.90 0.23 0.29 0.18 1.60 0.98 1.31 0.17 1.71 0.27 6.5 5.3 508 321
31.5 6.0 4.5 3.1 29.3 14.8 0.85 0.18 0.28 0.21 1.14 0.70 1.30 0.16 1.68 0.27 6.8 4.6 588 447
36.1 9.1 4.9 3.6 33.5 25.7 0.85 0.25 0.23 0.11 1.23 0.95 1.30 0.17 1.63 0.30 4.3 3.1 403 290
20/10–20/10 6/2–6/2 20–40/20 0.7/0.5–0.7/0.5 16 0.2/ 0.2 1.6/1.6 1.5/1.5–2.0/2.0 5.9/3–5.9/3.0 200/100–200/100
27.8 9.5 4.4 2.1 30.6 29.2 0.83 0.18 – 1.09 0.47 1.18 0.09 1.58 0.25 4.8 6.2 540 338
31.3 10.0 4.3 2.9 30.5 14.8 1.00 0.21 0.18 0.09 1.34 0.67 1.30 0.17 1.59 0.25 4.3 3.1 467 367
29.4 6.4 3.8 2.4 29.9 18.4 0.90 0.26 0.31 0.19 1.44 0.73 1.33 0.15 1.72 0.27 6.2 3.8 529 350
32.7 6.7 3.2 3.4 33.0 19.1 0.88 0.18 0.21 0.10 1.01 0.78 1.36 0.16 1.70 0.25 6.7 4.4 494 294
35.1 9.5 4.2 3.0 34.2 22.8 0.91 0.19 0.25 0.15 1.02 0.66 1.33 0.16 1.65 0.29 6.1 4.1 424 236
20/10–20/10 6/2–6/2 20–40/20 0.7/0.5–0.7/0.5 16 0.2/ 0.2 1.6/1.6 1.5/1.5–2.0/2.0 5.9/3–5.9/3.0 200/100–200/100
Female Serum retinol (g/dl) Serum 25-OH-calciferol (g/dl) Serum -carotene (g/dl) Serum tocopherol (total) (mg/dl) Serum phyllochinon (g/dl) Urine thiamine (mol/l) Vitamin B2 (-EGR) Vitamin B6 (-EGOT) Serum folic acid (ng/ml) Serum vitamin B12 (pg/ml) *
Normal/Slightly decreased/Significantly decreased.
Table 33. Mineral status (mean SD) in Austrian children and adolescents (6–14 years), 1994 Male
6 years
7–9 years
10–12 years
13–14 years
15–18 years
Reference values*
Serum iron (g/dl) Urine calcium (mmol/g creat.) Urine magnesium (mg/g creat.) Urine potassium (mmol/g creat.) Serum zinc (mg/l)
65 42 1.43 0.97 10.2 4.0 81 40 1.03 0.24
82 26 1.60 1.08 7.8 4.4 66 37 0.98 0.22
86 36 1.42 1.13 8.7 6.7 79 59 1.12 0.27
86 32 0.90 0.85 9.2 13.2 58 53 1.13 0.33
107.8 40 0.99 0.81 6.26 3.7 45.9 36.9 1.18 0.28
60/40–60/40 0.5–6.6/0.5 2–11/2 30–84/30 0.9/0.7–0.9/0.7
70 18 2.01 1.23 6.6 2.8 73 41 0.97 0.11
85 38 1.56 1.15 7.9 3.9 51 31 1.01 0.22
99 33 1.71 3.36 10.8 16.1 73 94 1.08 0.26
95 34 1.23 1.54 8.8 11.1 61 62 1.04 0.30
97.2 44.9 1.56 2.17 6.93 7.6 52.0 99.6 1.06 0.31
60/40–60/40 0.5–6.6/0.5 2–11/2 30–84/30 0.9/0.7–0.9/0.7
Female Serum iron (g/dl) Urine calcium (mmol/g creat.) Urine magnesium (mg/g creat.) Urine potassium (mmol/g creat.) Serum zinc (mg/l) *
Normal/Slightly decreased/Significantly decreased.
Adults In both male and female adults the average energy intake was relatively constant up to the age of 64 years, but then showed a considerable decrease (table 34). The
Annexes
mean proportion of protein in total energy intake was within a normal range. Hence, a sufficient supply of protein can be assumed. In contrast, the mean intake of carbohydrates was low in all age groups, especially in 85
Table 34. Mean daily intake of energy and macronutrients (mean SD) in Austrian adults (18– 64 years) Women
Total (n 1,568)
24 years (n 372)
25–50 years (n 777)
51–64 years (n 357)
65 years (n 62)
SCF
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
8.4 2.9 15 4 46 11 11 7 19 9 36 10 16 5 14 4 63 317 203 35 9 14
8.8 2.9 14 5 48 11 12 7 19 8 36 10 16 5 14 5 63 323 212 25 6 13
8.4 2.9 15 5 45 11 11 6 19 9 36 10 17 5 13 4 63 306 204 45 10 15
8.5 2.7 15 5 44 10 10 6 19 8 38 9 17 3 15 3 63 333 187 35 9 14
6.7 2.4 17 5 44 10 74 17 8 37 9 18 5 13 3 64 338 218 25 59
7.3–9.0 10–15** 55* 10** 25* 30* 10* – 6–10* 300** – 10***
Men
(n 1,013)
(n 188)
(n 511)
(n 263)
(n 51)
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
10.6 4.0 15 5 43 10 10 7 20 9 37 10 17 5 14 4 63 429 328 56 17 23
11.3 4.7 15 5 45 11 10 7 19 9 36 10 17 5 13 4 64 411 286 47 15 26
10.7 3.9 15 5 43 10 10 7 20 9 37 10 17 5 14 4 63 436 383 56 16 23
10.6 3.7 15 5 41 9 96 21 9 39 9 18 4 15 4 65 440 257 56 20 23
8.0 2.9 18 7 41 11 65 19 10 35 11 16 6 13 5 62 366 181 67 17 22
8.0–12.8 10–15** 55* 10** 25* 30* 10* – 6–10* 300** – 20***
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** Upper level recommended by D-A-CH (2000); should not be consumed daily.
adults at the age of 25 years and older. Also the intake of dietary fibre should be increased. With about 20 g/day it is clearly below the 25 g/day recommended by Eurodiet (2000). The mean proportion of fat and especially of SFA in total energy intake was relatively high in Austrian adults. Consequently the mean intake of cholesterol was above the recommendation as well. In women it was only slightly beyond 300 mg/day, in male adults it was even higher than 400 mg/day. The intake of vitamin D in adults was on average higher than in Austrian adolescents (apprentices) but it was in both male and female adults still below the recommended value indicated by DACH (2000) (table 35). Only the group of men older than 50 years showed a sufficient intake. The supply of vitamin E was compared to 86
Annexes
the national recommendations [DACH, 2000] too low in men and women older than 64 years. The other age groups of both sexes showed a sufficient intake. Compared to the Eurodiet recommendations for folate, the average intake in Austrian adults has to be regarded as insufficient. According to table 36 the mean intake of minerals was in general within the normal range indicated by the SCF. Compared to the recommendations of Eurodiet, the average calcium intake was too low in Austrian adults older than 65 years. The mean intake of iodine was too low in women of all age groups and in men older than 50 years. The average iron intake in women was below the recommendations of Eurodiet in all age groups. Further, the mean potassium intake was relatively low in Austrian adults.
Table 35. Mean daily vitamin intake (mean SD) in Austrian adults (18– 64 years) Women
Total (n 1,568)
24 years (n 372)
25–50 years (n 777)
51–64 years (n 357)
65 years (n 62)
SCF
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.2 1.1 3.6 3.8 3.7 5.0 12.5 8.1 1.3 0.8 1.7 1.0 29 13 5.5 3.2 1.8 1.4 58 54 255 115 56 131 110
1.2 0.9 3.3 3.3 3.3 4.0 12.7 8.1 1.3 0.9 1.7 1.1 29 14 5.7 3.3 1.9 1.6 61 55 256 110 55 127 106
1.3 1.2 3.8 4.1 3.7 5.1 12.9 8.5 1.3 0.8 1.7 0.9 30 14 5.7 3.4 1.9 1.5 62 62 264 120 54 138 114
1.3 1.3 3.5 3.6 4.1 5.8 12.3 7.6 1.2 0.7 1.6 0.9 29 12 5.3 2.8 1.7 0.9 51 42 247 112 57 126 111
0.9 0.7 2.6 2.1 2.6 2.5 8.2 4.6 0.9 0.4 1.2 0.5 25 11 3.9 1.5 1.3 0.6 36 17 199 91 43 98 84
0.6 2–4* 0–15; 5* 12/11* 0.9 1.3 14 3–12 1.1 15–100 200/400** 1.4 45
Men
(n 1,013)
(n 188)
(n 511)
(n 263)
(n 51)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.4 1.2 3.5 3.5 4.2 5.8 13.8 9.1 1.6 0.9 2.0 1.2 38 17 6.5 4.0 2.2 1.6 64 63 284 137 7 13 151 132
1.4 1.5 3.1 2.8 3.3 4.1 14.3 10.3 1.7 0.9 2.1 1.5 42 21 7.2 5.3 2.6 2.3 66 72 286 152 89 161 154
1.3 1.0 3.5 3.5 4.1 5.7 14.1 9.2 1.6 1.1 2.0 1.2 39 17 6.7 4.0 2.3 1.6 69 72 294 138 78 156 130
1.4 1.2 3.9 4.0 4.9 6.5 13.8 8.7 1.5 0.7 1.9 1.1 36 15 6.1 3.2 2.0 1.0 56 37 277 123 77 142 123
1.3 2.0 2.7 2.6 5.4 7.0 9.0 4.6 1.1 0.5 1.3 0.6 30 9 4.4 1.7 1.5 0.5 39 19 217 115 8 10 108 107
0.7 2–4* 0–15; 5* 15/14/13/12* 1.1 1.6 18 3–12 1.5 15–100 200/400** 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1 2
Elderly In 2002 a study was carried out in elderly people living in Vienna in order to evaluate their nutritional and health status and habits. In the course of this study people living in private households as well as in nursing homes were interviewed. In elderly people a decrease in energy intake could be observed with increasing age (table 37) which results in an increase in the proportion of underweight people. There was hardly any difference in energy intake between elderly women living in private households (7.3 MJ/day) and those living in nursing homes (7.4 MJ/ day). There was, however, a considerable difference in
Annexes
the male collective (8.7 MJ/day in private households vs. 7.6 MJ/day in nursing homes). The mean share of protein in total energy intake was within the normal range of the WHO (2003). In both males and females, the average relative protein intake was higher in persons living in nursing homes than in those living in private households. The fat intake of the elderly was comparable to that of Austrian adults. The relative proportion of fat in total energy intake increased in both males and females with increasing age. Among participants living in nursing homes the fat intake was on average higher than in those living in private households (39 vs. 37 %E in women; 40 vs. 38 %E in men). 87
Table 36. Mean daily mineral intake (mean SD) in Austrian adults (18– 64 years) 24 years (n 372)
Women
Total (n 1,568)
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Manganese (mg) Copper (mg)
889 496 2.6 1.0 315 112 13.3 6.8 10.2 3.7 131 76 4.6 2.4 2.0 0.7
Men
(n 1,013)
(n 188)
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Manganese (mg) Copper (mg)
987 570 3.0 1.5 371 150 15.4 7.1 12.7 4.9 154 211 4.6 2.4 2.3 0.8
1,045 588 3.0 1.4 385 169 15.6 6.7 13.3 5.5 160 234 4.5 2.6 2.3 0.8
*
938 461 2.5 0.9 313 110 13.1 7.2 10.3 3.6 127 73 4.5 2.5 2.0 0.7
51–64 years (n 357)
65 years (n 62)
SCF
900 474 2.7 1.0 323 117 13.7 7.0 10.2 3.8 137 80 4.6 2.4 2.1 0.7
844 467 2.6 0.9 307 100 13.0 5.5 10.3 3.7 128 70 4.5 2.3 2.1 0.7
727 433 2.3 0.9 268 104 11.1 4.5 9.8 3.7 103 68 5.1 2.9 1.8 0.7
700/800* 3.1 150–500 16* 7 130/150* 1–10 1.1
(n 511)
(n 263)
(n 51)
1,000 582 3.1 1.7 379 154 15.5 7.8 12.5 4.9 165 254 4.6 2.3 2.3 0.8
981 528 3.0 1.1 362 129 15.6 6.4 12.8 4.9 135 74 4.7 2.3 2.2 0.8
661 504 2.4 0.8 286 95 12.9 4.4 11.7 4.0 109 59 4.8 2.4 2.1 0.8
700/800* 3.1 150–500 9 9.5 130/150* 1–10 1.1
Eurodiet (2000).
The proportion of SFA in total fat intake was relatively high as well. The mean intake of carbohydrates as well as of dietary fibre was, mainly as a consequence of the high proportion of fat and animal products, below the recommended level of Eurodiet (2000). On average the folate intake was below the guideline indicated by Eurodiet (2000) in Austrian elderly of all age groups (table 38). Those living in nursing homes had an average intake of 175 g/day (f ) and 171 g/day (m), respectively compared to 207 g/day (f ) and 244 g/day (m), respectively in those living in private households. The mean intakes of vitamin B6 and riboflavin were low in elderly men. For a sufficient supply of vitamin D in elderly people Eurodiet (2000) recommends a daily intake of 10 g/day. On average the intake was far below this recommended level in both male and female elderly persons. Vitamin E was – compared to national recommendations [DACH, 2000] – a critical nutrient as well in elderly living in Vienna. The intake of this vitamin in people living in private households [8.6 mg/day (f ) and 9.4 mg/day (m), respectively] was on average higher than in those living in nursing homes [6.9 mg/day (f ) and 6.6 mg/day (m), respectively]. Compared to the recommendation of Eurodiet (2000) (table 39), calcium was a critical nutrient in most age 88
25–50 years (n 777)
Annexes
groups of elderly, both males and females. Also the iodine intake (without considering the iodine from fortified salt) was too low in Austrian elderly. The average intake of potassium was below the recommendation of the SCF in elderly of all age groups. Vitamin Status in Elderly In the course of the study among elderly people blood samples were taken in order to measure the status of some vitamins. The average plasma vitamin C concentration was in the female sample slightly higher than in the male sample (table 40; fig. 62). A marginal vitamin C status was found in 31% of the male and 30% of the female sample. The status of -carotene in Austrian elderly people was insufficient. About 96% of the male participants and 88% of the female participants had a plasma -carotene concentration below 0.7 mol/l. The average plasma 25-hydroxyvitamin D concentration in Austrian elderly people was above the lower level of 25 nmol/l. In both men and women it was higher in persons living in private households than in those living in nursing homes. The reason for this is probably the higher age of the female participants living in nursing homes. In men it could be due to the relatively small sample size. 13% of the male and 23% of the female
Table 37. Mean daily intake of energy and macronutrients (mean SD) in Austrian elderly (55– 84 years) Elderly women
Total (n 554)
55–64 years (n 180)
65–74 years (n 121)
75–84 years (n 160)
84 years (n 93)
SCF
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E
7.4 2.1 16 4 46 9 95 19 7 37 8 18 3 14 2 53 309 168 13
7.5 2.3 16 4 47 9 95 21 8 36 9 17 4 14 3 53 299 172 14
7.5 2.0 16 5 46 8 95 20 7 37 7 17 3 14 2 62 325 222 12
7.4 1.9 16 5 45 9 95 18 7 38 8 19 4 14 2 52 300 130 12
7.1 2.0 16 4 43 9 95 16 6 40 8 20 3 15 2 52 337 225 12
7.3–7.7 10–15** 55* 10** 25* 30* 10* – 6–10* 300** 20***
Elderly men
(n 87)
(n 21)
(n 22)
(n 22)
(n 22)
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E
8.4 2.6 15 5 44 9 98 20 8 38 7 18 3 15 2 52 378 166 34
9.0 3.2 16 5 45 9 85 20 7 36 6 16 2 15 2 52 466 232 35
8.7 2.3 16 5 45 10 84 23 9 36 7 17 3 14 2 52 323 113 24
8.7 2.3 16 4 42 6 73 22 9 40 6 20 3 15 2 52 377 119 23
7.4 2.4 14 5 44 11 11 15 15 5 40 8 20 3 15 2 52 354 155 23
8.0–9.2 10–15** 55* 10** 25* 30* 10* – 6–10* 300** 10***
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** Upper level recommended by D-A-CH (2000); should not be consumed daily.
collective had a plasma 25-OH-vitamin D concentration below 25 nmol/l and thus an insufficient vitamin D status. The average plasma phyllochinon concentration of Austrian elderly people was also beyond the lower level of 0.38 nmol/l. In 18% of the male and 16% of the female sample the concentration was below this level and can thus be regarded as insufficient. Pregnant Women According to the SCF, the energy intake in pregnant women should be increased by 1.7 MJ/day in underweight women, by 0.75 MJ/day in normal weight women and by 0.5 MJ/day in overweight women. The interviewed pregnant women younger than 35 years however had an average energy intake which was even below the average requirements of non-pregnant women; in those at the age of 36–45 years this difference was even more significant (table 41).
Annexes
The share of protein intake in total energy was within the normal range of the WHO. The absolute mean protein intake was 71 g/day which was above the recommended level of 57 g/day indicated by the SCF for pregnant women. A sufficient supply can thus on average be assumed. The total fat intake was higher than the upper level given by Eurodiet (2000). However, considering the national recommendation of DACH (30–35 %E) the average fat intake of the interviewed pregnant women was within a normal range. The carbohydrate intake was around 50 %E and according to the DACH recommendations at a normal level as well. Only in 36–45 year old women was it slightly too low. The high proportion of SFA in total fat intake, as well as the low intake of dietary fibre and the high cholesterol intake in pregnant women younger than 25 years relates to a too high proportion of animal products in the daily diet. 89
Table 38. Mean daily vitamin intake (mean SD) in Austrian elderly (55– 84 years) Elderly women
Total (n 554)
55–64 years (n 180)
65–74 years (n 121)
75–84 years (n 160)
84 years (n 93)
SCF
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.1 1.0 2.9 3.0 3.7 5.3 8.0 4.6 1.1 0.5 1.4 0.6 25 8 4.3 1.7 1.3 0.6 39 21 201 76 4.1 2.4 94 68
1.1 0.9 3.2 2.7 3.4 4.4 8.6 5.2 1.2 0.5 1.4 0.6 25 8 4.5 1.7 1.4 0.6 40 40 223 88 3.9 2.1 109 73
1.2 1.2 2.7 3.1 4.7 6.2 9.3 5.5 1.1 0.5 1.5 0.6 25 10 4.6 2.0 1.4 0.6 45 32 210 68 4.4 2.9 98 66
1.1 1.1 2.9 3.5 3.6 6.1 7.2 3.2 1.0 0.4 1.4 0.5 24 8 4.1 1.5 1.3 0.5 36 17 189 67 4.1 2.5 87 63
1.0 1.0 2.3 2.6 3.1 3.5 6.3 2.7 0.9 0.4 1.3 0.6 23 8 3.8 1.6 1.2 0.5 33 14 166 60 3.9 2.3 71 62
0.6 2–4* 0–15; 10** 11* 0.9 1.3 14 3–12 1.1 15–100 200/400** 1.4 45
Elderly men
(n 87)
(n 21)
(n 22)
(n 22)
(n 22)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.2 1.1 2.7 2.1 4.2 4.3 8.6 3.8 1.2 0.5 1.4 0.6 27 10 4.5 1.8 1.4 0.5 41 19 218 79 4.7 2.6 104 102
1.5 1.6 2.9 2.1 5.0 5.7 9.9 4.2 1.4 0.7 1.5 0.8 31 13 5.0 2.6 1.6 0.6 50 28 234 92 5.3 3.4 97 85
1.3 1.1 2.8 2.5 5.1 5.3 9.0 3.1 1.2 0.4 1.5 0.4 27 7 4.7 1.5 1.4 0.4 43 15 232 70 4.9 2.6 113 104
1.2 0.8 3.0 2.1 3.4 2.2 9.3 4.1 1.2 0.4 1.4 0.3 28 8 4.4 1.2 1.5 0.5 37 13 232 80 5.3 3.2 109 86
0.9 0.4 2.2 1.9 3.4 3.1 6.2 2.9 1.0 0.4 1.3 0.5 23 9 3.7 1.5 1.1 0.4 35 14 174 61 4.0 1.8 93 133
0.7 2–4* 0–15; 10** 12* 1.1 1.6 18 3–12 1.5 15–100 200/400** 1.4 45
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1 2
The mean folate intake through food in pregnant women was much below the population reference intake recommended by Eurodiet (table 42). The intake of vitamins and minerals by supplements was not included in the results presented here. Thus, the actual intake might be higher. However, this outcome shows that supplementation of folate during pregnancy is of great importance. The intake of vitamin D in pregnant women was far below the recommendations made by the SCF as well. That of vitamin E was only slightly below the recommended intake for pregnant women indicated by DACH (2000). About 56% of all interviewed women indicated taking multivitamin supplements. 90
Annexes
The average potassium intake in pregnant women was below the recommended level of 3.1 g/day (table 43). The SCF does not give any recommendations for the amount of iron which should be taken during pregnancy but only recommends a general supplementation with this micronutrient. According to the recommended intake level of DACH (2000) the iron intake in Austrian pregnant women through food was too low. Thus, supplementation would be advantageous. Only 37% of the interviewed sample indicated taking iron supplements, about 11% took a combination of folate and iron. The iodine intake was below the recommended level of Eurodiet in pregnant women older than 35 years.
Table 39. Mean daily mineral intake (mean SD) in Austrian elderly (55– 84 years) Elderly women
Total (n 554)
55–64 years (n 180)
65–74 years (n 121)
75–84 years (n 160)
84 years (n 93)
SCF
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g)
778 388 2.4 0.8 273 102 11.8 5.8 10.1 3.4 126 54
831 409 2.6 0.9 286 98 12.6 6.6 10.4 3.3 130 56
799 402 2.6 0.9 288 101 12.3 5.0 10.3 3.7 135 55
780 361 2.3 0.8 271 110 11.0 4.1 10.1 3.1 122 56
649 351 2.1 0.8 235 86 11.1 7.3 9.2 3.4 111 42
700/800* 3.1 150–500 9 7 130/150*
Elderly men
(n 87)
(n 21)
(n 22)
(n 22)
(n 22)
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g)
738 376 2.5 1.0 292 113 13.3 5.1 11.5 4.8 120 43
635 402 2.6 1.2 311 152 14.2 5.4 12.7 7.1 123 52
959 400 2.8 1.0 341 98 14.7 4.3 12.5 3.9 136 54
695 266 2.5 0.8 281 85 14.4 6.0 11.8 3.3 119 23
642 642 1.9 1.9 233 84 10.0 2.9 9.1 3.3 102 34
*
700/800* 3.1 150–500 9 9.5 130/150*
Eurodiet (2000).
Table 40. Vitamin status (mean SD) in Austrian elderly (55– 84 years) Male
Plasma vitamin C (mol/l) Plasma retinol (mol/l) Plasma -carotene (mol/l) Plasma 25-hydroxyvitamin D (nmol/l) Plasma -tocopherol (mol/l) Plasma phyllochinon (nmol/l)
Female
Reference value
NH (n 8)
PHH (n 22)
NH (n 49)
PHH (n 133)
53 23 2.3 0.4 0.35 0.21 38.4 19.0 35.2 13.3 0.85 0.50
55 16 2.2 0.4 0.33 0.22 50.7 17.8 40.4 14.5 0.79 0.50
59 19 2.1 0.5 0.40 0.29 34.9 17.5 38.7 11.2 0.96 0.65
59 19 2.0 0.5 0.44 0.33 42.3 18.6 40.4 10.9 0.84 0.52
45 0.7 0.75 25 16.3 0.38
NH Nursing homes; PHH private households.
Vitamin and Mineral Status in Pregnant Women The riboflavin and vitamin B6 status seem on average to be suboptimal in Austrian pregnant women (table 44). The high standard deviation refers to a relatively high variation. The average iron status in pregnant women was not satisfying and should be improved (table 45). Lactating/Breastfeeding Women The SCF calculated for lactating women the following average energy requirements: on the basis of the
Annexes
recommendations for non lactating women an additional energy intake of 1.5 MJ/day within the first month post partum, 1.8 MJ/day within the second month, 1.92 MJ/ day within the third and 1.71 MJ/day within the fourth to sixth month post partum is recommended. Table 46 shows that the average intake of the interviewed women was lower than these recommendations. The mean protein intake was above the population reference intake indicated by the SCF. A sufficient supply can thus be assumed. The fat intake in the examined sample was relatively high with an average of 38% of 91
Percentage of total sample
120 96
100
Men
Women
88
80 60 40
31
30
23
0
18
13
20 Plasma vitamin C (45 mol/l)
Plasma -carotene (0.7 mol/l)
Plasma 25-OHvitamin D (nmol/l)
16
Plasma phyllochinon (0.38 nmol/l)
Fig. 62. Prevalence of low plasma vitamin C, plasma -carotene, plasma 25-OH-vitamin D and plasma phyllochinon status in Austrian elderly (55– 84 years). Source of raw data: FAO, 2003.
total energy intake. DACH (2000) recommends for lactating women a mean fat intake of 30–35 %E; the upper limit was thus exceeded. Consequently, the mean carbohydrate intake was relatively low with an average of 47 %E. Further, the proportion of sucrose was very high (⬃16 %E). Due to the high fat intake in lactating women, the average intake of cholesterol was by far above the upper intake level indicated by the WHO (2003). Table 47 shows that the mean vitamin D intake was marginal in Austrian lactating women. Vitamin E was also below the recommended level of 16 mg/day (DACH, 2000) in all recording periods as well. The
Table 41. Mean daily intake of energy and macronutrients (mean SD) in Austrian pregnant women (25–45 years)
intake of folate was on average far below the recommendations of Eurodiet and the SCF. Not even the half of the population reached the reference intake during all periods of the survey. However, the intake of nutrients by supplements was not considered and the actual intake of some vitamins might be higher than these results. In the lactating women the average intake of calcium was below the population reference intake recommended by the SCF (table 48). Also that of zinc was slightly below the recommended level for lactating women. Vitamin and Mineral Status in Lactating Women The vitamin B6 status in Austrian lactating women has to be valuated as insufficient (table 49). This result refers to the average low intake data for this vitamin. Especially the iron status should be improved in lactating women (table 50). The status of this micronutrient is due to losses at childbirth particularly low in lactating women. However, it has to be considered that these status data were derived from women who did not take iron-supplements. Hobby Athletes People doing regular physical activity have an elevated energy requirement compared to people with a low level of physical activity. Nevertheless, the interviewed
Pregnant women
Total (n 250)
25 years (n 63)
25–35 years (n 158)
36–45 years (n 27)
SCF
Energy (MJ)
8.5 2.6
8.9 3.0
8.4 2.5
7.8 2.3
1.7/
Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E
15 4 50 9 14 7 21 10 35 7 16 3 13 2 63 340 262 0.2 0.7
15 4 51 7 14 8 19 8 34 7 16 3 13 2 52 394 394 0.1 0.2
15 5 50 9 14 8 22 11 35 8 16 3 13 2 63 327 234 0.2 0.8
16 4 47 6 13 6 20 8 37 5 17 2 14 2 62 298 176 0.3 0.9
10–15*** 55** 10*** 25** 30** 10** – 6–10** 300***
0.75/0.5*
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * In underweight/normal weight/overweight women (before pregnancy); ** Eurodiet (2000); *** WHO (2003).
92
Annexes
Table 42. Mean daily vitamin intake (mean SD) in Austrian pregnant women (25–45 years)
Pregnant women
Total (n 250)
25 years (n 63)
25–35 years (n 158)
36–45 years (n 27)
SCF
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.3 1.3 4.0 4.6 2.2 2.4 12.7 8.4 1.3 0.7 1.7 0.9 28 12 1.8 1.0 54 42 250 118 4.4 6.0 143 122
1.3 1.0 3.8 4.8 2.1 2.2 12.6 8.6 1.3 0.7 1.8 1.0 29 12 1.9 1.0 49 27 253 112 4.1 2.3 144 107
1.2 1.2 3.9 4.4 2.3 2.6 12.7 8.9 1.2 0.7 1.6 0.8 27 12 1.7 0.9 54 42 245 107 3.8 2.5 137 109
1.5 1.5 4.2 5.9 2.5 2.3 12.2 5.9 1.3 0.5 1.7 0.8 26 9 1.6 0.7 46 22 237 113 4.6 2.6 140 136
0.7 2–4* 10 13* 1.0 1.6 14 1.3 15–100 400** 1.6 55
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1 2
Table 43. Mean daily mineral intake (mean SD) in Austrian pregnant women (25–45 years)
Pregnant women
Total (n 250)
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) *
25–35 years (n 158)
36–45 years (n 27)
SCF
893 433 937 483 2.7 1.0 2.7 0.9 307 112 296 103 13.6 5.2 13.2 4.5
872 391 2.6 1.0 309 113 13.4 5.3
890 517 2.8 1.3 287 103 13.6 5.8
10.8 3.6 149 74
10.6 3.7 150 79
10.7 3.7 133 57
700/800* 3.1 150–500 Supplements; 30** 7 130/150*
Eurodiet (2000); **
Riboflavin (-EGR) Vitamin B6 (-EGOT) Serum cobalamin (ng/l) Serum folic acid (g/l) Serum ascorbic acid (mg/dl) Serum retinol (g/dl) Serum -carotene (g/dl) Serum tocopherol (mg TE/dl) Tocopherol/Cholesterol (mg/g) Serum vitamin K (g/l)
Annexes
11.1 3.4 156 71
D-A-CH (2000).
Table 44. Vitamin status (mean SD) in Austrian pregnant women (1997)
*
25 years (n 63)
Pregnant women (n 218)
Reference values*
1.33 0.19 1.81 0.34 429 590 5.3 7.0 0.92 0.37 23.2 7.9 41.6 22.6 1.18 0.32 5.20 1.53 0.53 0.44
1.2/1.2–1.5/1.5 1.5/1.5–2/2 200/150–200/150 5.9/3–5.9/3 0.8/0.3–0.8/0.3 20/10–20/10 40/20–40/20 0.7/0.5–0.7/0.5 – 0.16/ 0.16
Normal/Slightly decreased/Significantly decreased.
93
Table 45. Mineral status (mean SD) in Austrian pregnant women (1997)
Serum magnesium (mg/dl) Serum iron (g/dl) Serum selenium (g/l) *
Pregnant women (n 218)
Reference values*
1.43 0.25
1/ 1
49.5 21.6 61.9 18.4
60/40–60/40 2.6/2.2–2.6/2.2
Normal/Slightly decreased/Significantly decreased.
Table 46. Mean daily intake of energy and macronutrients (mean SD) in Austrian lactating women (1–4 weeks, 5–8 weeks, 9–12 weeks and 13–16 weeks post partum)
hobby athletes showed on average a lower energy intake than the Austrian adults, in both men and women. In regard to the different sport categories, the individual athletes showed the highest energy intake, and the athletes frequenting fitness centres or gymnastic clubs had the lowest average energy intake (table 51). The share of protein in total energy was above the recommended normal range of the WHO, especially in male hobby athletes. In the female group there was no difference in protein supply between the different sport categories. Among the male athletes the highest protein
Lactating women
Week 4 pp (n 39)
Week 8 pp (n 36)
Week 12 pp (n 36)
Week 16 pp (n 32)
SCF
Energy (MJ) Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E n-6 fatty acids %E n-3 fatty acids %E Cholesterol (mg) Alcohol %E
9.7 1.9 78 16 47 8 16 8 18 7 38 7 4.1 1.3 0.7 0.2 414 204 0.8 1.7
9.4 1.8 75 13 47 6 16 6 18 7 38 5 4.4 1.3 0.7 0.3 409 248 1.0 1.8
9.7 2.3 76 11 47 6 16 7 17 6 38 6 4.4 1.5 0.7 0.1 413 161 1.0 1.6
9.3 2.2 73 11 46 5 15 5 19 7 39 5 4.7 1.4 0.7 0.2 368 118 1.1 1.8
– 59–62 55* – 25* 30* – – 300** –
pp Post partum; %E % of total energy; * Eurodiet (2000); ** WHO (2003).
Table 47. Mean daily vitamin intake (mean SD) in Austrian lactating women (1–4 weeks, 5–8 weeks, 9–12 weeks and 13–16 weeks post partum)
Lactating women
Week 4 pp (n 39)
Week 8 pp (n 36)
Week 12 pp (n 36)
Week 16 pp (n 32)
SCF
Vitamin A1 (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g)
0.9 0.6 2.3 1.5 12.8 4.1 1.3 0.3 1.9 0.5 29 6 1.6 0.5 154 51 5.5 2.2
0.9 0.7 3.4 2.5 11.8 3.5 1.2 0.3 1.8 0.6 27 5 1.5 0.3 134 52 6.6 8.8
1.0 0.8 3.6 2.5 12.8 4.9 1.3 0.3 1.9 0.5 28 5 1.5 0.3 139 42 6.3 6.1
1.1 1.1 2.7 1.8 12.8 4.1 1.2 0.4 1.7 0.7 27 5 1.5 0.3 151 60 6.3 10.5
0.95 10 17* 1.1 1.7 16 1.4 350/400** 1.9
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals); pp post partum. * D-A-CH (2000); ** Eurodiet (2000). 1 2
94
Annexes
Table 48. Mean daily mineral intake (mean SD) in Austrian lactating women (1–4 weeks, 5–8 weeks, 9–12 weeks and 13–16 weeks post partum)
Lactating women
Week 4 pp (n 39)
Week 8 pp (n 36)
Week 12 pp (n 36)
Week 16 pp (n 32)
Calcium (mg/MJ) 1,135 388 1,081 357 1,125 320 1,097 344 Magnesium (mg/MJ) 359 84 338 71 349 68 353 91 Iron (mg/MJ) 13.0 3.0 12.7 2.4 13.3 2.6 13.0 2.5 Iodine (g/MJ) 264 114 244 83 251 74 240 87 Zinc (mg/MJ) 11.7 2.4 10.9 2.0 11.3 1.9 10.9 2.0
SCF
1,200 150–500 10 160 12
pp Post partum.
Table 49. Vitamin status (mean SD) in Austrian lactating women (1–4 weeks, 5–8 weeks, 9–12 weeks and 13–16 weeks post partum)
Table 50. Mineral status (mean SD) in Austrian lactating women (1–4 weeks, 5–8 weeks, 9–12 weeks and 13–16 weeks post partum)
Lactating women
Week 4 pp (n 39)
Week 8 pp (n 36)
Week 12 pp (n 36)
Week 16 pp (n 32)
Riboflavin (-EGR) Vitamin B6 (-EGOT) Serum cobalamin (ng/l) Serum folic acid (g/l) Serum retinol (g/dl) Serum tocopherol (mg TE/dl) Serum vitamin K (g/l)
1.3 0.13 1.9 0.24 670 654 5.4 5.1 34 8.9 1.0 0.2 0.44 0.27
1.3 0.12 1.8 0.13 246 192 1.0 0.6 32 7.0 0.8 0.2 0.35 0.22
1.3 0.16 1.8 0.17 507 168 0.6 0.8 31 6.7 0.8 0.2 0.33 0.19
1.3 0.10 1.9 0.32 275 241 2.2 2.3 31 5.8 0.7 0.3 0.32 0.10
Lactating women
Week 4 pp (n 39)
Week 8 pp (n 36)
Week 12 pp (n 36)
Week 16 pp (n 32)
Serum calcium (mmol/l) Serum magnesium (mmol/l) Serum iron (g/dl)
2.7 0.9 0.8 0.1 53 32
2.8 0.8 0.7 0.1 46 33
3.1 0.8 0.7 0.1 52 31
2.4 0.8 0.7 0.1 58 25
intake was observed in the category ‘fitness centre and gymnastic club’ with 18 %E and the lowest in individual athletes with 16 %E. As bodybuilders were excluded from this study, a higher protein intake than in adults who do not exercise, is not necessary. In contrast, for hobby athletes, especially endurance sportsmen and sportswomen, an increased intake of carbohydrates would be desirable. However, the average carbohydrate intake in the participating hobby athletes was on average relatively low, although their share in total energy intake was higher than in Austrian adults. The intake of total fat was higher than the normal range indicated by Eurodiet (2000). The proportion of saturated fatty acids in total fat supply was also higher than the recommended upper level of Eurodiet (2000) with an average of 15 %E in the male participants and 16 %E in the female participants. Annexes
The interviewed male hobby athletes had with 3.5 %E a higher relative alcohol consumption than the female participants (1.8 %E). In both men and women the highest intake of alcohol was observed in individual athletes and those training in fitness centres and gymnastic clubs. Team sport athletes showed a much lower alcohol intake. The recommendations of vitamin D intake indicated by DACH (2000) were not reached by any of the subgroups of hobby athletes (table 52). However, if the athletes are mainly doing outdoor exercise, they might have an increased body production of vitamin D due to longer periods of sun exposure compared to the average population. During the winter period the contribution of vitamin D produced in the body might not be sufficient and thus a higher intake of vitamin D would be desirable. The intake of vitamin E was on average slightly below the recommended level of DACH (2000). 95
Table 51. Mean daily intake of energy and macronutrients (mean SD) in Austrian hobby athletes (15– 65 years)
Men
Total (n 92)
IA (n 36)
TA (n 38)
FC/GC (n 18)
SCF
Energy (MJ) Protein (g/MJ) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E Alcohol %E
9.5 4.8 17 5 46 12 10 7 19 11 34 11 15 5 3.5 7.5
10.0 3.6 16 5 45 12 10 7 21 11 35 11 16 5 4.1 7.5
9.8 6.3 17 5 49 12 11 9 17 10 32 10 14 5 2.6 7.2
8.1 3.0 18 6 42 13 86 19 11 36 12 16 4 4.2 7.9
9.2–12.8* 10–15*** 55** – 25** 30** 10** –
Women
(n 106)
(n 28)
(n 23)
(n 55)
Energy (MJ) Protein (g/MJ) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E Alcohol %E
7.4 2.9 16 5 48 10 96 20 8 35 9 16 5 1.8 4.3
8.6 4.0 16 6 44 10 96 20 8 38 10 17 6 2.6 5.2
7.5 2.8 16 4 49 10 85 22 8 35 9 15 7 0.3 1.0
6.8 2.1 16 4 49 9 10 7 20 8 33 8 15 4 2.0 4.5
7.7–9.0* 10–15*** 55** – 25** 30** 10** –
IA Individual athletes; TA team athletes; FC/GC athletes in fitness centres or gymnastic clubs; %E % of total energy; SFA saturated fatty acids. * Average energy requirement of adults indicated by the SCF; it has to be considered that physical activity increases energy requirements; ** Eurodiet (2000); *** WHO (2003).
The mean intake of folate was in Austrian hobby athletes in all age groups and in men and women below the recommendation of 400 g/day given by Eurodiet (2000). The supply of this vitamin has to be considered as insufficient. In regard to the recommendations of Eurodiet for calcium (800 mg/day), the mean intake in female hobby athletes as well as in male hobby athletes going to fitness centres or gymnastic clubs has to be valuated as too low (table 53). In the female hobby athletes the mean iron intake was too low. An increase, especially in premenopausal women, would thus be desirable. The supply of potassium was below the population reference intake of the SCF as well and can thus be regarded as insufficient. The supply of all other minerals in hobby athletes can be regarded as sufficient as they were all above or within the recommendations made by the SCF (and DACH for potassium). Mean Intake of Vegetables and Fruits in the Austrian Population In the course of the nutritional assessments accomplished in the period of 1998–2001, the average food 96
Annexes
intake was assessed as well. Table 54 shows that the average intake of fruits was clearly higher than the average intake of vegetables. In the vegetable intake there was no notable difference between the male and the female population groups. The mean fruit intake was higher in 11–14 year old females than in males of the same age group, but in the age group of 15–18 years it was clearly higher in males. In all other age groups there was no meaningful difference in fruit intake. Belgium For the Belgian population only intake data of energy and macronutrients is available. The data of the different population groups was derived from different studies (table 55). Children The mean energy intake in Belgian children at the age of 6–12 years approximately corresponded to the average requirements indicated by the SCF for this age group (table 56). The average proportion of protein in total
Table 52. Mean daily vitamin intake (mean SD) in Austrian hobby athletes (15– 65 years)
Men
Total (n 92)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Vitamin B1 (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Vitamin B12 (g) Vitamin C (mg)
2.0 4.2 2.3 4.8 2.1 4.7 2.3 1.9 2.4 2.1 2.0 1.6 3.5 5.6 4.5 7.3 2.8 4.1 11.7 9.3 11.5 6.6 13.1 12.5 1.4 0.7 1.5 0.6 1.4 0.9 1.9 1.5 1.8 0.9 2.0 2.2 36 19 35 13 38 25 6.0 5.2 5.9 3.2 6.6 7.3 2.0 1.7 1.9 1.0 2.3 2.5 48 29 52 29 48 34 265 171 282 149 257 188 8 11 9 12 7 11 138 148 133 126 149 186
Women Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Vitamin B1 (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Vitamin B12 (g) Vitamin C (mg)
(n 106)
IA (n 36)
(n 28)
TA (n 38)
(n 23)
0.9 0.7 1.0 0.6 0.9 0.5 2.9 2.6 2.8 2.8 3.2 2.7 2.9 4.0 3.7 3.1 1.8 1.7 11.1 6.1 12.9 5.9 11.8 5.6 1.0 0.5 1.2 0.5 1.0 0.4 1.3 0.6 1.3 0.5 1.3 0.6 25 10 28 11 24 10 4.2 1.9 4.5 1.8 4.1 1.5 1.4 0.7 1.5 0.6 1.4 0.6 41 34 47 38 39 16 239 113 258 112 267 141 33 43 32 97 87 85 48 101 78
FC/GC (n 18)
SCF
1.1 0.9 2.8 2.3 3.1 4.0 9.1 4.5 1.2 0.5 1.6 0.5 32 11 5.0 1.7 1.8 0.8 43 15 247 178 75 124 89
0.7 2–4* 0–10; 5* 13–15* 1.1 1.6 18 3–12 1.5 15–100 200/400** 1.4 45
(n 55) 0.9 7.6 2.9 2.5 3.0 4.9 9.9 6.2 1.0 0.5 1.2 0.6 25 10 4.0 2.1 1.3 0.7 38 37 217 98 32 101 105
0.6 2–4* 0–10; 5* 12* 0.9 1.3 14 3–12 1.1 15–100 200/400** 1.4 45
IA Individual athletes; TA team athletes; FC/GC athletes in fitness centres or gymnastic clubs. 1 Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000), for the age group 19–65 years; ** Eurodiet (2000).
energy intake was within the normal range of the WHO (2003). The share of carbohydrates was below the recommended level of Eurodiet of 55 %E. As a result of the low carbohydrate intake in Belgian children, the mean proportion of fat in total energy intake was relatively high at 37% and far above the recommended upper level of Eurodiet (2000). The share of SFA in total fat intake was with 15 %E above the recommended upper level of 10 %E, that of PUFA was with 6 %E within a normal range. The average intake of cholesterol was in Belgian children already relatively high with 256 mg/day.
Annexes
The mean calcium and iron intakes were relatively high in Belgian children. Adolescents In male adolescents the mean energy intake was 11.1 MJ/day, in female adolescents it was 8.2 MJ/day (table 57). In both male and female it approximately corresponded to the average requirements indicated by the SCF. The mean proportion of protein was in both male and female adolescents within the normal range indicated by the WHO (2003); that of carbohydrates was 97
Table 53. Mean daily mineral intake (mean SD) in Austrian hobby athletes (15– 65 years)
Men
Total (n 92)
IA (n 36)
TA (n 38)
FC/GC (n 18)
SCF
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg)
863 594 2.8 1.3 337 159 13.8 6.2 12.7 5.2
866 419 2.8 0.9 347 118 14.7 4.8 13.4 3.9
913 769 2.9 1.8 345 210 13.8 8.0 12.7 6.6
751 471 2.6 0.9 301 93 12.1 3.9 11.2 4.2
700/800* 3.1 150–500 9 9.5
Women
(n 106)
(n 28)
(n 23)
(n 55)
Calcium (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg)
730 403 2.4 0.8 291 102 12.0 4.7 10.2 3.6
763 437 2.4 0.7 300 109 12.9 4.3 11.3 3.8
803 446 2.5 1.0 301 97 11.4 4.2 10.1 3.6
684 366 2.3 0.8 282 103 11.7 5.0 9.6 3.5
700/800* 3.1 150–500 16* 7
IA Individual athletes; TA team athletes; FC/GC athletes in fitness centres or gymnastic clubs. * Eurodiet (2000).
Table 54. Mean daily fruits and vegetables intake in the Austrian population
Age/population group
3–6 years 7–10 years 11–14 years 15–18 years* 19–60 years 60 years** Pregnants *
Fruits (g/d), mean SD Total
Male
Female
177 162 156 196 255 295 145 171 183 227 240 200 291 296
180 159 158 197 149 289 187 192 186 218 241 194 –
174 166 48 61 47 62 50 60 155 198 73 90 74 98 71 81 264 305 72 100 74 101 71 99 94 124 78 56 86 59 67 51 179 240 148 134 153 136 140 131 230 224 145 122 142 116 155 141 – 168 148 – –
Apprentices; **
with 49 %E in both male and female adolescents below the recommended level of at least 55 %E. The mean intake of dietary fibre was particularly low in female adolescents with 16 g/day, in the male group it was higher with 20 g/day, but still below the recommended intake of 25 g/day. The share of fat in total energy intake was on average far above the recommended upper level of Eurodiet (2000) of 30 %E. Also the proportion of SFA was too high in both male and females. This refers to a high proportion of animal fat in total fat intake. The mean intake of cholesterol was in boys on average of 265 mg/day, higher than in female adolescents (206 mg/day). 98
Annexes
Vegetables (g/d), mean SD Total
Male
Female
Viennese seniors.
The average share of alcohol in total energy intake in Belgian adolescents was relatively low with only 1%. Adults Table 58 shows that the relative share of protein in total energy intake was at about the same level in male and female adults and within the normal range indicated by the WHO (2003). The mean proportion of carbohydrates in total energy intake was very low in adults of Flanders, both male (39%) and female (40%), as well as in men of the Gent region (42%). Despite this low proportion of carbohydrates, which was far below the recommended range of Eurodiet (2000), the average
Table 55. Study collective and periods of different studies in Belgium
Study population
Age
N
Study
Year(s) of study
Children Adolescents Adults Male adults Elderly
6–12 years 13–18 years 25–74 years 45–64 years 70–75 years
1,320 341 6,870 210 220
PIH-study Not available BIRNH-study EURONUT-study EURONUT seneca-hamme
1989 Not available 1979–1984 Not available 1988
Table 56. Mean daily intake of energy, macronutrients and minerals (mean) in Belgian children (6–12 years) Children (6–12 years) (n 1,320)
Boys
Girls
SCF M
Energy (MJ) Protein %E Carbohydrates %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Linoleic acid Cholesterol (mg) Sodium (g) Calcium (mg) Iron (mg)
8.4 14 49 21 37 15 14 6 9 267 2.0 935 10.4
7.9 13 49 19 38 15 14 7 7 245 1.8 848 10.0
F
8.4/9.6 7.5/8.4 10–15** 55* 30* 10* 6–10*
450–1000 4–10/18
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003). Table 57. Mean daily intake of energy and macronutrients (mean) in Belgian adolescents (13–18 years) Adolescents (13–18 years)
Male
Female
SCF M
Energy (MJ) Protein %E Carbohydrates %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E
11.1 2.2 14 2 49 5 20 6 36 5 15 2 14 2 62 265 72 12
8.2 1.9 15 3 49 5 16 5 35 5 14 2 13 3 61 206 66 11
F
11.7 8.8 10–15** 55* 25* 30* 10* 6–10* 300**
%E % of total energy; NSP non-starchy polysaccharides; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Annexes
intake of dietary fibre was relatively high with 23 g/day in men and 21 g/day in women of the BIRNH study but still below the recommended level. In men (of both studies) and women the mean share of fat in total energy intake was very high with about 41–42% and was thus far above the recommended upper level of Eurodiet (2000) of 30 %E. Also the proportion of SFA in total fat intake was high. However, the average intake of PUFA was 8–9 %E which was – compared to other countries – relatively high, which has to be valuated positively. The mean intake of cholesterol was particularly in men very high and far above the recommended upper level of the WHO (2003). Further the share of alcohol in total energy intake was in women 5 %E, in men of the BIRNH study it was 9 %E. Elderly On average the energy intake in elderly people in Belgium was higher than the indicated average requirements of this age group (table 59). The proportion of macronutrients was comparable to that of Flemish adults. The mean share of protein in total energy intake was in the male participants about 13% and in the females about 14%. The proportion of carbohydrates was very low whereas the proportion of fat was in both male and female elderly higher than 40 %E and thus far above the recommended upper level of the Eurodiet (2000). Here again the share of SFA in total fat intake was high, but also the share of PUFA in Belgian elderly people was relatively high. The mean intake of cholesterol was in the male participants slightly above the recommended upper level of the WHO (2003), in female elderly it was below it. The average share of alcohol in total energy intake was in male elderly 5 %E and in the female participants 2 %E.
Denmark The survey method used for the assessment of this data was a combination of a personal interview and 99
Table 58. Mean daily intake of energy and macronutrients (mean) in Belgian adults (24–74 and 45–64 years)
Adults (flanders only)
Energy (MJ) Protein %E Carbohydrates %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E
Adults (24–74 years) Men (n 3,596)
Women (n 3,274)
11.9 3.9 14 4 39 8 23 10 41 9 16 5 15 4 85 411 273 98
8.8 2.7 15 4 40 8 21 8 42 9 17 5 15 4 95 331 220 55
Men (45–64 years) (n 210)
SCF
10.3 2.7 15 3 42 7 20 8 42 8 16 4 15 4 84 370 175 –
8.0–12.8 7.3–9.0 10–15** 55* 25* 30* 10* – 6–10* 300** –
M
F
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Table 59. Mean daily intake of energy and macronutrients (mean) in Belgian elderly (70–75 years) Elderly (70–75 years)
Male (n 120)
Female (n 100)
SCF M
F
Energy (MJ) 10.4 2.9 8.4 1.9 9.2/8.0 7.7/7.3 Protein %E 13 3 14 3 10–15** Carbohydrates %E 41 7 43 8 55* Fat %E 41 7 42 8 30* SFA %E 16 4 17 5 10* MUFA %E 15 5 15 4 – PUFA %E 95 84 6–10* Cholesterol (mg) 318 140 273 107 300** Alcohol %E 56 23 – %E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
self-administered diet records. The interview took about half an hour and included information about social background, attitudes, some health data and detailed information about dietary habits. Dietary data were recorded for seven consecutive days in supplied booklets with pre-printed fixed answering categories supplemented with open categories. The quantity of foods eaten was estimated from household measures and four different series of pictures. Data was collected in three periods in 1995: January/February, April/May and 100
Annexes
August/September, to take into account seasonal variations in the diet. Children On average, the energy intake in Danish children was relatively high and above the average requirements indicated by the SCF for these age groups (table 60). As expected, boys generally had a higher intake than girls of the same age. The share of protein was within the normal range indicated by the WHO (2003) in both girls and boys. The average total intake was in both boys and girls far above the population reference intakes of the SCF for these age groups. The carbohydrate intake in Danish children was relatively high although below the recommended level of Eurodiet (2000). Only in girls aged 7–10 years the average proportion of carbohydrates was low with less than 50 %E. The share of added sugar in total carbohydrate intake was relatively high in boys and girls aged 4–14 years. The rise in energy intake with increasing age indicates an increase in total food intake, therefore the average intake of dietary fibre in Danish children increased with age as well. The mean share of fat in total energy intake was far above the normal range indicated by Eurodiet (2000). However, DACH (2000) indicates for children a normal range of fat intake of 30–35 %E. Regarding this recommendation, the average fat intake in Danish children can be regarded as satisfactory. However, the mean share of
Table 60. Mean daily intake of energy and macronutrients (mean SD) in Danish children (1–14 years)
Boys
1–3 years (n 129)
Energy (MJ) 6.9 Protein %E 13 Protein (g) 52 Carbohydrates %E 51 Added sugar %E 11 Dietary fibre (g) 15 Fat %E 36 SFA %E 17 MUFA %E 10 PUFA %E 5 Cholesterol (mg) 207 Girls
(n 149)
Energy (MJ) 6.4 Protein %E 14 Protein (g) 54 Carbohydrates %E 50 Added sugar %E 11 Dietary fibre (g) 14 Fat %E 36 SFA %E 17 MUFA %E 10 PUFA %E 4 Cholesterol (mg) 221
4–6 years (n 136)
7–10 years (n 185)
11–14 years (n 162)
SCF
8.1 14 64 52 14 17 34 16 10 4 265
9.8 14 82 51 13 20 35 15 10 5 345
10.9 14 89 51 14 21 35 15 10 5 371
5.0/6.7/8.4/9.6 10–15** 15/19/27/42 55* 10** – 30* 10* – 6–10* –
(n 137)
(n 191)
(n 172)
7.3 13 56 52 14 15 34 16 10 5 234
8.8 14 73 49 13 17 35 16 10 5 334
8.7 15 75 51 13 19 35 15 10 4 281
4.8/6.3/7.5/8.4 10–15** 15/19/27/42 55* 10** – 30* 10* – 6–10* –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
SFA in total fat intake was relatively high in both girls and boys with around 15–17 %E whereas the share of PUFA in total energy intake was relatively low. This high proportion of animal fat in total fat intake is not desirable. As a result of this high intake of animal fats and thus animal products, the average cholesterol intake in Danish children was very high as well. In 7–14 year old boys as well as in 7–10 year old girls it was even higher than 300 mg/day. The mean intake of vitamin D was relatively low in Danish children (table 61). The SCF recommends a population reference intake of 0–10 g/day. The actual requirement depends on the amount of sun exposure. Regarding this fact, the relatively low intake of vitamin D in Danish children may not be sufficient especially during winter months, where the amount of sun irradiation is low in this region. Measurements of serum 25-OHD in 12–13 years old girls and boys have shown values of
Annexes
34 nmol/l, 9% of the children were below 20 nmol/l and 66% below 37.5 nmol/l. According to the recommendations of the SCF, the intake of all other vitamins can on average be regarded as sufficient in Danish children. The average sodium intake was relatively high and increased with increasing age from 2.2 to 3.4 g/day in Danish boys and from 1.9 to 2.7 g/day in Danish girls (table 62). The average supply of potassium in Danish children can be regarded as sufficient. Only in girls of the oldest age group was the mean intake below the population reference intake recommended by the SCF for this age group. About 75% of girls in this age group had an intake lower than the recommended 3.1 g/day. The supply of calcium was on average very good in Danish children. Apart from 1–3 year old boys and 4–6 year old girls the average intake was around 101
Table 61. Mean daily vitamin intake (mean SD) in Danish children (1–14 years)
Boys
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
1–3 years (n 129)
4–6 years (n 136)
7–10 years (n 185)
11–14 years (n 162)
0.9 1.9 1.7 5.3
1.1 2.9 2.3 6.3
1.4 2.9 2.9 7.7
1.6 3.2 2.6 8.4
Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
0.9 1.5 15 1.0 189 4.1 55
1.1 1.7 18 1.1 209 4.9 65
1.3 2.1 24 1.4 270 6.7 71
1.5 2.2 27 1.7 304 6.7 79
Girls
(n 149)
(n 137)
(n 191)
(n 172)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
0.9 2.4 1.8 5.1
1.0 2.6 1.7 6.1
1.3 4.1 2.4 7.1
1.2 2.9 2.3 6.3
0.9 1.6 16 1.0 183 4.7 64
0.9 1.5 16 1.0 189 4.1 61
1.1 1.8 22 1.3 229 5.2 66
1.1 1.7 23 1.4 238 5.1 72
SCF
0.4/0.5/0.6/0.7 0–10/15 (0.4 g PUFA) 3.6/3.6/4.8/5.6 0.5/0.7/0.8/1.0 0.8/1.0/1.2/1.3 9/11/13/15 0.7/0.9/1.1/1.3 100/130/150/180 0.7/0.9/1.0/1.3 25/25/20/35
0.4/0.5/0.6/0.6 0–10/15 (0.4 g PUFA) 2.8/3.6/4.4/4.0 0.5/0.7/0.8/0.9 0.8/1.0/1.2/1.2 9/11/13/14 0.7/0.9/1.1/1.1 100/130/150/180 0.7/0.9/1.0/1.3 25/25/20/35
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent (1 mg niacin 60 mg tryptophan), 4 Folate equivalent (1 g food folate 0.5 g folic acid). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996. 1 2
1,000 mg/day or even higher (up to ⬃1,300 mg/day in boys of the last age group). The intake of magnesium was in general satisfactory as well. Only girls at the age of 11–14 years had a mean intake (263 mg/day) lower than the average requirements for their age group (280 mg/ day). The median of the magnesium intake in this age group was 256 mg/day and thus more than half of the interviewed girls had an intake below the recommended level. The average intake of iron can be regarded as sufficient in Danish boys and girls at the age of 1–10 years. In the 11–14 years group the girls had an average intake far below the population reference intake of the SCF. Practically none of the participating girls of this age group reached this recommendation. Various studies have 102
Annexes
shown that 2.3–15.7% of boys and 6.5–14.9% of girls aged 12–15 years have serum ferritin below 15 g/l. The supply of iodine was insufficient in Danish boys and girls of all age groups. Adolescents Male adolescents in Denmark had an average energy intake of 11.9 MJ/day which was slightly higher than the average requirement calculated by the SCF for this group (table 63). The mean share of protein in total energy intake was in both female and male adolescents 14% and thus within the range indicated by the WHO (2003). The proportion of carbohydrates in total energy intake was on average below the range suggested by Eurodiet (2000).
Table 62. Mean daily mineral intake (mean SD) in Danish children (1–14 years)
Boys
1–3 years 4–6 years 7–10 years (n 129) (n 136) (n 185)
11–14 years (n 162)
SCF
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
2.2 2.2 910 1,143 228 6.7 7.5 58 24
3.4 3.3 1,286 1,704 324 11.1 12.7 82 42
– 0.8/1.1/2.0/3.1 400/450/550/1,000 300/350/450/775 85/120/200/280 4/4/6/10 4/6/7/9 70/90/100/120 10/15/25/35
Girls
(n 149) (n 137) (n 191)
(n 172)
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
1.9 2.1 996 1,168 214 6.0 7.4 61 25
2.7 2.7 1,061 1,419 263 8.9 10.7 65 34
2.6 2.4 1,053 1,345 252 7.9 9.1 69 30
2.2 2.1 890 1,152 217 6.8 7.7 59 26
3.3 2.8 1,224 1,612 288 9.9 11.5 84 39
2.9 2.6 1,093 1,426 264 8.5 10.4 75 35
– 0.8/1.1/2.0/3.1 400/450/550/1,000 300/350/450/625 85/120/200/280 4/4/6/18 4/6/7/9 70/90/100/120 10/15/25/35
Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
Table 63. Mean daily intake of energy and macronutrients (mean SD) in Danish adolescents (15–18 years) Adolescents (15–18 years)
Male (n 68)
Female (n 84)
SCF M
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Added sugar %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
11.9 14 97 49 13 21 35 15 10 5 313 2 9
10.0 14 80 50 13 19 34 15 10 4 333 2 6
F
11.7 8.8 10–15** 55 45 55* 10** 25* 30* 10* – 6–10* 300** – –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
Annexes
In the male group carbohydrates constituted 49% of total energy and in the female it was only slightly higher with about 50 %E. The share of added sugar in total carbohydrates was in both male and female adolescents relatively high and should be decreased. In contrast, the intake of dietary fibre was relatively low in the Danish adolescents. The proportion of fat in total energy intake was relatively high, and also the proportion of SFA. This refers to a high amount of animal fat in total fat intake and thus a general high consumption of animal products. In contrast, the mean proportion of PUFA in total fat intake was below the recommended level of Eurodiet (2000). The mean consumption of cholesterol was relatively high as well. It was with 313 mg/day in male adolescents and 333 mg/day in female adolescents above the upper level indicated by the WHO (2003). The share of alcohol in total energy intake was 2% and thus relatively low in this population group. For a sufficient supply of vitamin D the SCF suggests a population reference intake up to 15 g/day for adolescents (table 64). As mentioned before, the actual requirements depend on the amount of sun exposure. With an average intake of 3.0 g/day in male and 2.7 g/day in female adolescents, the supply may especially in winter 103
Table 64. Mean daily vitamin intake (mean SD) in Danish adolescents (15–18 years) Adolescents (15–18 years)
Male (n 68)
Female (n 84)
SCF M
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.4 2.1 3.0 9.1
1.3 3.6 2.7 7.4
1.5 2.3 30 1.7 295 7.1 65
1.2 1.8 25 1.5 266 5.5 79
F
0.7
0.6 2–4* 0–15 (0.4 g PUFA) 6.0 4.8 1.1 0.9 1.6 1.3 18 14 1.5 1.1 200/400** 1.4 40
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid). * D-A-CH (2000); ** Eurodiet (2000). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996. 1
Table 65. Mean daily mineral intake (mean SD) in Danish adolescents (15–18 years) Adolescents (15–18 years)
Male (n 68)
Female (n 84)
SCF M
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
4.1 3.5 1,362 1,848 360 11.8 14.2 113 43
3.2 3.0 1,121 1,492 292 9.4 11.0 90 37
F
– 3.1 1,000/800* 775 625 300 13 17/16* 9.5 7 130 45
* Eurodiet (2000). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
months with low amounts of sun irradiation not be sufficient. In regard to the recommendations of Eurodiet (2000) for folate intake (400 g/day), the mean intake of this 104
Annexes
vitamin has to be valuated as insufficient in Danish adolescents. The male adolescents participating in this survey had a very high average sodium intake with about 4.1 g/day. In the female group it was lower with 3.2 g/day, but still relatively high (table 65). In female adolescents the mean intake of potassium was 3.0 g/day, slightly below the population reference intake of 3.1 g/day. The median was with 2.6 g/day even much lower, the recommended level was only reached at the 75th percentile. The mean calcium intake was especially in male but also in female adolescents clearly above the population reference intake of the SCF for this age group. Therefore the average supply can be regarded as sufficient. However, the median in the female group (988 mg/day) shows that about the half of the female participants of this age group had an intake below the recommended level. In the male group the median was higher than the mean intake and the supply of this nutrient was much better than it was in the female group. In the male group of adolescents the mean magnesium intake was clearly above the average requirement for this nutrient indicated by the SCF (300 mg/day). On average a sufficient supply can be assumed. In females the average intake of magnesium was slightly below the average requirement indicated by the SCF. The median was 270 mg/day indicating that more than the half of this population group had an average intake below the recommended level of the SCF. The average iron intake was below the population reference intake of the SCF in both male and female adolescents. More than the half of the male group had an intake lower than 13 g/day. In the female group, the recommended 17 g/day was only reached at the 99th percentile. Serum ferritin in adolescents has been measured in a number of studies. In boys 0–7% and in girls 10–12% were found to have serum ferritin values below 15 g/l. The mean intake of iodine as well as of selenium was below the recommendations of the SCF in both male and female adolescents. An increase in the intake of these micronutrients would be desirable. Adults The mean energy intakes in Danish adults corresponded approximately with the average requirements indicated by the SCF for these age groups (table 66). The average share of protein in total energy intake was within a normal range and the absolute protein intake numbers show that a sufficient supply of protein in Danish adults can be assumed in both male and female
Table 66. Mean daily intake of energy and macronutrients (mean SD) in Danish adults (19–64 years)
Men
19–24 years (n 86)
25–34 35–44 45–54 55–64 SCF years years years years (n 142) (n 135) (n 147) (n 140)
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Added sugar %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
12.4 14 103 45 10 22 35 15 11 5 391 6 23
12.1 14 98 42 9 21 36 14 11 5 422 8 32
Women
(n 100) (n 161) (n 158) (n 155) (n 128)
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Added sugar %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
9.0 13 72 48 12 17 36 15 10 5 292 3 10
9.2 14 76 47 10 19 36 15 11 5 344 3 9
11.2 15 97 43 7 23 36 15 11 5 414 6 23
8.5 15 73 44 9 16 36 15 11 5 332 5 15
11.0 14 92 41 7 22 37 16 12 5 416 7 25
8.4 15 73 43 8 18 37 16 11 5 349 5 14
11.1 14 91 42 7 22 38 16 11 5 467 6 22
8.3 15 72 43 8 17 35 15 11 5 344 6 17
12.8/11.3/9.2 10–15** 56 55* 10** 25* 30* 10* – 6–10* 300** – –
9.0/8.6/7.7 10–15** 56 55* 10** 25* 30* 10* – 6–10* 300** – –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
adults of all age groups. Especially in Danish men, but also in Danish women the average share of carbohydrates in total energy intake was very low. It was in both male and female adults far below the suggested range of Eurodiet (2000). The proportion of added sugar in total energy intake was in most age groups lower than 10%. The mean intake of dietary fibre in Danish men was between 21 and 23 g/day, slightly below the recommended level of Eurodiet (2000). In women the average intake of dietary fibre was lower with about 16–19 g/day. The proportion of fat in total energy intake was on average very high in Danish adults and increased with increasing age in men. Besides this high intake of total
Annexes
fat, the proportion of SFA in total fat intake was very high as well in both men and women. This high proportion of SFA refers to a high proportion of animal fat in total fat intake and thus a generally high intake of animal products. Further, the proportion of PUFA was relatively low in both men and women of all age groups with about 5 %E. As a consequence of the high proportion of animal fats the mean intake of cholesterol was very high too, particularly in men with an average of 390–470 mg/day. The average share of alcohol in total energy intake was relatively high in Danish adults, especially in men with about 6–8 %E. In women it was lower in the first 105
two age groups with about 3 %E but increased with increasing age to a level of 6 %E. Compared to Danish adolescents, the average supply of vitamin D was better in adults but still very low. An increase in vitamin D intake would be desirable, especially in months with low amounts of sun irradiation. The supply with all other vitamins was on average relatively good in Danish adults. Measurement of serum 25-OHD in women 45–58 years showed that 7% had a value below 25 nmol/l and 40% a value below 50 nmol/l (table 67). In Danish adults the average folate intake was below the recommended level of Eurodiet (2000) as well. It was higher in men than in women.
In male Danish adults the average intake of sodium was very high, the highest to be found in the age group of 19–24 year olds with 4.6 g/day (table 68). In Danish women the mean sodium intake was lower. The upper level of the acceptable range of intake was on average not exceeded by Danish women of any age group. The mean intake of potassium in men was far above the population reference intake indicated by the SCF and can thus be regarded as sufficient. In women the mean intake was lower and only reached the recommendation of the SCF in the age groups of 35–44 and 45–54 year old. On average, more than the half of Danish female adults had an intake below the population reference intake of the SCF.
Table 67. Mean daily vitamin intake (mean SD) in Danish adults (19–64 years) Men
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
19–24 years (n 86)
25–34 years (n 142)
35–44 years (n 135)
45–54 years (n 147)
55–64 years (n 140)
1.3 2.6 3.2 8.4
1.4 3.2 3.2 9.1
1.9 4.4 3.2 8.8
1.5 3.3 3.7 9.0
1.8 2.9 3.9 9.7
Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.5 2.3 34 1.9 313 7.0 65
1.4 2.0 37 1.8 282 6.3 65
1.5 2.0 38 1.8 329 7.1 77
1.3 1.9 35 1.7 291 6.6 88
1.4 2.1 35 1.6 313 7.7 82
Women
(n 100)
(n 161)
(n 158)
(n 155)
(n 128)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.1 2.9 2.4 6.7
1.2 3.2 2.7 8.0
1.2 3.3 2.8 6.9
1.2 3.4 3.6 7.0
1.4 3.7 4.0 6.9
1.1 1.7 24 1.3 244 4.9 72
1.1 1.6 27 1.3 266 5.0 82
1.1 1.5 28 1.3 234 4.8 76
1.0 1.6 28 1.3 248 5.3 78
1.0 1.6 27 1.3 241 5.7 82
SCF
0.7 2–4* 0–10 (0.4 g PUFA) 6.4/6.8/5.6/6.0/6.0 1.1 1.6 18 1.5 200/400** 1.4 45
0.6 2–4* 0–10 (0.4 g PUFA) 4.4/4.8/4.4/4.4/4.0 0.9 1.3 14 1.1 200/400** 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4Folate equivalent ( 1 g food folate 0.5 g folic acid). * D-A-CH (2000); ** Eurodiet (2000). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996. 1 2
106
Annexes
Table 68. Mean daily mineral intake (mean SD) in Danish adults (19–64 years)
Men
19–24 years (n 86)
25–34 35–44 45–54 years years years (n 142) (n 135) (n 147)
55–64 SCF years (n 140)
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
4.6 3.6 1,379 1,893 396 12.3 15.0 110 46
4.2 3.7 1,121 1,747 403 12.1 14.6 166 47
3.4 3.8 1,051 1,674 383 11.6 13.8 147 48
Women
(n 100) (n 161) (n 158) (n 155)
(n 128)
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
3.1 2.8 1,100 1,380 290 8.5 10.3 102 34
2.5 3.0 885 1,287 295 8.9 10.6 158 39
3.3 3.0 1,015 1,403 316 9.5 11.0 117 39
3.9 4.0 1,027 1,708 408 12.6 14.9 161 48
2.9 3.1 901 1,292 310 8.7 10.6 134 36
3.8 3.8 983 1,614 394 11.8 13.9 160 47
2.8 3.1 947 1,332 313 8.9 10.9 150 38
0.6–3.5 3.1 700/800* 550 150–500 9 9.5 130 55
0.6–3.5 3.1 700/800* 550 150–500 16* 7 130 55
* Eurodiet (2000). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
The mean calcium and magnesium intake was in men and women of all age groups higher than the population reference intakes of the SCF and Eurodiet. On average, a sufficient supply can thus be assumed. The intake of iron in Danish women was far below the recommended 16 mg/day. Practically none of the participating women reached this population reference. In line with this, 8.6–20% of women aged 18–50 years have been found to have a serum ferritin below 15 g/l and 0–8% to have iron deficiency anaemia. The mean intake of iodine was below the population reference intake of the SCF in men of the first age group and in women of the first two age groups. The participants of all other age groups had mean intakes above the recommended level. Iodine excretion in casual urine samples was 61 g/l in men and women aged 18–65 years. No clear sex difference was found, however a geographical difference was found with lowest values in the western part of the country and highest in the eastern part. The western part of the country has mild to moderate iodine deficiency and the eastern part has a
Annexes
mild iodine deficiency according to the iodine concentration in casual urine samples. The average intake of selenium was below the population reference intake in men and women of all age groups. It has to be considered that the selenium intake is very difficult to measure as the content of this micronutrient in food depends very much on the selenium concentration in the soil. Elderly In Danish elderly the mean energy intake was again higher than the average requirements indicated by the SCF (table 69). However, in elderly people a higher BMI is associated with a higher life expectancy, thus this relatively high intake is not to be valuated negatively. The mean share of protein in total energy intake was on average lower in male than in female elderly. In both male and female elderly of both age groups the average absolute protein intake was above the population reference intake of the SCF. Danish elderly women also had a higher contribution of carbohydrates 107
Table 69. Mean daily intake of energy and macronutrients (mean SD) in Danish elderly (65–80 years)
Elderly
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Added sugar %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
Male
Female
SCF
65–74 years (n 122)
75–80 years (n 64)
65–74 years (n 103)
75–80 years (n 44)
M
F
10.9 14 91 41 7 25 39 17 12 5 466 6 22
10.5 13 76 41 7 20 38 16 11 6 415 8 32
8.5 16 76 43 8 19 39 17 11 5 382 2 7
8.2 14 68 45 9 18 38 17 11 5 387 3 8
9.2/8.0 7.7/7.3 10–15** 56 55* 10** 25* 30* 10* – 6–10* 300** – –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * WHO (2003). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
in total energy intake compared to elderly men. It was for both population groups far below the recommended normal range of Eurodiet (2000). However, the share of added sugar in total energy intake was relatively low for both males (7%) and females (8–9%). The mean intake of dietary fibre was satisfactory in men aged 65–74 years, in all other elderly participants it was on average relatively low. The mean proportion of fat in total energy intake was equal in male and female elderly. The share of SFA in total fat intake was very high in both male and female elderly of all age groups, indicating a relatively high amount of animal fat in total fat intake and thus of animal products in total food intake. Consequently, the mean intake of cholesterol was too high in both men and women older than 65 years as well. Especially Danish elderly men had a relatively high alcohol intake with about 6–8 %E. The mean intake of vitamin D was at about the same level as in Danish adults. It has to be considered, that particularly elderly people tend to leave their homes less often which leads to a lower amount of sun exposure and consequently to increased requirements of vitamin D. Eurodiet (2000) recommends for this population group a daily intake of 10 g. This level was on average not 108
Annexes
reached by Danish elderly. Measurement of serum 25-OHD has shown low values. Among 104 elderly people above 65 years 80 had a serum 25-OHD below 50 nmol/l and among 231 healthy 80 year old men and women 24% had a serum 25-OHD below 30 nmol/l (table 70). Also folate intake was below the recommended level of Eurodiet. In Danish elderly men the mean intake of sodium was relatively high as well, although not as high as in Danish male adults (table 71). The mean intake of potassium in elderly men was higher than the population reference intake and was thus on average sufficient. In women it was slightly higher than the recommendation of the SCF in the first age group; in the last age group it was below it. The median of potassium intake in elderly women was around 3.1, thus about half of these women had a mean intake of this micronutrient below the population reference intake. The average calcium intake decreased in both male and female elderly with increasing age. It was however in both age groups above the population reference intakes of the SCF and Eurodiet. On average, a sufficient supply of calcium in elderly Danish people can be assumed. The supply of magnesium can be regarded as
Table 70. Mean daily vitamin intake (mean SD) in Danish elderly (65–80 years)
Elderly
Male
Female
SCF
65–74 75–80 65–74 75–80 M years years years years (n 122) (n 64) (n 103) (n 44) Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
1.6 3.2 4.1 9.2
1.4 2.8 3.7 10.8
1.6 3.4 3.3 7.8
1.6 2.8 3.2 7.8
Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.3 1.9 36 1.7 301 6.8 79
1.2 1.7 29 1.5 259 5.7 69
1.1 1.6 29 1.4 261 6.1 79
1.0 1.6 24 1.3 273 6.2 77
F
0.7
0.6 2–4* 0–10/10** (0.4 g PUFA) 6.0/6.4 4.8/4.4 1.1 0.9 1.6 1.3 18 14 1.5 1.1 200/400** 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid). * D-A-CH (2000); ** Eurodiet (2000). Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996. 1 2
Table 71. Mean daily mineral intake (mean SD) in Danish elderly (65–80 years)
Elderly
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
Male
Female
SCF
65–74 years (n 122)
75–80 years (n 64)
65–74 years (n 103)
75–80 years (n 44)
M
F
3.6 3.8 954 1,641 380 11.9 13.5 143 49
3.4 3.3 822 1,404 334 9.7 11.1 101 41
2.8 3.2 912 1,366 307 9.0 11.2 111 41
2.5 2.8 864 1,264 276 8.5 9.8 115 39
0.6–3.5 3.1 700/800** 550 150–500 9 9.5 7 130 55
Source: Danskernes kostvaner 1995 Hovedresultater. Publikation nr 235 Levnedsmiddelstyrelsen 1996.
sufficient as well. The mean iron intake in elderly men was above the recommended level of 9 mg/day, in women of the first age group it corresponded to it, and in the second age group it was slightly below. The median intake in women of both age groups showed that about
Annexes
half of the participating elderly women had an intake below the recommended level. The mean intake of iodine was, apart from men aged 65–74 years, below the population reference intake of the SCF. Also the supply of selenium seemed to be insufficient in Danish elderly. 109
Conclusion The dietary survey from 1995 showed that the Danish diet contained too much fat and especially too much SFA. Children and young people also consumed too much added sugar. The amount of dietary fibre in the diet was generally low. The content of micronutrients in the average diet was generally satisfactory, but was low for vitamin D, iodine and iron for fertile women. In line with this low serum 25-OHD were found in a considerable part of a group of 12–13 year old children, a group of 80 year old men and women, as well as 8.6–20% of women ages 18–50 years have been found to have a serum ferritin below 15 g/l and 0–8% to have iron deficiency anaemia. Concerning iodine the western part of the country has mild to moderate iodine deficiency and the eastern part has a mild iodine deficiency according to the iodine concentration in casual urine samples. The dietary survey from 1995 showed that Danish diet contained too much fats, fatty dairy products and fatty meat. Children and young people also consumed too much sweets and soft drinks. The consumption of bread and cereals, and vegetables was too low, and males consumed too little fruit, compared to the recommendations at that time. Fifty percent of the population almost never ate fish – an important cause for the low intake of iodine and vitamin D. Results on energy intake and intake of foods from the national dietary survey 2000–2001 (Fagt, S. et al., 2004) show that from 1995 to 2000/2001 the content of butter and margarine has decreased in the Danish diet. This taken together with the replacement of full fat dairy products with low fat types has resulted in reduced average fat energy percent for children from 35 to 34 %E and for adults from 39 to 34 %E.
The content of fish in the Danish diet has decreased. Furthermore the intake of whole meal bread has decreased, and especially children ate less rye bread in 2000/2001 compared to 1995. This taken together with a decreased intake of ‘coarse’ vegetables such as root vegetable and cabbage, results in a decrease of dietary fibre in children. The intake of potatoes is stagnated. The diet of children and adults contained respectively 40 and 22% more sugar sweetened soft drink in 2000/ 2001 compared to 1995. Together with an increase in intake of candy this results in an increased energy percent from added sugar in the diet of children, from 13.7 to 14.0. The surveys also show an increase in alcohol intake from 5 to 6.1 %E for adults. Prevalence of Overweight and Obesity in Denmark Adolescents The prevalence of overweight among adolescents (age 14–16 years), using international borderlines [Cole, TJ et al. BMJ 2000;320:1240–1243], increased from 5.1% in 1971/1972 to 15.5% in 1996/1997 for boys, and for girls from 6.2 to 15.6% the same years. Using 25 kg/m2 as the borderline the prevalence has increased from 2.3 to 7.4% for boys, and from 3.9 to 10.4% for girls [Petersen TA-G et al. Ugeskrift for læger 2002;164:5006–5010]. Adults The prevalence of overweight and obesity among Danish men and women, based on self-reported data from the Danish Health and Morbidity Survey 2000 is shown in table 72. The prevalence of obesity among adults is 9.5%, and the prevalence of overweight (incl. obesity) is higher among men (49.6%) than among women (34%).
Table 72. Prevalence of overweight and obesity among men and women, %, based on self-reported data. (n number. Overweight: BMI 25.0, Obese: BMI 30) Age 16–24
Age 25–44
Age 45–66
Age 67–79
Age 80
In all
Men Overweight (incl. obese) Obese
(n 1,108) 22.7 5.4
(n 2,822) 45.5 7.8
(n 3,045) 62.3 13.8
(n 872) 55.8 10.3
(n 279) 45.5 4.3
(n 8,126) 49.6 9.8
Women Overweight (incl. obese) Obese
(n 1,047) 16.0 3.0
(n 2,936) 29.7 9.1
(n 2,921) 40.4 10.6
(n 950) 47.4 12.1
(n 421) 35.8 8.5
(n 8,275) 34.0 9.1
Source: Kjøller and Rasmussen (2002).
110
Annexes
Finland
mass index has increased [Nutrition in Finland, KTL, 2004].
Nutrition plays a major role in the aetiology of the most prevalent health problems in Finland: coronary heart disease, cerebrovascular disease, hypertension, and cancer, and apparently also in the development of diabetes and osteoporosis. Obesity may also contribute to the development of musculoskeletal disease. Food elimination is a crucial factor in the care of food allergies. Furthermore, food habits contribute to the prevalence of dental caries [Nutrition in Finland, KTL, 2004]. Type 1 diabetes, usually starting in childhood or adolescence, has become increasingly common in Finland since the 1950’s, and the prevalence figures are now the highest in the world. Type 2 diabetes – usually occurring in adulthood – has also increased, but to a lesser extent than Type 1. Osteoporosis is a growing health problem, among the ageing female population in particular. The oral health of children and young people has improved significantly over the past few decades. Finnish children aged 12 currently have cavities or fillings only in 1.1 teeth on average. The prevalence of asthma and allergies has increased during the past 20 years. It is estimated that about 10% of children under 6 years of age have a food allergy. However, the prevalence of food allergies is decreasing with age, even though 1–2% of adults are estimated to be sensitive to some foods [Nutrition in Finland, KTL, 2004]. Blood pressure levels in the population have slightly dropped during the past 25 years. This is due to improved detection of those who need treatment and improved treatment coverage. Other cardiovascular risk factor levels have also changed among adults of working age. Due to the favourable changes in diet, the serum cholesterol concentration in the Finnish population has dropped quite markedly. Compared internationally the figures still remain very high, because only 30% of Finns have serum cholesterol level lower than the recommended reference: 5 mmol/l. In addition, decreases in smoking habits are among the most decisive factors in relation to cardiovascular health. Trends in obesity are of great concern, since both the mean body mass index and the prevalence of obesity have increased among adults during the past 25 years. Presently, 20% of adults of working age are obese (BMI 30 kg/m2). In addition, almost 50% of men and 33% of women are overweight (25 kg/m2 BMI 30 kg/m2). The risk factors in children and adolescents have changed in a similar way. The cholesterol levels of adolescents have decreased considerably, while the body
Annexes
Infants There is a large population-based prediction and prevention study on diabetes (DIPP) underway in Finland, where also food consumption data on infants (3 and 6 months) is collected. The first results on nutrient intake are expected to be ready for publication in 2005. Hanna Lagström (1999) has included the intake of nutrients of children at the age of 8 months (n 215) in her dissertation information. This data was collected as a part of the special Turku Coronary Risk factor Intervention (STRIP) Project. In the STRIP Project, families were recruited by nurses at the child health centres in the City of Turku. At the child’s routine 5-months visit to the child health centre, all families were informed of the possibility to participate in the STRIP trial. The children and their families who volunteered were randomly assigned to an intervention group or a control group. The intervention group was met at 1–3-month intervals until the child was 2 years old. Families in the intervention group received dietary counselling and therefore data on their diet was not included in this report, but the results presented here reflect the nutrient intake in the control group. There is a possibility that the intervention has had an effect also on the control group and therefore the information may not be representative of the total population of this age group. Dietary intake was assessed by 3-day food record until the child was 2 years old, and by 4-day food record after that. Boys’ and girls’ nutrient intakes have been combined in all tables of the STRIP Study. Lagström (1999) indicated that the energy and energy nutrient intake as well as the amount of essential fatty acids in the 8 months old infants’ diet was adequate when compared to the Nordic Nutrition Recommendations (NNR) (table 73), and that the proportion of linoleic and linolenic acid (not given in the table) met the recommendations by NNR. According to table 74 Finnish children’s diet is characterised by low content of vitamin D [Lamberg-Allardt et al., 1984 in Lagström, 1999]. The low intake of vitamin D is compensated by supplemental vitamin D, as recommended by the child health centres. The results from this study support this practice/recommendation. According to these results there is no need for population-based vitamin A supplementation in this age group. 111
Table 73. Mean daily intake of energy and macronutrients (mean SD) in Finnish infants (8 months)
Table 75. Mean daily mineral intake (mean SD) in Finnish infants (8 months)
Nutrient
Age: 8 months Mean SD (n 215)
SCF
Mineral
Age: 8 months Mean SD (n 215)
SCF
Energy (MJ) Protein (g) Protein %E Carbohydrates (g) Carbohydrates %E Sucrose (g) Sucrose %E Dietary fibre (g) Fat (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg)
3.5 0.6 25 6 12 3 122 24 58 11 5.4 4.1 32 6.7 2.9 27 6 28.8 4.1 12.6 2.3 8.7 1.5 4.9 0.8 73 31
– 15 –
Calcium (mg) Sodium (mg) Iron (mg) Zinc (mg)
425 107 683 339 7.5 1.7 4.1 1.3
400 – 6 4
–
Source: Lagström, 1999.
– – – – – – –
Table 74. Mean daily vitamin intake (mean SD) in Finnish infants (8 months) Vitamin
Age: 8 months Mean SD (n 215)
SCF
Vitamin A1 (g) Vitamin D (g) Vitamin E (mg) Vitamin C (mg)
720 677 0.6 1.0 5.9 1.7 99 30
350 102 42 20
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita: Helsinki; 1998. Source: Lagström, 1999. 1
Iron intake was somewhat lower than recommended by SCF (table 75). However, calcium and zinc intake was considered adequate. Mean sodium chloride intake per day was 1.6 grams at the age of 8 months. This was higher than recommended by NNR. Children The following tables on 1–7 year old children’s daily energy and nutrient intakes are based on two nutrition studies on children, one by Hanna Lagström (1999) as described earlier, and the other by Katriina Ylönen et al. on dietary intake in children aged 1–7 years (1996). 112
Annexes
Families with 1–7 year old children in the Ylönen et al. (1996) study were recruited from two child health centres in Southern Finland. Children in Ylönen et al’s study were healthy age- and sex-matched children in the control group of a larger study by Virtanen et al. (1992) to investigate food and nutrient intake and metabolic control in young diabetic children. The aim of the study (Ylönen et al., 1996) was to describe the composition of diet in relation to fat intake in children aged 1–7 years, but also the absolute daily intakes of nutrients were reported. Energy and nutrient intakes were assessed with 3-day food records. There were 30 children in the 1–3 year old group (14 boys and 16 girls), and 47 children in the 4–7 year old group (26 boys and 21 girls). The response rate was 86% (Ylönen et al., 1996). On average, energy derived from protein and fat is proportionately fairly high in Finnish children’s diet according to these studies as well as the energy derived from sugar. It seems that special attention should be paid to increasing the consumption of healthy carbohydrates, i.e., cereals and vegetables, and decreasing the consumption of sugar (tables 76 and 77). Vitamin D intake was low and supports the vitamin D supplementation among young children (tables 78 and 79). In addition to low vitamin D intake, high salt consumption characterises the diet of young children. Snacking has become more common in Finland and it contributes to the high sodium intake (tables 80 and 81). As among adults, bread, cereals and meat dishes are major sources of salt also among children. Adults The first survey on Finnish diet as part of the FINMONICA risk factor survey was done in 1982, and
Table 76. Mean daily intake of energy and macronutrients (mean SD) in Finnish children (13 months, 2, 3 and 4 years) Nutrient
Energy (MJ) Protein (g) Protein %E Carbohydrates (g) Carbohydrates %E Sucrose (g) Sucrose %E Dietary fibre (g) Fat (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg)
13 months Mean SD (n 449)
2 years Mean SD (n 433)
3 years Mean SD (n 398)
4 years Mean SD (n 359)
4.2 7.6 42 10
4.8 8.6 45 10
5.2 1.0 47 12
5.7 1.1 51 11
17 4 134 26 54 10 13.0 7.9 53 9.0 2.9 31 8 28 5 12.4 3.1 8.8 2.0 3.8 1.3 109 45
16 3 143 28 50 10 24.0 11.1 84 9.1 2.8 42 10 33.0 4.8 14.5 3.0 10.8 2.0 4.4 1.4 157 65
15 4 156 33 50 11 30.5 12.9 10 4 9.7 2.8 45 11 33.4 4.6 14.7 2.7 10.9 1.9 4.7 1.2 171 66
15 3 173 33 51 10 36.1 16.0 11 5 10.9 3.2 49 13 33.1 4.7 14.6 2.8 10.7 1.8 4.6 1.2 182 68
SCF
– 1.1 g/kg of body weight/day – – – – – – – – –
Source: Lagström, 1999.
Table 77. Mean daily intake of energy and macronutrients (mean SD) in Finnish children (1–3 and 4–7 years)
Nutrient
1–3 years Mean SD (n 30)
4–7 years Mean SD (n 47)
5.7 1.3 52 14
7.0 1.3 61 15
Carbohydrates (g) Sucrose (g) Dietary fibre (g) Fat (g) SFA (g) MUFA (g) PUFA (g) Cholesterol (mg)
168 38 47 19 10.5 3.2 55 16 24.1 7.7 18.9 5.8 9.7 3.8 217 86
220 49 72 31 13.2 3.4 63 18 26.9 7.6 21.6 6.8 11.6 4.7 255 112
Protein (%) Fat (%) SFA (%) MUFA (%) PUFA (%) Carbohydrate (%) Sucrose (%)
15 4 36 11 16 5 13 4 63 49 11 14 4
15 4 34 10 14 5 12 4 63 51 12 17 7
Energy (MJ) Protein (g)
SCF 1–3 years
SCF 3 years
– 1.1 g/kg of body weight – – – – – – – –
– 1.0 g/kg of body weight – – – – – – – –
10–151 30–351 – – – 50–601 –
10–151 301 – – – 55–601 10*1
1
National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita:Helsinki; 1998. * Added sucrose. Source: Ylönen et al., 1996.
Annexes
113
Table 78. Mean daily vitamin intake (mean SD) in Finnish children (13 months, 2, 3 and 4 years)
Vitamin
13 months Mean SD (n 449)
2 years Mean SD (n 433)
3 years Mean SD (n 398)
4 years Mean SD (n 359)
SCF
Vitamin A1 (g) Vitamin D (g) Vitamin E (mg) Vitamin C (mg)
717 581 1.4 1.3 3.7 1.7 67 32
665 527 1.8 1.0 4.7 1.8 73 38
767 624 1.9 1.0 5.3 1.7 76 44
880 691 2.1 1.1 5.5 1.7 75 40
400 10, 52 – 25
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita:Helsinki; 1998. Source: Lagström, 1999. 1 2
Table 79. Mean daily vitamin intake (mean SD) in Finnish children (1–3 and 4–7 years)
Vitamin
1–3 years Mean SD 794 569 2.1 2.1 1.0 0.3 1.7 0.6 19.5 5.8 87 39
Vitamin A1 (g) Vitamin D (g) Vitamin B1 (mg) Vitamin B2 (mg) Niacin2 (mg) Vitamin C (mg)
4–7 years Mean SD 771 422 2.4 1.7 1.2 0.3 1.9 0.5 23.1 5.4 116 64
SCF 1–3 years
4–6 years
7–10 years
400 103 0.5 0.8 9 25
400 5 0.7 1.0 11 25
500 5 0.8 1.2 13 25
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids, Niacin equivalent (1 mg niacin 60 mg tryptophan), 3 National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita:Helsinki; 1998. Source: Ylönen et al., 1996. 1 2
Table 80. Mean daily mineral intake (mean SD) in Finnish children (13 months, 2, 3 and 4 years)
Mineral
13 months Mean SD (n 449)
2 years Mean SD (n 433)
3 years Mean SD (n 398)
4 years Mean SD (n 359)
SCF
Calcium (mg) Sodium (mg) Iron (mg) Zinc (mg)
807 240 1,569 522 6.4 1.8 6.2 1.7
833 238 1,809 505 7.0 2.2 6.6 1.6
845 247 1,957 532 7.8 2.5 7.0 1.6
905 240 2,129 555 8.8 3.1 7.6 1.7
400/450 – 4 4/6
Source: Lagström, 1999.
every fifth year after (Männistö et al., 2003; Uusitalo et al., 1987). The National FINDIET 2002 Study was carried out as part of the chronic disease risk factor monitoring FINRISK 2002 Study. A random sample involving 13,500 people 25–74 years of age and stratified for sex and 10-year age groups was taken from the population register. The participation rate was 65%, i.e., 8,799 subjects. In five areas, 32% of the invited subjects were 114
Annexes
randomly selected also to the dietary survey [Valsta and the National FINDIET 2002 Study Group, 2003]. The aim of this National FINDIET 2002 Study was to measure the average food and nutrient intake in adults in early spring of 2002. The areas were the same as in 1997: Helsinki and Vantaa (the metropolitan area), the cities of Turku and Loimaa as well as some rural communities in Loimaa, and the provinces of North Karelia,
Table 81. Mean daily mineral intake (mean SD) in Finnish children (1–3 and 4–7 years)
Mineral
Calcium (mg) Potassium (mg) Magnesium (mg) Iron (mg) Zinc (mg) Iodine (g) Phosphorus (mg) Sulphur (mg)
1–3 years Mean SD 828 273 2,398 666 199 48 8.4 3.2 7.6 1.9 250 95 1,047 279 638 256
4–7 years Mean SD 973 323 2,737 639 237 51 10.2 3.1 8.9 2.1 299 133 1,225 319 741 250
SCF 1–3 years
4–6 years
400 300 – 4 4 70 300 –
450 350 – 4 6 90 350 –
Source: Ylönen et al., 1996.
North-Savo and Oulu. The final sample size of the dietary survey was 2,007 participants (63% of those invited). For the dietary assessment, the participants were interviewed using the 48-hour recall method. A new interview-based program Finessi was developed for this study for entering and processing the dietary interview data. Also the National Food Database Fineli used for the nutrient intake estimations was updated. The dietary intake data consisted of all days of the week except Fridays. Altogether 1,554 different food codes of the National Food Database were used to enter the food consumption data. The diet of the subjects contained on average 25 different foods per day. The average intake of nutrients in different population groups was evaluated according to the newest Finnish dietary recommendations from 1998. According to the National FINDIET 2002 Study, the average dietary energy intake was 9.2 MJ/day among men and 6.6 MJ/day among women. Among men, dietary energy intake was the highest in the eastern research areas, but there were no regional differences in the energy intake among women. About half of the energy was derived from main meals on average, but one third of energy was derived from snacks. There were two energy intake peaks, one at lunchtime and the other at dinnertime (11 a.m. and 5 p.m.). One third of energy was derived from bread and other cereal products, and another third was derived from meat dishes and milk products. Meat dishes, sausages, milk and fat spreads contributed most (about 60–70%) to the dietary fat intake. Meat and sausage dishes (including other dishes containing these ingredients), fat spreads, cheese, and milk products were the main sources of hard fat. Margarines and other vegetable fat spreads were the main sources of essential fatty acids, linoleic and
Annexes
alpha-linolenic acid. Main sources of cholesterol were meat products and meat dishes, eggs and milk products. Bread (especially rye bread) contributed about half of fibre intake. The intake of fat, hard fat (sum of saturated and trans fatty acids) and protein was high, whereas the intake of carbohydrate and fibre was low compared to the Finnish nutrition recommendations (table 82). The intake of polyunsaturated fatty acids was close to the recommendation and the intake of essential fatty acids and monounsaturated fatty acids was at the recommended level. The fibre recommendation (3 g/MJ) was reached only among women in North Karelia and among women in the oldest age group, 55–64 years of age. The energy adjusted intake of sucrose was higher than recommended among women and highest among the youngest women. Alcohol (ethanol) contributed on average 3.5% of total energy among men and 1.5% of total energy among women. This was not beyond the recommended maximum level (5% of energy). However, alcohol intake was underestimated, because Fridays were not included in the study protocol. Alcohol intake among those, who reported consumption of alcoholic beverages, was close to double compared to the recommended maximum intake. Men’s diet contained more fat and alcohol, but less carbohydrates than the women’s diet [Valsta and the National Findiet 2002 Study Group, 2003]. Especially in the youngest age group the intake of vitamin D in women and the intake of folate in both women and men were below the recommendations (table 83). The intake of most nutrients varied very little by education. However, men in the highest educational group had the highest intake of vitamin E and C. Women in the lowest educational group had the lowest intake of fibre and 115
Table 82. Mean daily intake of energy and macronutrients (mean SD) in Finnish adults (25–64 years) Men
25–34 years Mean SD (n 190)
35–44 years Mean SD (n 215)
45–54 years Mean SD (n 232)
55–64 years Mean SD (n 275)
All Mean SD (n 912)
Recommendation1
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Water-soluble f. (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
10.0 2.8 16 4 47 8 10 5 21 10 42 34 7 14 4 12 3 52 291 151 36 12 25
9.3 3.1 16 4 45 7 95 21 10 52 35 7 15 4 12 3 52 270 138 37 13 36
8.9 2.6 16 4 45 10 96 22 10 52 35 8 14 5 12 3 52 266 141 48 14 34
8.7 2.8 16 3 45 8 95 23 11 52 36 8 15 5 12 3 52 276 167 36 8 21
9.2 2.9 16 4 46 8 95 22 10 52 35 8 14 4 12 3 52 275 151 37 12 29
10.0 10–15 55–60 10 25–35 – 30 10 10–15 5–10 – 5 –
Women
(n 263)
(n 266)
(n 275)
(n 291)
(n 1,095)
Energy (MJ) Protein %E Carbohydrates %E Sucrose %E Dietary fibre (g) Water-soluble f. (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
7.1 2.2 16 4 51 8 12 5 17 6 42 32 7 13 4 10 3 52 187 103 14 4 11
6.7 2.0 17 3 49 8 11 5 19 7 42 34 7 14 4 11 3 52 197 108 14 39
6.6 2.0 17 4 48 8 10 5 19 8 52 33 7 14 4 11 3 52 187 86 24 5 11
6.2 1.9 17 4 50 8 10 5 20 8 52 31 7 13 4 10 3 52 182 98 14 37
6.6 2.0 17 4 50 8 11 5 19 8 42 32 7 14 4 11 3 52 188 99 24 4 10
8.0 10–15 55–60 10 25–35 – 30 10 10–15 5–10 – 5 –
1
National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita: Helsinki; 1998. Source: Finravinto, 2002.
vitamin C and the highest intake of saturated fatty acids and selenium. More than half of vitamin C intake was derived from fruit and berries. Similarly, more than half of thiamine was derived from cereals and meat dishes. Other B vitamins were mainly derived from cereals, meat and milk products (Valsta and the National FINDIET 2002 Study Group, 2003). In regard to the recommendation of Eurodiet for folate (400 g/day), the average intake of this vitamin has to be considered insufficient in Finnish adults. The intake of minerals was as recommended except for salt intake (NaCl), which was higher than the recommendations and except for the total daily intake of 116
Annexes
iron among women, which did not reach the recommendations. Cereals, meat and milk were also important food sources of minerals. Bread, other cereals and meat dishes contributed most to sodium intake. The iron intake in premenopausal women has on average to be regarded as insufficient (table 84). The National FINDIET 2002 Study to assess the average diet of Finnish adults was the first in Finland to use the 48-hour dietary recall method. To validate the method, it was compared to the 5-day dietary information (48-hour recall a three day dietary record) in 146 men and 185 women. Both methods yielded similar results for energy and for nutrient densities. Energy intake by the 48-hour dietary recall was
Table 83. Mean daily vitamin intake (mean SD) in Finnish adults (25–64 years) Men
25–34 years Mean SD (n 190)
35–44 years Mean SD (n 215)
45–54 years Mean SD (n 232)
55–64 years Mean SD (n 275)
All Mean SD (n 912)
SCF
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g)
1.0 1.0 2.3 2.2 4.2 3.2
1.1 2.4 2.1 1.9 4.9 4.8
1.0 1.2 2.3 2.4 6.1 6.8
1.0 1.2 1.9 2.0 7.3 7.6
1.0 1.5 2.1 2.1 5.8 6.2
Vitamin E2 (mg) Vitamin B1 (mg) Vitamin B2 (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Vitamin B12 (g) Vitamin C (mg)
12.1 5.6 1.4 0.5 2.2 0.9 34 15 2.4 2.9 281 100 6.9 5.1 104 87
11.5 5.2 1.4 0.6 2.0 0.9 32 12 2.0 0.8 275 164 6.8 11 95 82
11.5 4.9 1.3 0.5 2.0 0.8 30 10 2.0 0.8 274 108 7.0 5.9 87 67
12.1 6.4 1.4 0.6 1.9 0.7 29 11 1.9 0.8 267 108 7.2 6.1 83 71
11.8 5.6 1.4 0.6 2.0 0.8 31 12 2.0 1.5 273 122 7.0 7.4 91 77
0.7 – 5 over 61 years: 105 105 1.1 1.6 18 1.5 200/4006 1.4 45
Women
(n 263)
(n 266)
(n 275)
(n 291)
(n 1,095)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g)
0.8 0.5 2.5 2.2 2.9 2.6
0.9 0.8 2.8 2.9 3.5 3.8
1.1 1.6 2.7 3.0 3.7 3.9
1.0 1.3 2.7 2.6 4.8 5.3
0.9 1.1 2.7 2.7 3.8 4.1
Vitamin E2 (mg) Vitamin B1 (mg) Vitamin B2 (mg) Niacin3 (mg) Vitamin B6 (mg) Folate4 (g) Vitamin B12 (g) Vitamin C (mg)
8.9 3.5 1.0 0.5 1.6 0.6 23 8 1.7 0.7 214 73 4.3 2.7 104 69
8.6 3.5 1.0 0.4 1.5 0.6 22 7 1.5 0.5 219 86 4.7 3.2 98 72
8.8 3.9 1.0 0.4 1.5 0.6 22 7 1.5 0.6 233 115 5.2 6.7 106 69
9.5 5.8 1.1 0.4 1.6 0.7 21 7 1.5 0.6 229 110 5.2 5.5 112 71
8.9 4.3 1.0 0.4 1.6 0.6 22 7 1.5 0.6 224 98 4.9 4.9 105 70
0.6 – 5 over 61 years: 105 85 0.9 1.3 14 1.1 200 /4006 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals), 5 National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita: Helsinki; 1998, 6 Eurodiet (2000). Source: Finravinto 2002. 1 2
99% of the energy intake obtained by the 5-day data among men and women. The only exception was alcohol consumption, which was underestimated, due to the omission of Fridays in the 48-hour recall method, as described earlier in this report. The new methods of assessing dietary intake adopted in the National FINDIET 2002 Study performed well. Also the data collection phase worked according to the study plan. Only the participation rate (63% of those invited) was lower than in the earlier national dietary surveys, which makes it harder to generalise the results to
Annexes
the whole population. The reasons for the lower participation rate can hardly be related to the FINDIET field study processes, but is most probably related to the general problems of participation, e.g., lack of time. Finns are not paid for their participation in research studies, but have until now been known for their high participation rates. According to the results of this study, special attention in the diet of Finnish men should be paid to the quality of fat consumed as well as the low amount of whole grain cereal products, vegetables, fruit and berries in the diet. While the quality of fat in the diet of Finnish women did 117
Table 84. Mean daily mineral intake (mean SD) in Finnish adults (25–64 years) Men
25–34 years Mean SD (n 190)
35–44 years Mean SD (n 215)
45–54 years Mean SD (n 232)
55–64 years Mean SD (n 275)
All Mean SD (n 912)
SCF
Calcium (mg) Potassium (g) Sodium (g) Magnesium (mg) Phosphorus (mg) Iron (mg) Zinc (mg) Iodine (g) Selenium (g)
1,391 623 4.1 1.2 4.1 1.2 410 124 1,878 600 13.3 5.2 12.7 7.1 320 116 83 30
1,203 607 4.0 1.3 3.9 1.4 409 148 1,761 643 13.1 5.8 12.5 3.9 284 112 81 28
1,137 535 4.1 1.2 3.8 1.4 411 124 1,754 573 13.0 5.5 11.8 3.3 270 107 78 27
1,075 509 3.9 1.1 3.9 1.5 392 120 1,733 603 13.4 5.8 9.1 3.3 275 108 75 31
1,187 575 4.0 1.2 3.9 1.4 405 129 1,775 606 13.2 5.6 11.5 4.8 285 112 79 29
700/8003 3.1 11 3501 550 9 9.5 130/1503 55
Women
(n 263)
(n 266)
(n 275)
(n 291)
(n 1,095)
Calcium (mg) Potassium (g) Sodium (g) Magnesium (mg) Phosphorus (mg) Iron (mg)
1,001 455 3.1 0.9 2.7 0.9 299 88 1,314 450 10.0 3.5
986 404 3.2 0.9 2.7 0.9 311 93 1,315 426 10.0 3.5
954 397 3.2 0.9 2.7 0.9 311 88 1,309 439 9.9 3.4
946 418 3.3 0.9 2.7 1.0 315 92 1,349 482 10.2 4.8
971 419 3.2 0.9 2.7 0.9 309 90 1,322 450 10.0 3.9
10.4 3.3 215 80 55 20
10.3 3.7 218 121 58 19
10.1 3.1 203 75 56 18
9.2 3.4 214 77 55 20
10.1 3.4 212 90 56 19
Zinc (mg) Iodine (g) Selenium (g)
700/8003 3.1 11 2801 550 16* 82 7 130/1503 55
1
National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Edita: Helsinki; 1998, 2 Postmenopausal, 3 Eurodiet (2000). Source: Finravinto 2002.
not meet the recommendations, neither did the quality of carbohydrates, and both need improvement. Especially among the youngest women an increase in the consumption of whole grain cereals and a decrease in sugar-rich foods would be desirable to improve the diet. The low energy intake commonly seen among young women sets special requirements to the quality of the diet. In addition to the problems caused by alcohol, attention should also be paid to the considerable amount of energy obtained from alcoholic beverages in different population groups. The diet of middle-aged and older women has still the best nutritional quality compared to other groups in Finland (Valsta and the National Findiet 2002 Study Group, 2003). Vitamin D Supplementation in Finland It is recommended that the diet in Finland is supplemented with vitamin D. The Ministry of Social Affairs and Health has recommended that infants under the age 118
Annexes
of 1 year who are breastfed (exclusively or complementarily) should receive a supplemental dosage of 10 g of vitamin D per day. Children receiving milk formula should get 6 g of supplemental vitamin D per day. All children at the age of 1–3 years should get 5–6 g of supplemental vitamin D daily. Children who consume the unfortified types of milk (farm milk) or organic milk should receive a supplement of 10 g. (Fortification in Finland: 0.5 g vitamin D3/100 ml liquid milk products; 10 g/100 g of fat spreads.) Also 3–15 year old children, who do not regularly consume fortified milk products or who have a dark complexion, should receive a daily supplement of 5–6 g of vitamin D from October to March or all year round, respectively. During the dark autumn and winter months of October through March, a daily dose of 10 g is recommended for pregnant and lactating women and 5 g for all adults who do not regularly consume fortified milk
products. Elderly people who rarely get exposure to sunlight should receive a supplement of 10 g of vitamin D daily throughout the year. There are several ongoing smaller studies on food consumption and nutrient intake in varying age-groups in Finland. The Nutrition Surveillance system (established in 1995) at the National Public Health Institute routinely collates such results into its special annual reports (Ravitsemuskatsaus) with varying foci each year.
France The data used to show the dietary intake and nutritional status in the French population was obtained from the SU.VI.MAX Study. The SU.VI.MAX study is an 8-year long primary prevention trial which started in 1994 and evaluated the effects of daily antioxidant supplementation (vitamin C, vitamin E, -carotene, selenium and zinc) at nutritional doses on the incidence of cancers and cardiovascular diseases. The cohort consisted of women at the age of 35–60 years at baseline (mean: 46.4, SD: 6.7) and men at the age of 45–60 years at baseline (mean: 51.1, SD: 4.7) and none of them used vitamin supplements. Subjects were invited to participate by a multimedia campaign in the whole of France. Potential subjects
Table 85. Mean daily intake of energy and macronutrients (mean SD) in French adults (45–60 and 35–60 years)
received detailed information on the study and performed a self-test of acceptability of the daily supplements. In total 12,735 subjects were included at baseline in 1994 with a male/female ration of 2:3. The study population covered all France, but cannot be seen as representative of the general French population as they were volunteers for a long-term intervention trial. They were probably more health conscious and may therefore have had a healthier diet and a better nutritional status than the general French population. Adults The mean energy intake in French adults was below the average requirements calculated for this population group by the SCF (table 85). The share of protein in total energy intake was with 17% in men and 18% in women above the recommended normal range of the WHO (2003). The absolute intake data show that the mean intake was above the recommended absolute intake of the SCF. A sufficient supply of protein in this sample can thus be assumed. The average proportion of carbohydrates in total intake in this sample was very low with 39% in men and 40% in women. Consequently also the mean intake of dietary fibre was very low in French adults. The proportion of fat in total energy intake was on average very high. In the male sample as well as in the female sample it was far above the recommended
Adults
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Linoleic acid (n-6) %E -Linolenic acid (n-3) %E Cholesterol (mg) Alcohol %E Alcohol (g)
Male 45–60 years (n 3,323)
Female 35–60 years (n 4,879)
SCF
9.5 2.3 17 4 98 24 39 12 20 8 37 11 15 7 14 4 52 4.1 1.6 0.4 0.1 609 316 77 23 21
7.1 1.9 18 5 75 20 40 13 17 6 39 13 16 6 14 5 52 4.2 1.8 0.4 0.1 497 268 35 9 12
11.3
M
F 8.6 10–15**
56
47 55* 25* 30* 10* 6–10* 300**
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Annexes
119
upper level of Eurodiet of 30 %E with 37 and 39 %E respectively. Further, the share of SFA in total fat intake was relatively high as well with 15 and 16 %E respectively and also the mean cholesterol intake in this population was very high. In women it was around 500 mg/ day, in men it was even higher than 600 mg/day. The average share of alcohol in total energy intake was relatively high as well, especially in the male sample with 7 %E ( 23 g/day). In the female sample it was lower with about 3 %E ( 9 g/day). In general, more men than women reached the recommendations for vitamins because of their higher general intake of foods. Particularly the intake of vitamin A,
vitamin C, vitamin D, vitamin E, folate, calcium and magnesium was low, and a large part of the population was thus at risk of having an intake of these nutrients below their needs (table 86). The low consumption of fruits and vegetables was probably the main reason for these low intakes. Also the consumption of dairy products was not sufficient to cover the recommendations for calcium intake. Furthermore, the dairy products in France are not fortified with vitamin D, which explains the extremely low intake of vitamin D. As expected the intake of iron was particularly low in women (table 87). This was probably due to the low intake of meat, especially among women at childbearing
Table 86. Mean daily vitamin intake (mean SD) in French adults (45–60 and 35–60 years)
Male (n 3,323)
Adults
Female (n 4,879)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
0.9 1.4 3.6 2.8 2.9 2.4 11.2 4.6
0.7 1.0 3.4 2.8 2.4 2.1 9.5 4.0
Vitamin B1 (mg) Vitamin B2 (mg) Vitamin B6 (mg) Folic acid3 (g) Vitamin B12 (g) Vitamin C (mg)
1.8 0.7 1.8 0.6 2.0 0.5 320 101 8.2 6.8 92 50
1.5 0.6 1.5 0.5 1.6 0.5 272 93 6.1 5.2 88 46
SCF M
F
0.7
0.6 0–15; (0.4 g PUFA)
5.0 1.1 1.6 1.5
3.9 0.9 1.3 1.1 200/400* 1.4 45
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent (mg -tocopherolmg -tocopherol 0.5 mg
-tocopherol 0.25mg -tocotrienol 0.33), 3 Folate equivalent (1 g food folate 0.5 g folic acid (PGA)0.6 g folic acid taken with meals). * Eurodiet (2000). 1 2
Table 87. Mean daily mineral intake (mean SD) in French adults (45–60 and 35–60 years)
Adults
Male (n 3,323)
Female (n 4,879)
SCF M
Calcium (mg) Sodium (g) Magnesium (mg) Iron (mg) *
120
Annexes
Eurodiet (2000).
936 336 3.5 1.1 322 86 14 4
821 303 2.6 0.9 251 73 10 3
F 700/800* 0.6–3.5 150–500
9
16*
Table 88. Vitamin status (mean SD) in French adults (45–60 and 35–60 years)
Adults
Men
Women
M
F
Serum ferritin (g/l) Serum zinc (mol/l) Serum selenium (mol/l) Plasma vitamin C (mol/l) Red cell folate (nmol/l)* Plasma folate (nmol/l) Plasma retinol (mol/l) Plasma -carotene (mol/l) Plasma 25-hydroxyvitamin D (nmol/l) Plasma -tocopherol (mol/l)
196 163 13.5 1.9 1.1 0.2 50 27 631 203 5.8 4.4 2.5 0.7 0.46 0.32 63 30 32 8
55 53 12.9 1.8 1.1 0.2 59 28 603 206 7.1 5.3 2.1 0.6 0.68 0.50 59 30 31 8
20 – – 11 350 6.3 0.7 0.75 25 11.6
15 – – – – – – – – –
*
Measured during the 3rd study year.
age. It is important to note that also the consumption of tea, a known inhibitor of iron absorption, was higher among women than among men, whereas the consumption of fruits containing vitamin C, a known enhancer of iron absorption, was lower in women than in men. This means that a large part of the women in this population are at high risk of having low iron stores and iron deficiency. Vitamin and Mineral Status in Adults As expected from the information on dietary intake, the levels of the antioxidant vitamins and minerals, especially -carotene is low. Men seem to be at a higher risk of sub marginal vitamin and mineral status, probably due to their higher needs. A sub marginal status of these vitamins and minerals may be important with regards to the risk of cancer, and may be also cardiovascular disease. The plasma as well as red blood cell concentrations of folate were low in men and women, which may increase the risk of several diseases like congenital malformations (for women of childbearing age), cardiovascular disease, cancer and cognitive decline (table 88). Fourteen percent of the subjects exhibited low 25-hydroxyvitamin D values ( 30 nmol/l), which represent the lower limit (2 SD) for a normal adult population measured in winter with the same method. This means that in this population, diet failed to provide an adequate amount of vitamin D in adults with a limited exposure to sunshine. The low iron status in women, as estimated by serumferritin concentrations, results in a high proportion of women who are iron depleted or who have anaemia (figure 63). This is especially a problem in premenopausal women; the percentages of postmenopausal
Annexes
25 Premenopausal women Postmenopausal women Men
22.7 20
15
10 6.2
5.3 5 1.8
2.6 1.6
0 Depletion
Anemia
Fig. 63. Percentage of French men and women with iron depletion or anaemia.
women with iron depletion or anaemia approach those in men. In total 2% of the men and 20% of the women had serum-ferritin concentrations 16 g/l. Health Status of Adults Blood lipids were within normal ranges in this population, with the mean of total cholesterol in men nearly reaching the cut-off level for hypercholesterolemia (table 89). Indeed 60% of the men were classified as hypercholesterolemic (defined as total cholesterol 6.5 mmol/l and/or use of lipid lowering medication) as opposed to 43% of the women. Nevertheless the prevalence of hypercholesterolemia is high in both sexes and indicates that this population is at risk for cardiovascular disease. One of the objectives of the National Programme for Nutrition and Health is therefore to 121
Table 89. Concentrations of total cholesterol, serum-triglycerides and homocysteine in French men and women
Total cholesterol (mmol/l)
n mean SD n mean SD n mean SD
Serum-triglycerides (mmol/l)
Homocysteine (mol/l)
Total
Men
Women
8,083 6.02 1.02 8,080 1.09 0.71 2,905 9.90 3.73
3,287 6.20 0.99 3,285 1.36 0.87 1,238 11.30 4.22
4,796 5.90 1.03 4,795 0.89 0.48 1,667 8.86 2.91
Table 90. Anthropometrical measures in French men and women
Weight (kg)
Height (cm)
Body mass index (kg/cm2)
Waist-hip-ratio
n mean SD n mean SD n mean SD n mean SD
Total
Men
Women
6,534 67.28 13.30 6,535 166.52 8.43 6,534 24.14 3.74 6,532 0.83 0.10
2,687 76.76 10.87 2,688 173.48 6.29 2,687 25.48 3.13 2,687 0.92 0.06
3,847 60.66 10.56 3,847 161.66 5.97 3,847 23.21 3.84 3,845 0.77 0.07
reduce the mean blood cholesterol concentration in the general adult population by 5%. The levels of homocysteine in this population were normal. Still, 12% of the men and 4% of the women had homocysteine levels above 15 mol/l, probably due to the low folate intake and status. Folate status is also included as one of the specific nutritional objectives in the National Programme for Nutrition and Health, in order to increase folate intake, especially in women of childbearing age. Anthropometrical measures are shown in table 90. As expected the BMI was somewhat higher in men than in women, and especially the waist-to-hip ratio was higher in men compared to women. Forty-six percent of the men and 17% of the women were overweight and 8% of the men and 6% of the women were classified as obese according to the WHO criteria. The proportion of subjects who are overweight is especially high in men, who in general do not realise they have a weight problem. One of the objectives of the National Programme for 122
Annexes
Table 91. Systolic and diastolic blood pressure in French men and women
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Total
Men
Women
n
9,242
3,756
5,486
mean SD
123.6 13.7
129.4 13.9
119.7 13.6
n
9,242
3,756
5,486
mean SD
79.7 8.7
83.6 8.5
77.0 8.5
Nutrition and Health is therefore to reduce the prevalence of overweight and obesity in the general adult population by 20%. Systolic and diastolic blood pressure were higher in men than in women, which was reflected in the proportion of men and women with hypertension (table 91); 26% of the men and 13% of the women were classified as hypertensive (defined as systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg and/or use of blood pressure lowering medication). Again, blood pressure is included in the main objectives of the National Programme for Nutrition and Health, which aims at a reduction of systolic blood pressure in the general adult population of 10 mm Hg. According to WHO criteria, an indication of an iodine-replete population consists of a median value for urinary iodine concentration greater than or equal to 10 g/100 ml; no more than 20% of the samples should be below 5 g/100 ml. In the present population, the median urinary iodine was 8.5 g/100 ml in men and 8.2 g/100 ml in women. The proportion of subjects with iodine deficiency (5 g/100 ml) was 15.2 in men and 19.2 in women (table 92). Almost 40% of the men and the women had a urinary iodine concentration above the critical level of 10 g/100 ml. These results underline the risk for the French adult population of being exposed to mild iodine deficiency. The overall goitre prevalence was 11.3% in men and 13.9% in women, suggesting that the thyroid is most probably exposed to a mild goitrogenic effect due to moderate iodine deficiency. Table salt fortified with iodine is introduced in France on a voluntary basis (in 1952), but is not obligatory, which may explain part of these results. The number of current smokers was similar in men and women, but more men had smoked at least once
Table 92. Distribution of concentrations of urinary iodine and thyroid-stimulation hormone in French men and women
Urinary iodine (mg/100 ml ) 2 2–5 5–10 10 Thyroid-stimulating hormone (mUI/ml ) 0.4 0.4–4.0 4.0
Total
Men
Women
n total
7,887
3,211
4,676
n % n % n % n %
91 1.15 1,294 16.41 3,564 45.19 2,938 37.25
27 0.84 460 14.33 1,524 47.46 1,200 37.37
64 1.37 834 17.84 2,040 43.63 1,738 37.17
n total
7,478
2,932
4,546
n % n % n %
484 6.47 6,386 85.40 608 8.13
203 6.92 2,599 88.64 130 4.43
281 6.18 3,787 83.30 478 10.51
Table 93. Smoking and physical activity in French men and women
Smoking Non-smokers Ex-smokers Current smokers Physical activity Irregular Walks 1 hour/day (or equivalent activity) Walks 1 hour/day (or equivalent activity)
Total
Men
Women
n total n % n % n %
7,924 3,761 47.46 3,051 38.50 1,112 14.03
3,213 1,120 34.86 1,651 51.38 442 13.76
4,711 2,641 56.06 1,400 29.72 670 14.22
n total n % n
8,032 2,039 25.39 2,514
3,265 770 23.58 805
4,767 1,269 26.62 1,709
% n
31.30 3,479
24.66 1,690
35.85 1,789
%
43.31
51.76
37.53
than 1 hour of walking. Although the measure of physical activity is crude and only performed by questionnaire, the estimated physical activity correlates well with the measured BMI in this population, which gives certain validity to the estimation of physical activity by the questionnaire. It is clear though that the actual amount of activity may be overestimated. The number of subjects with cardiovascular disease was relatively low in this population (table 94). This is probably due to the fact that it consisted of volunteers for a long-term dietary intervention study. The subjects were in Table 94. Mortality and incidence of major chronic diseases in French men and women
Mortality Cardiovascular death Among which cerebrovascular (CVA) accident Death due to cancer Other Coronary heart disease at the end of follow-up No Yes Cancers at the end of follow-up No Yes CVA at the end of follow-up No Yes
regularly in their life (table 93). The French government tries to reduce the number of current smokers mainly by increasing the tax on tobacco products, but also through multimedia campaigns. Most of these campaigns, however, are aimed at the adolescent and young population. At least 50% of the men and almost 40% of the women had a daily physical activity resembling more
Annexes
Diabetes at baseline (fasting glucose 7 mmol/l and/or antidiabetic medication) No Yes
Total
Men
Women
n total n % n
119 25 21.01 4
69 21 30.43 2
50 4 8.00 2
n % n %
68 57.14 26 21.9
35 50.72 13 18.9
33 66.00 13 26.00
n total
8,165
3,288
4,877
n % n %
8,055 98.65 110 1.35
3,189 96.99 99 3.01
4,866 99.77 11 0.23
n total
8,155
3,308
4,847
n % n %
7,725 94.73 430 5.27
3,136 94.80 172 5.20
4,589 94.68 258 5.32
n total
8,201
3,323
4,878
n % n %
8,168 99.40 49 0.60
3,307 99.25 25 0.75
4,861 99.51 24 0.49
n total
7,922
3,217
4,705
n % n %
7,655 96.00 317 4.00
3,000 93.25 217 6.75
4,605 97.87 100 2.13
123
general highly motivated and rather health conscious and were of course followed up for cardiovascular risk factors. Most of the cancers in women were breast cancers, and those in men mainly prostate cancer. The number of total cancers in men has been lowered due to the intervention with antioxidant vitamins and minerals, and is therefore lower than what is expected in the general population. The percentage of subjects with diabetes was estimated using baseline data, and 4% of this population had either a too high fasting glucose or reported using medication against diabetes. Conclusion Although a large part of the French population has long been considered to have a healthy diet, the present data indicate that the normal diet in a large population from all over France does not correspond to the recommendations and that as in other countries fruit and vegetable consumption and the consumption of dairy products is too low. This results in a marginal intake of many of the vitamins and minerals. Energy intake and saturated fat intake are still too high and together with a lack of sufficient physical activity this has lead to a percentage of subjects with overweight or obesity, which can be considered as alarming. As has been said earlier the current population is not totally representative of the general population. The subjects were volunteers of a long-term primary prevention trial, and were therefore highly motivated. They can be considered health conscious and interested in nutrition in general and the habitual diet specifically. Nevertheless, levels of BMI for example are quite similar to what has been observed in studies evaluating anthropometrical parameters in the general population. A valid study on the habitual diet and nutritional status in a truly representative sample of the general French population is currently not available, but is planned to be carried out in 2005. The National Programme for Health and Nutrition was put in place in 2001 with the objective to improve the health status of the general population by acting on one of its major determinants, namely nutrition. Many public health actions have been or will be carried out, at several different levels (general population, specific subgroups, health professionals, schools etc.) in order to reach the nine general objectives and nine specific nutritional objectives that have been fixed. The actions include information, guidance and education of the public, prevention and screening, involvement of different partners (food industry, consumers, and scientists), 124
Annexes
surveillance and research. The national nutrition survey planned for 2005 should allow us to evaluate the impact of this programme on the dietary habits and nutritional status of the general French population.
Germany In Germany the nutrient and energy intake was calculated from food consumption data with the Bundeslebensmittelschlüssel (BLS version II.3). The consumption data was derived from Einkommens- und Verbrauchsstichproben (household budget surveys) conducted in 1998 in which about 32,000 people participated. The data presented in this report are previously unpublished, but they are similar to the data in the German ‘Ernährungsbericht 2004’ (German Nutrition Report), except that the results there are differentiated for the Western and Eastern part of Germany, whereas here overall means are given. Children (4–14 years) The average supply of energy in German boys and in girls approximately corresponded to the average requirements for these age groups indicated by the SCF (table 95). The share of protein in total energy intake was in both girls and boys of all age groups between 12 and 13% and thus within the normal range of the WHO. The absolute intake data show that a sufficient supply of protein can be assumed in German children at the age of 4–14 years. The intake of carbohydrates provided about 50–53% to total energy in boys and girls of all age classes. The proportion of sucrose in total carbohydrate intake was very high in German children with about 15–16 %E. The average proportion of fat in total energy intake was relatively high in German children. In boys it was between 34 and 36 %E and 34–37 %E in girls. Comparing these intake data with the recommendations of DACH (2000) shows that the fat intake was within a normal range or slightly too high in German boys and girls. The share of SFA in total fat intake was far above the estimated upper level indicated by the WHO (2003). Table 96 shows that vitamin D intake was relatively low in German children. Apart of the first age group the intake of this vitamin was on average slightly higher in boys than it was in girls. The SCF does not give any exact recommendations for vitamin D intake but only a population reference value of 0–10 g/day for children
Table 95. Mean daily intake of energy and macronutrients (mean SD) in German children (4–14 years)
Boys
4–6 years (n 559)
7–9 years (n 679)
10–12 years (n 640)
13–14 years (n 376)
SCF
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g) Other %E
6.1 12 45 51 16 14 36 15 12 6 176 0 0.0 1
7.2 12 52 52 16 17 35 14 12 6 199 0 0.0 1
8.4 12 60 52 15 21 35 14 12 7 220 0 0.0 1
9.9 12 72 52 15 24 34 14 11 7 257 0 0.0 1
6.7/8.4/9.6 10–15** 19/27/43 55*
Girls
(n 528)
(n 627)
(n 600)
(n 381)
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E Alcohol (g) Other %E
5.8 12 42 50 16 14 37 15 12 6 177 0 0.0 1
6.4 13 47 51 15 16 36 14 12 6 176 0 0.0 1
7.6 12 54 52 15 19 35 14 11 7 196 0 0.0 1
8.2 12 57 53 16 21 34 14 11 7 208 0 0.0 1
30* 10* 6–10*
6.3/7.5/8.4 10–15** 19/27/42 55* 30* 10* 6–10*
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
at the age of 4–10 years and 0–15 g/day for children aged 11–14 years. In regard to the average amount of sun irradiation in Germany, Austria and Switzerland, DACH (2000) recommends an average intake of 5 g/day for children of these countries. In regard of this recommendation made by DACH the average intake of vitamin D in German children has to be valuated as too low. Especially in winter months this low intake may not be sufficient. The intake of folate was below the population reference intake of the SCF in 10–14 year old girls. The average intake of potassium in German boys of the last three age classes was slightly below the population reference intake indicated by the SCF. In girls of the
Annexes
last two age groups the intake of potassium was clearly below the recommendations of the SCF, in the second age group it was slightly below it (table 97). The average calcium intake was in the last two age groups of both male and female clearly below the population reference intake for boys and girls aged 11–14 years. The mean intake of iron was satisfactory in the male sample and in 4–9 years old girls; in the last two age classes of the female sample it was too low. It has however to be considered that the iron requirements in women is increased due to the higher losses through the monthly period. Thus, the supply of iron was probably sufficient in the girls who had not had their period yet. 125
Table 96. Mean daily vitamin intake (mean SD) in German children (4–14 years)
Boys
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
4–6 years 7–9 years 10–12 years (n 559) (n 679) (n 640)
13–14years SCF (n 376)
0.6 1.5 1.6 9.2
0.7 1.7 2.0 10.3
0.8 1.6 2.1 11.9
0.8 1.6 2.4 14.3
Thiamine (mg) 0.8 Riboflavin (mg) 0.9 Niacin3 (mg) 15 Pantothenic acid (mg) 2.9 Vitamin B6 (mg) 1.0 Biotin (g) 26 Folate4 (g) 116 Cobalamin (g) 2.8 Ascorbic acid (mg) 73
0.9 1.0 17 3.4 1.1 31 145 3.2 80
1.1 1.2 20 3.8 1.4 34 168 3.6 92
1.3 1.4 24 4.4 1.6 38 195 4.2 103
Girls Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
(n 528) (n 627) (n 600)
0.4/0.5/0.6 2–4* 0–10/15 (0.4 g PUFA) 4.3/4.5/5.3/6.2 0.7/0.8/1.0 1.0/1.2/1.3 11/13/15 3–12 0.9/1.1/1.3 15–100 130/150/180 0.9/1.0/1.3 25/20/35
(n 381)
0.8 2.2 1.9 8.8
0.8 2.2 1.5 9.2
0.9 2.1 1.6 11.2
0.9 2.0 1.7 12.4
Thiamine (mg) 0.8 Riboflavin (mg) 0.9 Niacin3 (mg) 14 Pantothenic acid (mg) 3.0 Vitamin B6 (mg) 0.9 Biotin (g) 27 Folate4 (g) 129 Cobalamin (g) 2.8 Ascorbic acid (mg) 86
0.9 1.0 16 3.1 1.1 27 134 2.9 85
1.0 1.1 18 3.5 1.3 30 155 3.2 85
1.0 1.2 19 3.8 1.3 33 174 3.3 90
0.4/0.5/0.6 2–4* 0–10/15 (0.4 g PUFA) 3.9/4.2/4.8/4.9 0.7/0.8/0.9 1.0/1.2 11/13/14 3–12 0.9/1.1 15–100 130/150/180 0.9/1.0/1.3 25/20/35
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000). 1
The zinc intake was on average sufficient in the male participants, in the female sample it was slightly too low in the last two age groups. The iodine intake through food was not sufficient in girls and boys of all age groups. Adolescents (15–18 years) In German male adolescents the mean energy intake was with about 10.5 MJ/day below the average requirement for this age group indicated by the SCF (table 98). In general, people of Western countries show a sufficient 126
Annexes
or even excessive energy intake, thus an undersupply of energy in Germany does not have to be assumed. In the female sample the average energy intake of 8.8 MJ/day corresponded to the average requirement for this population group indicated by the SCF. The share of protein in total energy intake was in both male and female adolescents within the normal range recommended by the WHO (2003). The absolute intake data show that the supply of protein in German adolescents can be valuated as sufficient. The average share of carbohydrates in total
Table 97. Mean daily mineral intake (mean SD) in German children (4–14 years)
Boys
4–6 years (n 559)
7–9 years (n 679)
10–12 years (n 640)
13–14 years (n 376)
SCF
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g) Fluoride (mg)
1.2 1.7 554 797 206 7.7 6.4 1.1 2.6 48 0.4
1.6 1.9 639 939 244 9.2 7.5 1.4 3.3 56 0.5
2.0 2.3 726 1,088 291 11.1 8.7 1.7 3.9 68 0.7
2.4 2.7 835 1,252 338 12.9 10.1 1.9 4.5 86 0.9
– 1.1/2.0/3.1 450/550/1,000 350/450/775 120/200/280 4/6/10 6/7/9 0.6/0.7/0.8 1–10 90/100/120 1.1/1.1/2.0/3.2*
Girls
(n 528)
(n 627)
(n 600)
(n 381)
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g) Fluoride (mg)
1.2 1.7 594 786 205 7.7 6.0 1.1 2.3 51 0.4
1.7 1.9 582 855 219 8.7 6.9 1.2 2.7 54 0.5
2.0 2.2 667 986 259 10.1 8.0 1.5 3.4 66 0.7
2.1 2.4 746 1,067 290 10.7 8.5 1.7 3.9 73 0.8
*
D-A-CH (2000).
energy intake was between 51 and 52% in German adolescents and was thus below the normal range proposed by Eurodiet (2000). The proportion of sucrose in total carbohydrate intake was relatively high. The intake of sugar should be lowered in favour of a higher proportion of complex carbohydrates to increase the average intake of dietary fibre which was low as well. The average fat intake in German adolescents was relatively high with 34 %E in female and 35 %E in male adolescents. Also the mean proportion of SFA in total fat intake was relatively high in German adolescents. According to table 99 the average intake of carotene was in male adolescents below and in female adolescents within the normal range indicated by DACH (2000). For adolescents DACH (2000) recommends a daily vitamin D intake of 5 g/day. This intake level was on average reached neither by the male nor by the female sample. The mean folate intake was clearly below the guideline of Eurodiet in German adolescents. An increase in folate intake in this population group would
Annexes
– 1.1/2.0/3.1 450/550/1,000 350/450/625 120/200/280 4/6/18 6/7/9 0.6/0.7/0.8 1–10 90/100/120 1.1/1.1/2.0/2.9*
be desirable. The average intake of riboflavin was slightly below the recommended level of the SCF in the male participants. The mean potassium intake was in both male and female adolescents below the population reference intake of the SCF (table 100). Also the average calcium intake was too low in this population group, especially in the female sample. The average iron intake in male adolescents in Germany can be valuated as sufficient. In the female sample the average intake of iron was below the population reference intakes of Eurodiet and the SCF. The average iodine intake through food was – compared to the population reference intake of Eurodiet – not satisfactory. Adults (19–64 years) The energy intake in German adults increased with increasing age although the average requirements decrease with increasing age (table 101). The mean 127
Table 98. Mean daily intake of energy and macronutrients (mean SD) in German adolescents (15–18 years)
Table 99. Mean daily vitamin intake (mean SD) in German adolescents (15–18 years)
Adolescents (15–18 years)
Adolescents (15–18 years)
Male (n 796)
Female (n 772)
SCF M
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E Alcohol (g) Other %E
10.5 13 78 51 15 24 35 14 12 7 288 0 0.0 1
8.8 12 64 52 16 22 34 14 12 7 237 0 0.0 1
11.7 8.8 10–15** 55 45 55* 10** 25* 30* 10* – 6–10* 300** – 20 10*** –
share of protein in total energy intake was about the same in men and women of all age groups and within the normal range indicated by the WHO (2003). The absolute intake numbers show that a sufficient supply of protein in German adults can be assumed. The average carbohydrate intake of German adults was very low. In men the proportion of carbohydrates in total energy intake was on average higher than in women. Furthermore, the share of sucrose in total carbohydrate was relatively high in German adults. The amount of fat in the daily diet was also high in German adults. In women the average proportion of fat in total energy intake was between 34–37%, in men it was 36 %E. The high proportion of SFA in total fat intake refers to a high proportion of animal fat in total fat intake and thus a relatively high consumption of animal products in German adults. As a consequence of this high consumption of animal products the average cholesterol intake in German adults was too high in men and in women of the last age group. The share of alcohol in total energy intake was also relatively high in German men of the last two age classes. Women showed on average a lower alcohol intake, particularly when comparing the absolute alcohol intake numbers.
Annexes
Female (n 772)
SCF
F
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** D-A-CH (2000).
128
Male (n 796)
M Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
1.0 1.6 2.7 15.5
0.9 2.4 2.3 13.0
Thiamine (mg) Riboflavin(mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.4 1.5 26 4.7
1.2 1.3 22 4.1
1.6 42 199 4.9 98
1.4 37 190 3.5 106
F
0.7
0.6 2–4* 0–15 (0.4 g PUFA) 6.4 5.6 1.1 0.9 1.6 1.3 18 14 3–12 1.5
1.1 15–100 200/400** 1.4 40
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR--Tocopherol equivalent ( mg -tocopherol mg tocopherol 0.5 mg
-tocopherol 0.25 mg tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1
Table 100. Mean daily mineral intake (mean SD) in German adolescents (15–18 years) Adolescents (15–18 years)
Male (n 796)
Female (n 772)
SCF M
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g) Fluoride (mg) *
2.4 2.8 920 1,341 353 13.2 11.0 2.0 4.8 93 1.0
Eurodiet (2000); **
2.4 2.6 813 1,172 326 11.8 9.2 1.8 4.4 78 0.8
D-A-CH (2000).
F
– 3.1 1,000/800* 775 625 300 13 17/16* 9.5 7 1.0 1–10 130/150* 3.2** 2.9**
Table 101. Mean daily intake of energy and macronutrients (mean SD) in German adults (19–64 years) Men
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary Fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g) Other %E
Women
SCF
19–24 years (n 926)
25–50 years (n 5,037)
51–64 years (n 2,785)
19–24 years (n 786)
25–50 years (n 5,845)
51–64 years (n 2,867)
M
9.7 13 77 49 13 22 36 14 12 7 274 1 2.2 1
10.2 14 82 44 12 22 36 14 13 7 300 5 19.0 1
11.4 14 93 43 12 26 36 14 13 7 345 7 28.0 1
8.7 13 65 51 15 22 34 14 11 6 226 1 2.8 1
9.7 14 79 47 12 24 35 14 12 6 280 4 11.9 1
10.3 14 86 45 13 26 37 16 13 6 344 3 10.1 1
9.2–12.8 7.7–9.0 10–15** 56 55* 10** 25* 30* 10*
20
F
6–10* 300** – 10***
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** D-A-CH (2000).
In regard to the average amount of sun exposure in Germany, Austria and Switzerland, DACH (2000) recommends a daily vitamin D intake of 5 g/day for adults of these countries. On average, the intake of vitamin D was below this level in both men and women; the supply might thus be insufficient especially in months with low amounts of sun irradiation (table 102). The mean folate intake in German men and women of all age groups was clearly below the recommendation of 400 g/day (Eurodiet, 2000). In order to ensure a sufficient supply the intake should be increased in this population group. The average intake of sodium in German adults, especially in men, was relatively high. In men of the last age group it was above the acceptable range indicated by the SCF (table 103). Apart from men and women of the first age group, the intake of potassium was on average sufficient. The mean calcium intake was above the recommended level of 800 mg/day (Eurodiet, 2000) in men and women of all age groups. The supply of iron was on average sufficient in the male participants. The female participants had an average intake which was below the population reference intake of the SCF, especially in the first two age groups. In women aged 51–64 years the average intake was only slightly below the recommended 16 mg/day. Further, it
Annexes
has to be considered that in this age group there are already many postmenopausal women for whom this average intake was probably sufficient. The mean intake of iodine was clearly below the recommended level of Eurodiet (150 g/day) in all age groups of men and women. Elderly ( 65 years) The energy intake in elderly people in Germany was on average higher than the requirements indicated by the SCF for this group (table 104). The relative amount of protein intake was with 13 %E in both male and female elderly within the normal range indicated by the WHO (2003). The absolute numbers show that the average supply of protein can be valuated as sufficient. The relative proportion of carbohydrates in total energy intake was far below the normal range indicated by Eurodiet (2000). The intake of dietary fibre was sufficient in men, but slightly too low in women. The mean fat intake was relatively high in German elderly people, particularly in women (36 %E compared to 38 %E in women). Also the intake of SFA was relatively high in both male and female which refers again to a relative high proportion of animal fat in total fat and thus of animal products in the daily diet of German elderly people. 129
Table 102. Mean daily vitamin intake (mean SD) in German adults (19–64 years) Men
Women
19–24 years 25–50 years (n 926) (n 5,037) Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
51–64 years (n 2,785)
19–24 years (n 786)
SCF 25–50 years (n 5,845)
51–64 years (n 2,867)
M
0.7
1.0 1.8 2.3 15.2
1.2 2.2 3.5 14.8
1.5 2.7 4.5 16.6
1.0 2.8 2.1 11.9
1.4 3.4 2.5 12.7
1.7 4.0 3.0 14.8
Thiamine (mg) 1.3 Riboflavin(mg) 1.5 Niacin 3 (mg) 26 Pantothenic acid (mg) 4.5 Vitamin B6 (mg) 1.6 Biotin (g) 38 Folate4 (g) 195 Cobalamin (g) 4.8 Ascorbic acid (mg) 101
1.4 1.6 32 5.1 1.8 41 210 6.2 96
1.6 1.8 38 5.9 2.1 47 254 7.7 120
1.2 1.3 23 4.1 1.4 37 194 3.6 116
1.4 1.5 32 4.9 1.7 43 227 5.3 129
1.4 1.7 34 5.4 1.9 46 266 6.1 157
F
0.6 2–4* 0–10; 5* (0.4 g PUFA) 6.4–7.4 4.9–6.3 1.1 0.9 1.6 1.3 18 14 3–12 1.5 1.1 15–100 200/400** 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1 2
Table 103. Mean daily mineral intake (mean SD) in German adults (19–64 years) Men
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g) Fluoride (mg) *
Eurodiet (2000); **
Women
19–24 years (n 926)
25–50 years (n 5,037)
51–64 years (n 2,785)
19–24 years (n 786)
25–50 years (n 5,845)
51–64 years (n 2,867)
M
2.8 2.8 880 1,284 336 12.3 10.6 1.9 4.2 86 0.9
3.4 3.2 889 1,385 384 13.5 11.1 2.2 4.4 97 0.8
4.2 3.9 965 1,555 443 16.0 12.6 2.5 5.2 117 1.0
2.2 2.8 838 1,173 340 12.2 9.2 1.8 4.4 80 0.8
2.6 3.5 925 1,352 415 15.1 11.0 2.3 5.5 94 0.9
3.2 3.7 989 1,420 417 15.4 11.6 2.3 5.4 101 0.8
0.6–3.5 3.1 700/800* 550 150–500 9 16* 9.5 7.0 1.1 1–10 130/150* 3.8** 3.1**
F
D-A-CH (2000).
As a consequence of this high proportion of animal fat, the mean cholesterol intake was too high as well. The relative share of alcohol in total energy intake was with 6% in men also considerable; in women it was lower with 2 %E. 130
SCF
Annexes
Table 105 shows that the vitamin D intake was – compared to other population groups – relatively high, especially in men. However, it was below the recommended intake for elderly of 10 g/day, as indicated by Eurodiet. This low intake might thus be insufficient,
Table 104. Mean daily intake of energy and macronutrients (mean SD) in German elderly ( 65 years) Elderly ( 65 years)
Male (n 1,509)
Female (n 1,690)
SCF M
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol Alcohol %E Alcohol (g) Other %E
F
12.3 13 96 45
9.6 13 76 46
9.2/8.0 7.7/7.3 10–15** 56 55*
12 31
15 23
– 25*
36 14 12 7 358 6 24.3 1
38 16 13 6 328 2 5.9 1
30* 10* – 6–10* 300** – 20*** 10*** –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003); *** D-A-CH (2000).
Table 105. Mean daily vitamin intake (mean SD) in German elderly ( 65 years)
Elderly ( 65 years)
especially in those with little amounts of sun exposure. Also the mean intake of folate was clearly below the recommendation of Eurodiet (400 g/day). In regard to this low intake the supply of this nutrient has to be regarded as insufficient. The average sodium intake was relatively high and in men above the acceptable range of intake indicated by the SCF (table 106). The potassium intake in German elderly people can on average be regarded as satisfying as it was in both male and female clearly above the population reference intake of the SCF. The mean calcium intake was above the recommendation of Eurodiet with about 1,031 mg/day in elderly men and 886 mg/day in elderly women. Like in the other population groups in Germany the average iodine intake was below the recommended level of 150 g/day (Eurodiet, 2000). Conclusion The nutritional situation in Germany is characterised by a typical ‘western diet’ with only marginal regional differences in the energy and nutrient intake i.e. between the old (west) and new (east) states (reported in the 10th
Male (n 1,509)
Female (n 1,690)
SCF M
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folate4 (g) Cobalamin (g) Ascorbic acid (mg)
1.7 3.5 4.9 19.2
1.5 3.0 3.1 13.1
1.7 1.9 39 6.4 2.4 51 286 7.7 144
1.2 1.6 30 4.9 1.6 41 231 5.5 123
F
0.7
0.6 2–4* 10** (0.4 g PUFA) 7.3 6.1 1.1 0.9 1.6 1.3 18 14 3–12 1.5 1.1 15–100 200/400** 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherolx0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * D-A-CH (2000); ** Eurodiet (2000). 1 2
Annexes
131
Table 106. Mean daily mineral intake (mean SD) in German elderly ( 65 years) Elderly ( 65 years)
Male (n 1509)
Female (n 1690)
SCF M
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g) Fluoride (mg) *
4.3 4.2 1,031 1,657 474 17.8 13.5 2.7 6.0 127 1.1
Eurodiet (2000); **
3.0 3.5 886 1,276 377 13.4 10.1 2.1 4.6 91 0.7
F
0.6–3.5 3.1 700/800* 550 150–500 9 9.5 7 1.1 1–10 130/150* 3.2** 2.9**
D-A-CH (2000).
German Nutrition Report 2004). The average energy intake of the adult population was, depending on the age group, marginally or significantly above the corresponding guidelines. Due to the low amount of physical activity a positive energy balance explains the high prevalence of overweight in the population. The fat consumption (especially in the form of saturated fatty acids) is too high and the intake of carbohydrates (especially in the form of complex polysaccharides) too low. Also the average intake of dietary fibre is too low. The average alcohol intake accounts for nearly 6% of the total energy intake in males and for 4% in females. For most vitamins, minerals and trace elements the average supply is sufficient for the population. Among the vitamins special attention has to be given to folate and to vitamin D in the elderly, among the minerals and trace elements to sodium, calcium, iron and iodine. Especially in the elderly the sodium/salt intake is on average too high and increases the risk of hypertension in people with a genetic predisposition. The supply of calcium is inadequate in children, adolescents and some adults, increasing the risk for osteoporosis. Iodine deficiency is still endemic in Germany. After the integrated study ‘Iodine Monitoring 1996’ and the following efforts to improve the situation the iodine supply of the population has markedly increased but the average iodine intake still lies far below the recommended intakes. Persons especially affected by an iodine supply deficiency are new-borne infants as well as pregnant women and 132
Annexes
nursing mothers who do not take iodine supplements. Strong efforts in preventive measures with iodised salt and foods prepared with iodised salt are necessary. In order to examine nutrition from birth to the old age breastfeeding and infant nutrition focusing attention on breastfeeding conditions and a study on the nutrition of elderly people with the focus on the nutritional situation of 65–year-old German citizens able to perform every day tasks independently and living in private households were investigated in the SuSe-Study. Both studies are published in the German Nutrition Report 2000. Of all mothers 91% tried to breastfeed after delivery. Of all infants 58% were exclusively or predominantly breastfed at the end of the second month and 45% at the end of the fourth month. In order to fulfil the world-wide call for a 4 to 6 months duration of exclusive breastfeeding, improvements in the network of qualified breastfeeding care are absolutely necessary. In the representativedesigned study, the nutritional situation of elderly persons is not critical, but the intake of vitamin D, calcium and folate with the diet was not sufficient. The general nutritional advice for the population in Germany is focused on the following points: Enjoy a wholesome diet with variety, but limited amounts, in order to prevent overweight. Follow a lifestyle with regular physical activity to protect overweight. Dietary fat, mainly fat of animal origin, should be decreased to approximately 30 %E and partly replaced by complex carbohydrates. Free sugars should be consumed only in moderate amounts. The saturated/unsaturated fatty acid ratio should be 1:2. Using preferably favourable plant derived oils the n–6 and n–3 fatty acid intake should reach a ratio of 5:1. Food consumption of plant origin, especially whole-grain products with complex carbohydrates and dietary fibres should be increased. Vegetables and fruits should be eaten 5 times a day, as well as more skimmed milk and milk products. Decrease the intake of table salt and smoked foods. Nutrition based on these recommendations does not need a supplementation of nutrients, except for iodine and folic acid (for certain groups of persons) and vitamin D for the elderly. The data presented in this report are based on calculations from the household budget survey food consumption data by means of the German Nutrient Food Code and Data Base. Even if this procedure may suffer from some limitations the large data base allows differentiated interpretations. This procedure was established as successful since the 3rd German Nutrition Report was
published in 1976. It was evaluated by some smaller regional nutrition surveys, like the Bavarian Nutrition Survey I and II. A further national nutrition survey is planned for 2005 that should allow the evaluation of the data from the Income and Consumption Survey and in the following of nutritional habits in Germany by comparing both national nutrition surveys.
Greece The purpose of this report is to present the current evidence on nutrient intake and health status of the Greek population. To date, a single population-based study examining nutrient intake and health among all age groups of the Greek population has not been undertaken. Information regarding the nutrient intake of the Greek population has been primarily derived from studies undertaken in localized settings, utilizing limited population samples, and usually within the context of Greek participation in multi-centre international studies. Cohort studies have also been conducted addressing, however, particular population groups. This report is mainly based on two large cohort studies conducted among Greek children and adolescents, and among adult and elderly people, respectively. Where evidence is not provided by the above indicated cohort studies, data from either smaller cohort studies and/or case-control studies are presented. With respect to casecontrol studies, only evidence provided from study control groups is presented. The reader is reminded that evidence from these sources should be considered with caution, as the Table 107. Prevalence of exclusive breastfeedinga in Greece
selection of study groups and measurement methods may differ between studies. Lastly, to facilitate international comparisons of nutrient intakes, S.I. units have been used throughout the report. We hope that this report provides useful information concerning the nutrient intake and health status of the Greek population. Infants Breastfeeding Human breast milk is the optimal source of nutrients needed for the first 6 months of infancy [WHO, 2003]. Monitoring of breastfeeding rates at the national level is essential for the evaluation of nutrient intake and nutritional status of infants. Current knowledge on breastfeeding rates in Greece is derived from small and select population groups, thus severely limiting knowledge of breastfeeding rates throughout the country. In the existing studies the rate of exclusive breastfeeding at 6 months of life ranges from 3 to 47%. Exclusive breastfeeding rates at six months during the years 1980, 1981, 1986 and 1989 in a study conducted in urban and rural areas of Greece were 0, 3, 5 and 5%, respectively [Matsaniotis et al., 1981]. Table 107 shows in detail recorded rates. In 1991 a cohort of Greek infants was assembled in order to participate in the Euro-Growth Study. The aim of this study was to record and compare feeding practices (milk feeding, introduction of complementary solid foods, vitamin and mineral supplementation) from birth until 3 years of life among healthy infants in Europe. Dietary data were collected from mothers by completing a semi-quantitative dietary recall. Exclusive
1980b
1981b
1986b
1989c
1991d
2001e
Number of mothers Breastfeeding at initiation (%) Exclusively breastfed infants (%) 1 month 2 months 3 months 4 months 5 months 6 months
1,660 65
1,432 71
1,042 72
1,023 77
129 –
27 16 9 4 1 0
50 32 19 10 6 3
48 33 22 14 8 5
49 35 23 13 8 5
90 80 74 60 55 47
4,200 24 – – – – – 28
a
Exclusive breastfeeding: breast milk only, without any other milk and/or solid foods. Source: b Matsaniotis et al., 1986; c Matsaniotis et al., 1990; d Freeman et al., 2000; e Bakoula, 2004.
Annexes
133
breastfeeding at six months was found to be 47%. It is significant to note that data for the Greek Euro-Growth Study were collected from infants born in a public maternity hospital, where breastfeeding is highly promoted [Freeman et al., 2000]. More recent data derived from a cohort of 4,200 Greek women, of all socioeconomic levels, who gave birth in maternity hospitals in the district of Attica (Athens and the surrounding areas) during 2001, show that the initiation rate for exclusive breastfeeding was 24%, while that for complementary feeding (breastfeeding plus other food, including formula) was 62%. At six months of life the rate of exclusive breastfeeding was 28% and of complementary feeding was 52% [Bakoula, 2004]. Data are not available for macronutrient and micronutrient, as well as for total energy intake, for infants. Other studies have been conducted, but they pertain to limited and non-representative study populations. Children and Adolescents Information concerning macronutrient and micronutrient, as well as total energy intake, of Greek children and adolescents is limited. A representative population-based study regarding nutrient intake among Greek children was conducted during 1985–1987 [Roma-Giannikou et al., 1997; RomaGiannikou et al., 1994]. The study population was a random stratified sample selected from three different counties of Greece and was comprised of 1936 children, aged 2–14 years. Information on nutritional habits was obtained using a 3 day household measured diet record. With respect to energy intake, the investigators have published the 10th, 50th and 90th percentiles of energy
intake by age and gender and commented that median energy intake for both boys and girls was found higher than the Average Requirement (AR; the average nutrient intake required for the specified population group) [European Commission, 1993] among preschool children, but lower than the AR among children aged 6–14 years. Daily energy intake was found to approximate that of the AR in one third of all children. They also reported that low calorie intake in Greek children younger than 10 years was not observed. A small percentage of preand pubertal children was observed to have a daily energy intake lower than 50% of the AR. The mean daily energy intake from protein, carbohydrate and fat was 15, 44 and 41%, respectively, in both genders (table 108). The mean daily protein intake in all age groups was found to be considerably higher than that of the Population Reference Intake (PRI; the nutrient intake that is adequate for all healthy persons of the specified population group) [European Commission, 1993] and none of the children had a daily intake lower than that of the AR. Mean daily protein intake among children and adolescents is presented in table 109. With regard to carbohydrate intake, an increase in the daily amounts consumed was found with progressing age, whereas boys had a higher daily carbohydrate intake than girls. The mean percentages of energy intake derived from carbohydrates in both sexes and all age groups were found to be lower than the AR. Mean daily carbohydrate intake among children and adolescents is presented in table 110. In relation to fat intake, boys were observed to have a higher mean daily fat intake than girls, primarily in
Table 108. Mean ( SD) daily protein, carbohydrate and fat intake in Greek children as percentage of total energy intake, by age and gender Boys
2–3 years
4–5 years
6–7 years
8–9 years
10–11 years
12–14 years
Protein (%E) Carbohydrates (%E) Fat (%E)
15.5 3.5 43 8 41 7
15.3 3.6 44 8 41 7
15.6 3.4 44 8 40 7
15.2 3.5 45 8 40 7
15.7 3.8 44 9 40 7
15.6 3.8 45 9 40 7
16 3.9 42 8 42 7
15.5 3.6 43 9 41 7
15.1 3.4 44 8 40 6
15.3 3.7 44 9 40 7
Girls Protein (%E) Carbohydrates (%E) Fat (%E)
%E Percentage of total energy intake. Source: Adapted from E. Roma-Giannakou et al., 1997.
134
Annexes
15.6 3.9 44 9 41 7
14.7 3.4 45 9 41 8
Table 109. Mean ( SD) daily protein intake (in g) in Greek children, by age and gender Age (years)
Boys
Girls
2–3 4–5 6–7 8–9 10–11 12–14
53 20 57 20 65 22 68 22 73 25 76 27
53 22 55 19 59 21 61 22 66 24 63 27
Source: Adapted from E. Roma-Giannakou et al., 1997.
Table 110. Mean ( SD) daily carbohydrate intake (in g) in Greek children, by age and gender Age (years)
Boys
Girls
2–3 4–5 6–7 8–9 10–11 12–14
146 49 165 52 183 55 199 64 205 61 220 77
136 45 154 48 174 56 174 55 183 61 187 66
Source: Adapted from E. Roma-Giannakou et al., 1997.
Table 111. Mean ( SD) daily fat intake (in g) in Greek children, by age and gender Age (years)
Boys
Girls
2–3 4–5 6–7 8–9 10–11 12–14
63 22 68 23 75 24 80 27 84 28 86 28
62 24 65 21 71 25 72 25 77 28 78 31
Source: Adapted from E. Roma-Giannakou et al., 1997.
pre- and pubertal age groups (table 111). The mean energy intake derived from fat was approximately 40% for boys and 41% for girls, being highest in children 2–3 years old (table 111). Eighty four percent of children had an energy intake from fat greater than that of the AR. Saturated fatty acids provided approximately 15%, monounsaturated fatty acids 17% and polyunsaturated fatty acids 6% of daily total energy intake. Mean saturated fatty acid intake was found to be considerably Annexes
higher than the AR, and 87% of Greek children were found to exceed the AR. Monounsaturated fatty acid intake provided 12–14% of the energy in 44% of the children, thus approximating that of the AR. With respect to polyunsaturated fatty acids, 42% of children had a greater intake and 12% lower intake than the AR, whereas none had an intake lower than the PRI. In relation to cholesterol, 63% of Greek children had an intake exceeding 300 mg per day, proposed by the American Academy of Cardiology as the upper limit of recommended intake (table 112). A total of 88% of children had a calcium intake greater than or equal to the PRI, whereas 4.2% had a calcium intake lower than the Lowest Threshold Intake (LTI) [Panel on Dietary Reference Values of the Committee of Medical Aspects of Food Policy of the Department of Health, 1991]. The adequacy of calcium intake in Greek children was attributed to the considerable amount of milk that they consume and not to the consumption of cheese. All children had a phosphorus intake greater than the PRI; 50% of them had a phosphorus intake greater than 1.5 g/24 hours. The majority of children had sufficient iron intake, with the exception of menstruating girls. Mean vitamin A intake was greater than the PRI and lower than toxic levels. All children had a vitamin C intake greater than the LTI. Median daily vitamin D intake varied from 1.7 to 2.1 micrograms. Table 113 presents mean daily intake of selected micronutrients among Greek children and adolescents. In conclusion, nutrient intake among Greek children is characterized by an adequate daily intake of energy, protein, polyunsaturated fatty acids, vitamin A, vitamin C, and calcium, a high intake of monounsaturated fatty acids, saturated fatty acids, and phosphorus, and a low intake of carbohydrates. Daily intake of vitamin D is low in small children, but the biological availability of vitamin D is apparently greater due to ample sunlight. Data regarding dietary intakes and energy intake in Greek adolescents are available, in the form of food groups, in a recent study. The study group consisted of a representative sample of 4,211 Greek adolescents (51.6% girls and 48.4% boys), aged 11.5, 13.5, and 15.5 years. Among them, 14.7% reported being on a diet in order to lose weight (girls: 19.5%; boys: 9.7%; p 0.001), and 22.9% were dissatisfied with their body weight but not on diet. TV viewing was positively associated with the consumption of sodas, crisps, cakes and pastries, and sweets and chocolates [Yannakoulia 135
Table 112. Mean ( SD) daily cholesterol (in mg) and dietary fibre (in g) intake in Greek children, by age and gender Boys
2–3 years
4–5 years
6–7 years
8–9 years
10–11 years
12–14 years
Cholesterol (mg) Dietary fibre (g)
352 169 10.6 6.1
335 194 11.9 6.2
350 194 13.9 6.5
337 178 14.7 6.9
353 207 15.6 7.9
358 229 16.7 8.2
354 203 9.8 5.2
329 174 11.6 6.8
318 167 12.8 6.6
323 194 13.1 6
329 196 14.1 6.9
349 248 15.4 8.2
Girls Cholesterol (mg) Dietary fibre (g)
Source: Adapted from E. Roma-Giannakou et al., 1997.
Table 113. Mean ( SD) daily micronutrient intake (in mg or g) in Greek children, by age and gender Boys
2–3 years
4–5years
6–7 years
8–9 years
10–11 years
12–14 years
Vitamin A (g) Calcium (mg) Iron (mg) Vitamin D (g) Vitamin C (mg)
978 1,273 824 307 7.7 4.7 4.1 7.0 77 93
955 1,572 823 301 8.6 4.7 4.7 19.0 78 84
981 1,285 899 335 9.6 3.9 4.6 9.0 104 119
990 1,022 938 362 10.2 4.6 5.2 9.0 102 103
1,167 1,844 963 402 11 5.1 5.3 10.0 119 137
1,151 2,764 960 403 11.9 6.1 4.8 8.0 118 122
990 1,976 782 301 7.2 3.7 3.6 6.0 67 76
936 1,185 754 306 8.3 4.5 4.4 7.0 84 80
862 1,404 819 323 8.8 3.8 3.8 6.0 93 94
1,035 1,621 822 334 9.3 4.3 5.9 23.0 101 113
1,049 1,490 851 395 10 4.9 4.3 8.0 108 119
922 1,062 748 321 10.1 4.8 6.2 11.0 118 135
Girls Vitamin A (g) Calcium (mg) Iron (mg) Vitamin D (g) Vitamin C (mg)
Source: Adapted from E. Roma-Giannakou et al., 1997.
et al., 2004]. Furthermore, boys had higher energy and macronutrient intakes compared to girls. Fat represented 41% and 43% of total energy intake for boys and girls, respectively. A percentage of adolescents also had lower than recommended daily intake levels of iron, vitamin A, folate and zinc, indicating an unbalanced diet. Another study conducted in northern Greece showed that the mean olive oil consumption of adolescents was 70.7 15.4 g/day. Vitamin E intake was 11.7 2.3 mg/day and olive oil provided 67% of this intake. The mean serum a-tocopherol levels were 0.79 mg/dl (range 0.7–1.02) [Hassapidou et al., 1996]. Young Adults While population based studies for determining the nutrient intake of young adults have not been conducted 136
Annexes
yet, moderately-sized cohort studies have been undertaken in order to assess daily food and nutrient intake of specific groups of young adults. In particular, the daily nutrient intake of university students has been examined. During the period 1989–2001, the daily food and nutrient intakes of 951 third-year medical students attending the University of Crete (451 female and 500 male students) was assessed [Mammas et al., 2004]. The mean age of both female and male participants was 22( 2) years. Food intake was evaluated with the use of a 24-hour dietary recall questionnaire and was administered to all participants on a weekday. Demographic and lifestyle information, as well as anthropometric measurements, were also collected. The mean daily energy and nutrient intakes of this cohort are presented in tables 114 and 115.
Table 114. Mean ( SD) daily energy intake (in kcal and kJ) and macronutrient intake (in g, mg, or percentage of energy) among University of Crete medical students, by gender
Energy, kcal (kJ) Proteins (%E) Carbohydrates (%E) Dietary fibre (g) Lipids (%E) SFA (%E) MUFA (%E) PUFA (%E) Cholesterol (mg) Alcohol (g)
Men (n 500)
Women (n 451)
2,493 992 (10,437) 14.2 4.0 44.8 9.7 16.9 10.7 40.2 8.5 12.9 3.8 17.1 5.6 5.1 2.7 300.3 221.6 301 376b
1,675 673 (7,012) 14.1 4.8 46.7 11.2 13.7 10.1 39.4 10.1 12.9 4.4 16.9 6.6 4.5 2.4 205.3 158.1 256 229a
%E Percentage of total energy intake. a Among female consumers (n 45), b Among male consumers (n 65). Source: Adapted from I. Mammas et al., 2004.
Table 115. Mean ( SD) daily micronutrient intake (in g, mg, or g) among University of Crete medical students, by gender Nutrient
Men (n 500)
Women (n 451)
Vitamin A (g) Vitamin E (mg) Vitamin B1 (mg) Vitamin B2 (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Vitamin C (mg) Calcium (mg) Sodium (mg) Potassium (mg) Magnesium (mg) Iron (mg)
909.1 1,292.3 8.9 15.2 2.2 2.1 2.2 1.3 21.7 11.0 1.9 1.3 282.7 190.4 5.3 11.4 146.1 129.5 990.9 613.9 2,591 1,452 3,091 1,478 280.7 126.5 13.7 6.4
882.5 1,324.1 6.2 4.6 1.3 0.9 1.5 1.0 14.0 7.7 1.3 0.7 220.7 184.3 3.8 9.7 144.5 120.3 744.1 438.3 1,660 955 2,361 1,110 212.7 101.9 9.7 5.4
Source: Adapted from I. Mammas et al., 2004.
Both daily total energy and cholesterol intakes are observed to be higher among young men than young women. Intake levels of protein and lipids are similar between both genders. Young men appear to have a higher intake of alcohol as compared to young women. In relation to daily alcohol intake, in a complementary study undertaken among 865 third-year medical students attending the University of Crete (397 women and Annexes
468 men), it was observed that 77.2% of the male participants and 58.0% of the female participants reported that they consumed alcohol on a regular basis. Of the total study population, 5.2% of the male participants and 3.6% of the female participants reported drinking heavily on a weekly basis (heavy drinking was defined as a consumption of 280 g of alcohol per week for males and 140 g for females) [Mammas et al., 2003]. It is important to note that all macro- and micronutrient intakes presented above are significantly higher among young males as compared to young females (p 0.001). Adults and the Elderly Evidence from Cohort Studies The European Prospective Investigation into Cancer and Nutrition (EPIC) is a multi-country prospective cohort study which investigates the role of nutrition and other lifestyle factors in the aetiology of cancer and other chronic diseases. This study provides the most recent and representative evidence of nutrient intake in the Greek adult and elderly population. The cohort of the Greek segment of the EPIC study was assembled during the period 1994–1999. It consists of more than 28,000 persons aged 25–82 years. Participants were recruited from regions all over Greece. In order to collect information regarding habitual food and nutrient intake participants completed, via direct interview, a validated semi-quantitative food frequency questionnaire regarding the frequency of food consumption during the course of one year [Katsouyanni et al., 1997]. The questionnaire included approximately 150 food items and beverages, as well as other questions, e.g. habitual cooking methods, type of lipids used in cooking. Standard portion sizes were used for the estimation of consumed quantities. Food and nutrient intakes were expressed as averages per day, whilst taking into account seasonal variation. Somatometric measurements concerning weight, height, sitting height, as well as waist and hip circumferences, were also undertaken. Subjects were measured without shoes, lightly clothed, and without any restrictive underwear. Arterial blood pressure measurements were done by specially trained physicians, through a mercury sphygmomanometer (Baumanometer, W. A. Baum Co. Inc., New York, USA). Individuals were seated on a chair, with their backs supported and their right arm bared at the level of the heart. After five minutes of rest, systolic and diastolic blood pressures were measured twice, with at 137
least a two minute interval between measurements. The average of the two readings for both systolic and diastolic blood pressure was used. Occupational and leisure-time activities were assessed by the use of a lifestyle questionnaire, which was also used for the overall evaluation of participants’ physical activity level. The average time per day spent on habitual, as well as sporting, activities was calculated. Repeated sensitivity analyses with varying weighting of the constituent sampling quotients showed that the Greek-EPIC findings adequately approximate a random overall sampling that would also have had to rely on volunteers. As a result, these findings contribute to the formation of a collective body of evidence describing the characteristics and behaviour of Greeks in areas that affect health. The distribution of the EPIC study population according to age and gender is presented in table 116. Tables 117 and 118 present unpublished data from the Greek EPIC database on the mean daily total energy and macronutrient intake and percentage of energy intake from selected macronutrients observed in women and men of the Greek EPIC cohort, respectively. The mean daily total energy intake in the EPIC cohort population is greater among men than women. Similarly,
mean daily intake of protein, carbohydrates, and lipids is also greater among men than women. Mean daily ethanol intake expressed both quantitatively and as a percentage of energy intake, among men is more than five times greater than that among women. Among women of the EPIC cohort population, mean daily total energy intake decreases significantly with respect to the progression of age. Mean daily total energy intake is greater among men than women at all ages, a similar decreasing trend in mean daily total Table 116. Age distribution (in years) of the Greek EPIC cohort, by gender Age groups (years)
All subjects n (%)
Men n (%)
Women n (%)
34 35–44 45–54 55–64 65–74 75 Total
2,111 (7.4) 6,506 (22.8) 6,695 (23.5) 6,584 (23.1) 5,964 (20.9) 695 (2.4) 28,555 (100)
903 (7.6) 2,994 (25.1) 2,825 (23.6) 2,441 (20.4) 2,437 (20.4) 344 (2.9) 11,944 (100)
1,208 (7.3) 3,512 (21.1) 3,870 (23.3) 4,143 (24.9) 3,527 (21.2) 351 (2.1) 16,611 (100)
Source: EPIC Newsletter Issue 3, 2002.
Table 117. Mean daily total energy intake (in kcal), macronutrient intake (in g), and percentage of energy intake from specific macronutrients among men of the Greek EPIC cohort, by age
Energy (kcal) Proteins (g) (%E) Carbohydrates (g) (%E) Lipids (g) (%E) SFA (g) (%E) MUFA (g) (%E) PUFA (g) (%E) Ethanol (g) (%E)
Total (n 11,323)
25–34 years (n 794)
35–44 years (n 2,776)
45–54 years (n 2,683)
55–64 years (n 2,353)
65–74 years (n 2,377)
75 years (n 340)
2,380 726 84 26 14 1.7 226 73 38 5.9 119 40 45 5.5 34 13 13 2.6 57 20 22 4.0 17 9 6 2.7 18 24 5 5.9
2,705 771 96 27 14 1.6 257 81 38 5.9 136 43 45 5.5 41 15 14 2.5 66 21 22 3.6 18 8 6 2.0 18 22 5 4.9
2,594 734 92 27 14 1.6 242 75 38 5.8 131 41 46 5.3 38 14 13 2.5 64 21 22 3.7 18 8 6 2.1 19 25 5 5.5
2,497 707 88 26 14 1.7 234 73 38 5.9 125 38 45 5.5 35 13 13 2.5 61 19 22 4.0 18 9 6 2.5 20 26 5 6.0
2,294 675 80 24 14 1.8 219 69 38 5.8 113 37 44 5.5 31 12 12 2.5 54 19 21 4.2 17 10 7 3.0 19 25 6 6.5
2,043 606 72 22 14 1.7 201 61 40 5.9 100 33 44 5.4 28 11 12 2.5 47 16 21 4.3 69 7 3.2 14 20 5 5.8
1,892 544 67 19 14 1.7 192 56 41 5.7 92 29 44 5.5 26 9 12 2.5 44 15 21 4.0 13 8 6 2.8 11 15 4 4.6
%E Percentage of total energy intake. Source: Unpublished data from the Greek EPIC database.
138
Annexes
Table 118. Mean ( SD) daily total energy intake (in kcal), macronutrient intake (in g), and percentage of energy intake from specific macronutrients among women of the Greek EPIC cohort, by age
Energy (kcal) Proteins (g) (%E) Carbohydrates (g) (%E) Lipids (g) (%E) SFA (g) (%E) MUFA (g) (%E) PUFA (g) (%E) Ethanol (g) (%E)
Total (n 16,119)
25–34 years (n 1,161)
35–44 years (n 3,380)
45–54 years (n 3,775)
55–64 years (n 4,020)
65–74 years (n 3,439)
75 years (n 344)
1,898 581 68 21 14 1.7 188 57 40 5.5 99 35 47 4.9 28 12 13 2.6 48 18 23 4.2 15 8 7 3.0 36 1 2.2
2,155 653 78 24 15 1.7 206 65 38 5.3 115 39 48 4.6 34 13 14 2.4 56 20 23 3.7 16 8 6 2.3 47 1 2.2
2,098 579 76 21 14 1.6 201 59 39 5.1 112 35 48 4.5 33 12 14 2.4 55 18 23 3.7 16 8 7 2.5 47 1 2.2
2,000 563 72 21 14 1.6 195 57 39 5.3 106 34 47 4.7 30 11 13 2.5 51 18 23 4.1 16 8 7 2.9 47 1 2.2
1,813 534 65 20 14 1.7 183 54 41 5.4 94 32 46 4.8 26 11 13 2.6 45 16 22 4.3 15 8 7 3.2 36 1 2.1
1,637 488 59 18 14 1.7 170 51 42 5.6 83 28 45 5.0 23 9 12 2.5 40 15 22 4.4 13 7 7 3.3 25 1 2.1
1,528 522 55 19 14 1.9 161 56 42 6.1 77 30 45 5.4 22 9 12 2.7 36 15 21 4.3 12 7 7 3.3 24 1 1.6
%E Percentage of total energy intake. Source: Unpublished data from the Greek EPIC database.
energy intake is observed among men with the progression of age. In addition, in the EPIC cohort population mean daily protein, carbohydrate, and lipid intake is greater among men as compared to women at all ages. As in the case of mean daily total energy intake, daily intake of the aforementioned macronutrients appears to decrease with the progression of age among both genders. The most moderate diminishment is observed in the case of monounsaturated fatty acids, particularly among women. It is of particular interest to note that primary analyses of dietary intake among elderly members of the EPIC cohort have indicated that the elderly strongly adhere to the traditional Mediterranean diet. In particular, it revealed elevated consumption of olive oil in this population group, a rich source of monounsaturated fatty acids [Costacou et al., 2003]. Similarly to the trends in total energy and macronutrient intake described above, mean daily alcohol intake is observed to be significantly lower among women as compared to men of the total Greek EPIC cohort population. However, trends in alcohol intake with respect to age differ between genders. Specifically, mean daily alcohol intake appears to decrease moderately with age among women. In contrast, while mean daily alcohol
Annexes
intake is lowest among elderly men, it appears to be most prominent among men aged 45–54 years. Evidence of mean total energy and macronutrient intake among adults and elderly is also provided by smaller cohort studies. An example of such is a cohort study conducted by J. Moschandreas and A. Kafatos whose primary aim was to assess food and nutrient intake among Cretan adults [Moschandreas and Kafatos, 1999]. The study population consisted of 470 Cretan adults, recruited from two population groups, those of bank employees and practicing lawyers residing in Crete. The age-range of the participants was 18–64 years, and the study population composition was 228 women (49%) and 242 men (51%). Anthropometric and dietary measurements were undertaken, as well as a complete medical examination. Food and nutrient intake were assessed using a validated 24 hour dietary recall which was administered by dieticians to all subjects. Food quantities were assessed by the use of household measures and food-model photographs. Nutrient intake was then calculated. Average daily total energy intake in this small cohort population is lower than that observed in both genders of the EPIC cohort. However, similarly to the observations drawn from the EPIC cohort, average daily total energy intake appears to decrease with 139
age. Whilst the observed average total energy intake in this cohort is lower than that of the EPIC cohort, other macronutrient intakes appear to be similar between the two cohort populations. In particular, the results of both cohort populations corroborate with scientific reports indicating that the mean daily intake of monounsaturated fatty acids is greater than 18% of total energy intake in the general Greek population [Hulshof et al., 1999]. It is significant to note that while the mean daily alcohol intake observed in this population is significantly lower than that observed in the total EPIC cohort, similarly to the male EPIC cohort population alcohol intake is observed to be highest among middle-aged persons. Smaller cohort studies have also been conducted in order to assess nutrient intake among the Greek elderly population. In a cohort study by A. Trichopoulou et al. dietary intake and overall survival of the elderly was examined [Trichopoulou et al., 1995a]. The original cohort population consisted of 182 (91 women and 91 men) free-living elderly persons, aged more than 70 years and residing in three rural villages of the area of Attica. At baseline, during 1988–1990, the dietary intake of these persons was assessed in-person through the utilization of a validated semi-quantitative food frequency questionnaire. The mean daily total energy intake of the study population was found to be 1,760 kcal (7,364 kJ) and 2,206 kcal (9,230 kJ) among women and men, respectively. These findings reveal an average daily total energy intake which is lower than that reported in the EPIC cohort. Among both genders the ratio of monounsaturated to saturated fatty acid intake was found to be 1.6. The mean daily alcohol intake among men was 10 g, while among women was 0. These findings agree with the significant differences in alcohol intake observed among both genders of the EPIC cohort. In another small cohort study conducted by A. Kafatos et al. food and nutrient intake of 167 free-living elderly Greeks residing in Crete was examined [Kafatos et al., 1993]. Food frequency intake, demographic, and anthropometric measurements were taken through in-person interviews. The results of the study revealed that total fat intake ranged between 40–45% of total energy intake among both genders, corroborating with the findings from the EPIC cohort. Moreover, the primary source of daily fat intake was found to be monounsaturated fatty acids. Similarly to the findings from the EPIC cohort, alcohol intake was statistically significantly greater among elderly men as compared to women. 140
Annexes
It is significant to emphasize that both the studies previously mentioned [Trichopoulou et al., 1995a; Kafatos et al., 1993] have revealed a consistent adherence of the elderly to the traditional Mediterranean diet and, in particular, to the intake of monounsaturated fatty acids. This is presumed to be primarily due to the elevated consumption of olive oil in this population group [Trichopoulou et al., 1995b]. Evidence from the followup prospective cohort Seven Countries Study has revealed changes in these dietary trends among the elderly population. The Seven Countries Study, originally consisting of a 686 male cohort and currently 245 male survivors, indicated that olive oil consumption dominated daily total lipid intake in both 1960 and at the time of follow-up in 1991. However, this study also revealed that the proportion of daily monounsaturated fatty acid intake during the 30 years of follow-up had significantly decreased among the elderly [Kafatos et al., 1997]. Special Population Groups Evidence on nutrient intake among special population groups is limited. A single cohort study conducted by Hassapidou and Mastrantoni (2001) assessed the nutrient intake of athletes. In this study the macronutrient intake of elite female Greek athletes aged 18–25 years and participating in 4 different sports (volleyball, middle distance running, ballet, and swimming) was recorded during both training and competition seasons utilizing a 7-day weighed dietary record. Mean daily total energy and macronutrient intake among this specific population group are presented in tables 119 and 120. Table 119. Mean ( SD) daily energy (in kcal and kJ) and macronutrient intakes (expressed as percentage of total energy) among female athletes, by athletic season Female athletes (n 35)
Energy, kcal (kJ) Protein (% energy) Carbohydrates (% energy) Fat (% energy)
Training
Competition
1,816 537 (7,598.1 2246.8) 15.3 2.5
1,868 681 (7,815.7 2,849.3) 14.2 2.2
47.4 7.5
50.8 8.2
39.6 6.4
38.0 7.2
Source: Adapted from Hassapidou and Mastrantoni, 2001.
Table 120. Mean ( SD) daily micronutrient intake (in g or mg) among female athletes, by sport and athletic season Female athletes (n 35) Volleyball
Vitamin A (g) Vitamin B1 (mg) Vitamin B2 (mg) Folic acid (g) Vitamin C (mg) Calcium (mg) Iron (mg)
Running
Ballet
T
C
T
C
T
894 192 1.2 0.4 1.4 0.4 219 35.5 109.7 43 838 199 14.2 1.6
995 114 1.6 0.6 2 0.4 247 45 120.4 25 1,272 406 14.8 3.2
961.8 560 975 952 937.4 662 1.1 0.3 1.2 0.4 1.1 0.2 1.4 0.4 1.8 0.6 1.4 0.5 206 18.5 195 54 244 42 98.3 60.7 100.2 57 101.8 58 876 341 878 252 958 312 11.4 3 13.8 3 12.6 2.9
Swimming C
T
C
995 814 1,134 180 1.1 0.2 1.4 0.5 1.5 0.3 1.9 0.8 220 86 275 101 110.4 62 134.5 82 832 293 1,063 287 11.4 2.7 14.5 3.8
1,273 130 1.3 0.8 2.2 1.5 201 164 120.2 64 1,149 475 13.2 5.6
T During training season; C During competition season. Source: Adapted from Hassapidou and Mastrantoni, 2001.
Table 121. Brief description of selected case-control and meta-analysis studies Reference
N
Cases/ controls
Both genders
Trichopoulou et al.,1993
838
838*
Yes
Tzonou et al., 1998
899
329/570
Yes
Bohlke et al., 1999
2,368
820/1,548
Kuper et al., 2000
693
333/360
Women only Yes
Peridou et al., 2002
212
106/106
Yes
Collective
Measurement method
Cases
Controls
Hospitalized chronic diseases Coronary infarct
Minor conditions Minor conditions Minor conditions Minor conditions Minor conditions
Breast cancer Hepatocellular carcinoma Oral carcinoma
Semi-quantitative FFQ Semi-quantitative FFQ Semi-quantitative FFQ Semi-quantitative questionnaire Semi-quantitative FFQ
FFQ Food frequency questionnaire. * Meta-analysis of controls participating in six case-control studies in Athens.
Evidence from Case-Control Studies In order to complement the data on micronutrients provided so far by the aforementioned cohort studies already undertaken in the Greek population, evidence from case-control studies assessing micronutrient intake is also presented. For the purposes of comparison, only those case-control studies and meta-analysis whose scope clearly involved the measurement of nutrient intake and collected dietary data using measurement tools described in the cohort studies above (i.e. a semiquantitative food frequency questionnaire) have been included. Moreover, only those case-control studies and meta-analysis including control participants presenting with minor conditions and ailments (i.e. head injury,
Annexes
head-nose-throat ailments) have been selected. A brief description of the case-control studies selected is presented in table 121. A meta-analysis of 610 female and 228 male control participants of six case-control studies undertaken in the 1980s in Athens indicated that the proportion of energy intake from saturated fat, monounsaturated fat, and total fat is higher among women than among men. In addition, this meta-analysis indicated that percent protein intake among controls was about 19%, percent carbohydrate about 37%, and from fats about 44% [Trichopoulou et al., 1993]. With regard to evidence retrieved from control series regarding daily alcohol intake, a case-control study 141
conducted by Kuper et al. (2000) indicated that the majority of female and male controls reported being non-drinkers (30.2% and 75.8% of males and females, respectively). However, 18.8% of male controls, in contrast to none of the women, reported consuming more than 40 glasses of alcohol per week. This relatively wide range of ethanol intake among men, but not among women, was also observed in the Greek EPIC cohort, as presented above (tables 117 and 118). Presented in table 122 is the evidence of daily micronutrient intake in specific control groups, as derived from case-control studies. Table 123 presents the median monthly intake of iron observed in control persons included in a case-control study by Tzonou et al. (1998). Table 122. Mean ( SD) daily micronutrient intake (in mg, g and IU) among a control group consisting of both men and women in a selected case-control study
Carotene (g) Retinol (g) -carotene (g) Vitamin B1 (mg) Vitamin B2 (mg) Vitamin B6 (mg) Vitamin C (mg) Vitamin E (IU) Calcium (mg) Sodium (mg) Potassium (mg) Magnesium (mg) Iron (mg) Zinc (mg) a b
Control women and men (n 106)a
Control women (n 1,548)b
3,410.0 1,870.0 – – 1.2 0.5 1.8 0.8 1.6 0.7 169 96.2 – 1,066.0 596.0 2,077.0 933.0 3,201.0 1,288.0 276.0 95.0 11.0 4.0 13.1 6.1
– 1,575.2 6,465.4 – – – 274.0 7.2 – – – – – –
Source: Peridou et al., 2002. Source: Bohlke et al., 1999.
As the above table displays, average daily iron intake in both genders and all age groups lies within the observed ranges reported in Peridou et al. (2002). However, it is significant to note that a dramatic decrease in iron intake levels is observed in women aged more than 60 years of age. Elderly control women, aged greater than 60 years, are observed to have distinctly decreased iron intake levels as compared to men.
Health Indicators and Status in the Greek Population Children Body Weight, Body Height and BMI Health indicators of Greek children, as reflected in height, weight and BMI, have been more extensively studied than nutrient and energy intakes. Obesity and overweight is considered an important public health problem for Greek children [Mamalakis et al., 1996]. In the study of Roma et al. (1997) during the years 1985–1987, the median weight of children in all age groups and for both genders was higher than recommended. The percentage of children with weight and height above the 97th percentile was 16.5% in both genders, while 29% had weight above the 90th percentile. The health status and representative growth data referring to weight and height of healthy Greek children have been compiled from 9,797 children of Hellenic origin aged 0–18 years living in the area of Athens during the period 2000–2001 [Chiotis et al., 2003]. The data were compared to those collected during the period 1978–1979, in the same geographical region. It was found that the height at the 3rd, 50th and 97th percentile has increased by 2, 1 and 3 cm, respectively for the 18-year old boys. For the same age group, weight at the 3rd, 50th and 97th percentile has increased by 4, 6, and 3 kg, respectively. For the 18-year old girls, the height and
Table 123. Median daily iron intake (in mg) among control persons, by gender and age Control men (n 324)
Iron (mg)
Control women (n 246)
49 years
50–59 years
60–69 years
70 years
49 years
50–59 years
60–69 years
70 years
9.8
11.5
9.8
11.5
9.8
11.5
8.2
8.2
Data were converted from monthly to daily iron intake by division with 30.5 days/month. Source: Adapted from Tzonou et al., 1998.
142
Annexes
weight at the 97th percentile has increased by 1 cm and 7 kg, respectively, whereas height and weight at the 3rd and 50th percentile remained the same. In the same population sample the prevalence of obesity and overweight was estimated by using the criteria proposed by the International Obesity Task Force [Chiotis et al., 2004]. Recently, a large epidemiological study was conducted using data collected from 18,045 children (8,552 boys, 9,493 girls), aged 1–19 years old, from all over Greece. In this study, one in every 10 children was found to be obese and one overweight. Table 124 shows the percentages of normal weight, overweight and obese children and adolescents by age groups, for both recent surveys [Chiotis et al., 2004 and Kapantais et al., 2004]. Another study by Karayiannis et al. provided national estimates for overweight and obesity in Greek schoolaged children and adolescents. A nationwide multistage procedure was followed to obtain a representative sample of children and adolescents aged 11.5, 13.5 and 15.5 years. The resultant sample consisted of 4,299 students, 51.3% girls and 48.7% boys. Self-reported weight and height data were used. Nine percent of girls and 21.7% of boys were classified as overweight, and 1.2% of girls and 2.5% of boys as obese. The authors concluded that compared to most other western countries the prevalence of obesity is lower in Greek children aged 11–16 years [Karayiannis et al., 2003].
Table 124. Prevalence of normal weight, overweight and obesity in Greek children and adolescents, by age and gender
Another study conducted in Northern Greece presented data concerning the height and weight of 2,458 school children aged 6–17 years (1,226 6–10 years, 1,232 11–17 years) from 27 primary and secondary public schools. In the younger group (6–10 years), the prevalence of overweight and obesity were 25.3 and 5.6%, while for adolescents (11–17 years) they were 19.0 and 2.6%, respectively. The prevalence was 25.9 and 5.1% for all males, and 19.1 and 3.2% for all females, respectively. Researchers concluded that the prevalence of overweight and obesity among schoolchildren residing in Northern Greece is 22.2 and 4.1%, respectively. Furthermore obesity has been increasing during the last decades, particularly among boys [Krassas et al., 2001]. The increasing prevalence of obesity among Greek children was also shown from a study conducted at Iraklion, Crete [Mamalakis et al., 2000]. Iron Deficiency Data related to iron deficiency anaemia in Greek children are summarized in table 125 [Frisiras et al., 2003]. Adults and the Elderly Health indicators, including height, weight, arterial blood pressure, smoking habits, and physical activity,
Age (years)
Normal (%)
Overweight (%)
Obese (%)
Girls
Chitotis et al., 2004
Chiotis et al., 2004
Kapantais et al., 2004
0–1 1–6 7–12 13–18 Total
81.68 88.68 81.82 81.87 83.22
9.16 8.0 14.49 14.48 13.05
– 6.4 11.1 12.5a –
9.16 3.31 3.69 3.65 3.73
– 14.4 7.2 3.6a –
87.05 79.95 72.10 67.57 72.11
2.88 10.88 18.48 20.63 17.48
– 7.6 12.7 20.7a –
10.07 9.17 9.42 11.80 10.40
– 15.5 10.0 8.9a –
Chiotis et al., 2004
Kapantais et al., 2004
Boys 0–1 1–6 7–12 13–18 Total a
Data refer to the 13–19 years of age. Source: Chiotis et al., 2004; Kapantais et al., 2004.
Annexes
143
Table 125. Summary of publications regarding iron deficiency and iron deficiency anaemia in the Greek population N
Age
% iron deficiency
% iron deficiency anemia
Reference
111 45 54 27 21 289 127 598 279 675 861 1,128 105 127 68 558 1,030 598 451 229
6–36 months 6–11 months 12–23 months 24–35 months 36–48 months 6–60 months 6–36 months 7–12 years 8–24 months 2–6 years 6–10 years 10–15 years 15 years 1–4 years 9–10 months 5–18 years 14–16 years 0.5–15 years 2 months–13 years 6 months–9 years
54 63 58.6 52.5 40 43.9 84.8 12.2 34.1 24.4 7.3 7.4 7.6 14.2 4.4 12.5 12 10.7 33 18
40 60 55.5 33.3 33.3 33.6 29 4.8 16.1 5.2 0.3 0.4 2.8 2.4 0.0
Matsaniotis N et al., 1969 A. Metaxotou-Mavrommati, 1971 A. Metaxotou-Mavrommati, 1971 A. Metaxotou-Mavrommati, 1971 A. Metaxotou-Mavrommati, 1971 Kattamis et al., 1974 Apostolopoulou-Michailidou and Kouri, 1974 Apostolopoulou-Michailidou and Kouri, 1974b Keramida et al.,1998 Keramida et al.,1998 Keramida et al.,1998 Keramida et al.,1998 Hatzis et al., 1998 Frisiras et al., 1999 Frisiras et al., 2000 Adamidis et al., 1997 Hatzigeorgiou et al., 1996 Oikonomopoulou et al., 1992 Karanikolaou et al., 1992 Krokidas et al., 1992
3.9 8.4
Source: Frisiras et al., 2003.
among Greek adults and the elderly have been assessed in the context of the Greek EPIC study. Body mass index Obesity is an important public health problem with increasing prevalence in developed countries. Body mass index (BMI) is a satisfactory obesity indicator, commonly used in scientific research and clinical practice. A BMI of 19–24.9 kg/m2 is considered as normal, while that between 25–29.9 kg/m2 reflects overweight and greater than 30 kg/m2 obesity. Increasing body mass index reflects increasing degree of obesity and consequent repercussions on health. Body mass index above the normal range is associated with increased risk of diabetes mellitus, hypertension, cardiovascular disease, some types of cancer, and overall mortality. Mean BMI across ages in both genders in the EPIC cohort population is presented in figure 64 and table 126. Men have a greater BMI than women up until 44 years of age, while in older age groups this relationship appears to be reversed. Body mass index increases steadily among men aged up to 64 years and women up 144
Annexes
to 74 years. The decline of BMI levels in older age groups may reflect the increased mortality of the obese. More than 50% of men in almost all age groups are overweight and 20–33% are obese, with the greatest prevalence of obesity observed among those older than 45 years. More than one third of women older than 35 years are overweight while the percentage of obese women is doubled after the age of 45 years and exceeds 50% among those aged 65–74 years (fig. 65). In another population-based study examining the prevalence of obesity in the Greek population [Ioannidis et al., 2004], somatometric characteristics of 9,107 women and 8,234 men, aged 20–72 years, were collected. The study participants were selected from all geographic areas of Greece. Standard BMI cut-off points were used for identifying normal weight, overweight, and obese persons. The results of this study indicated that 18.2% of women and 26.0% of men are obese, while 29.9% of women and 41.1% of men are overweight [Kapantais et al., 2004b]. Similarly to the findings from the EPIC cohort, this study revealed that the percentage of obese men exceeded that of women up
Total men: 11,579 Total women: 16,477
32.0 Mean body mass index (kg/m2)
31.0 30.0 29.0 28.0 27.0 26.0 25.0 24.0 23.0 22.0 21.0 0.0 25–34
35–44
45–54
55–64
65–74
75
Age (years)
Fig. 64. Mean body mass index (kg/m2) among Greek men and women, by age group.
Table 126. Mean ( SD) body mass index (kg/m2) of Greek men and women, by age group
Men
Women
Age (years)
25–34
35–44
45–54
55–64
65–74
75
Men Women
27.3 3.7 25.4 5.0
27.8 3.9 27.0 5.1
28.6 6.5 29.0 5.2
28.7 3.9 30.3 5.1
28.3 4.1 30.8 5.0
27.7 3.8 29.5 4.4
Source: EPIC Newsletter Issue 3, 2002.
to 50 years of age, after which the association was reversed. A direct comparison of the percentage of overweight and/or obese women and men by age group between the two studies is not feasible since the cut-off points of age groups differ between the two studies. However, it is significant to note that both studies show similar trends in the overweight and obese composition of the Greek population at all ages. Lipid Profile The levels of total and HDL cholesterol of a population are indicators of the risk for coronary artery disease in the adult and elderly population. Elevated levels of total blood cholesterol are associated with an increased risk for coronary artery disease, while high levels of HDL cholesterol are associated with decreased risk for coronary artery disease. Total blood cholesterol and HDL-cholesterol were measured among more than 20,000 individuals from the EPIC population, and are presented in tables 127 and 128. With respect to total cholesterol, men have higher levels than women up to the age of 45 years. However, after this age the relationship between the two genders
Annexes
appears to be reversed. This change coincides with menopause, which is considered to have adverse effects on the blood lipid profile of women. Women have higher HDL-cholesterol levels in all ages, as compared to men. The well-known protective effects of HDL-cholesterol may partially explain the relatively advantageous position of women with respect to the risk for coronary artery disease. Total cholesterol levels less than 200 mg/dl are desirable, while those greater than 240 mg/dl are considered elevated. HDL cholesterol levels greater than 60 mg/dl are desirable, while values less than 40 mg/dl are low. Elevated total cholesterol and decreased HDL cholesterol among the EPIC population is presented in the two figures 66 and 67. According to the aforementioned categorization, the percentage of individuals in the EPIC population with elevated total cholesterol increases with age. After the age of about 45 years women with hypercholesterolemia outnumber men. With respect to HDL-cholesterol, about 50% of men have low levels; the decrease of this percentage after the age of 55 years may be attributed to the increased mortality from coronary artery disease. 145
25
Percentages by BMI cut-offs
100 90
25–29.9
30
Men total: 11,579 21.6
26.7
16.8
16.1
20.4
53.7
51.2
48.2
29.5
32.7
31.4
45–54
55–64
65–74
21.9
80 70 60 50
53.4
55.4
52.9
40 30 20 10
20.5
22.9
25–34
35–44
24.8
0 75
Age (years) 25
25–29.9
30
Women total: 16,477
Fig. 65. Percentage of Greek men and women by body mass index (BMI 25: normal, BMI 25–29.9: overweight, BMI 30: obese) and age group. Source: EPIC Newsletter Issue 3, 2002.
Percentages by BMI cut-offs
100 90
10.7
15.4
39.9
80 70
14.0
23.6 56.6
37.2
60
36.0 42.5
38.4
50 38.3
40 30
28.1
10
48.7
37.9
20 15.2
21.8
25–34
35–44
53.4 42.2
0 45–54
55–64
65–74
75
Age (years)
Table 127. Mean ( SD) total blood cholesterol (mg/dl) of Greek men and women, by age group Age (years)
25–34
35–44
45–54
55–64
65–74
75
Men Women
194.0 39.1 183.9 37.1
204.5 44 197.7 39.5
210.5 41.6 214.2 42.5
211.8 40 226.5 43.4
212.2 41.8 226.5 42.9
209.0 40.5 223.2 44.3
Source: EPIC Newsletter Issue 3, 2002.
Table 128. Mean ( SD) HDL blood cholesterol (mg/dl) of Greek men and women, by age group Age (years)
25–34
35–44
45–54
55–64
65–74
75
Men Women
40.1 9.5 49.5 11.3
40.4 24.9 49.3 11.3
40.1 10.2 49.4 11.9
42.6 13.8 49.7 11.9
42.3 11 49.0 12
42.0 10.5 49.3 19.3
Source: EPIC Newsletter Issue 3, 2002.
146
Annexes
Percentages
50
Men total: Number of men with total cholesterol 240mg/dl:
8,728 1,891
40
Women total: 12,243 Number of women with total cholesterol 240mg/dl: 3,339
30
20
10
0
Fig. 66. Percentage of Greek men and women with total blood cholesterol equal or higher than 240 mg/dl (elevated cholesterol), by age group. Source: EPIC Newsletter Issue 3, 2002.
25–34
35–44
45–54
55–64
65–74
75
Age (years) Men
Men total: Number of men with HDL40mg/dl:
70
Women
8,723 4,263
Women total: 12,241 Number of women with HDL 40mg/dl: 2,542
60
Percentages
50 40 30 20 10
Fig. 67. Percentage of Greek men and women with blood HDL cholesterol less than 40 mg/dl, by age group. Source: EPIC Newsletter Issue 3, 2002.
Table 129. Mean ( SD) total serum cholesterol in the Cretan men of the Seven Countries Study
0 25–34
35–44
45–54
55–64
55–84
75
Age (years) Men
Women
Men
70–79 years (n 169)
80–84 years (n 58)
85–89 years (n 18)
Total serum cholesterol (mg/dl)
224 40.4
221.8 42.6
190.7 42.1
Source: Dontas et al., 1999.
Blood cholesterol levels among elderly Greek men were also studied in a small cohort from the Seven Countries Study. In 1960 686 Cretan men aged 40–59 years were selected to participate in the Seven Countries
Annexes
Study. In 1991, 245 survivors of the original cohort remained. Serum cholesterol levels are presented below [Dontas et al., 1999]. Patterns reflect both actual changes and selective survival.
147
Morbidity from Nutrition-Related Diseases Hypertension Hypertension is defined as a steady increase, under resting conditions, of systolic blood pressure to 140 mm Hg (millimetres of mercury) or higher and/or of diastolic pressure to 90 mm Hg or higher. Since blood pressure increases with age, hypertension is more frequent among the elderly. Prior to menopause hypertension is observed more rarely among women than to men. However, after menopause hypertension is observed with similar frequency among women and men. The prevalence of hypertension among men and women in the Greek EPIC cohort is presented in figure 68.
Diabetes Mellitus Diabetes mellitus is a metabolic disorder with severe health consequences since it is associated with elevated risk for cardiovascular disease and may cause severe damage to several organs, such as the eyes, the kidneys, the blood vessels, and the nervous system. While Type I diabetes mellitus is characterized by an onset of clinical symptoms during adolescence, the clinical symptoms of Type II diabetes mellitus most frequently present during adult age. Obesity and sedentary lifestyle are regarded as two of the most prevalent risk factors for Type II diabetes mellitus. The percentage of EPIC cohort members who report having diabetes mellitus is presented in figure 69.
Men (total) : Men with blood pressure 140mm Hg (total): 70
11,566 2,790
Women (total) : 16,460 Women with blood pressure 140mm Hg (total): 4,187
60 Percentages
50 40 30 20 10 0 25–34
Fig. 68. Percentage of Greek men and women with systolic blood pressure higher than 140 mm Hg (high blood pressure), by age group. Source: EPIC Newsletter Issue 3, 2002.
35–44
45–54
55–64
65–74
75
Age (years) Men
20.0
Women
Total men: Total men with diabetes mellitus:
11,555 845
Total women: Total women with diabetes mellitus:
16,475 1,144
18.0
Percentages
16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0 25–34
Fig. 69. Percentage of Greek men and women who report having diabetes mellitus by age group. Source: EPIC Newsletter Issue 3, 2002.
148
Annexes
35–44
45–54 55–64 Age (years)
64–74
75
Men
Women
Smoking Habits Smoking is associated with an increased risk for most types of cancer, cardiovascular diseases, and chronic pulmonary disorders. The adverse effects of smoking are proportionally associated with both the quantity of tobacco consumed and the duration of smoking. Smoking cessation constitutes the most cost-effective primary prevention measure. The increased risk of former smokers begins to decline two years after smoking cessation and approaches the relative risk of nonsmokers after at least a decade, provided that smoking cessation has been initiated before the age of 35 years. The smoking habits of women and men of the EPIC cohort population are presented in figure 70. The findings below are particularly alarming since almost 60% of men aged 25–34 years are smokers and approximately half of the men aged less than 54 years currently smoke. The percentage of smokers decreases significantly after the 54th year of age. This may be partially due to the fact
Current smokers
Non-smokers
Ex-smokers
100 Men (total) : 11,490 Non-smokers (total): 2,844 Ex-smokers (total): 3,856 Current smokers (total): 4,790
90
Percentages
80 70 60 50 40 30
that mortality among smokers increases sharply thereafter, as well as because of the increase in smoking cessation with the progression of age. Particularly elevated rates of smoking are observed among women in the younger age groups (up to 44 years of age) while 90% of women older than 55 years are non-smokers. This situation provides a grim prospect for the health of younger Greek women and predicts an increase in the prevalence of diseases associated with smoking. Physical Activity Regular physical activity is indispensable to every effort for better health and longevity. Increasing the levels of physical activity contributes significantly to body weight control and to the reduction of the risk for cardiovascular diseases, osteoporosis, and overall mortality. Even for individuals with normal body weight, daily physical activity equivalent to fast walking, swimming, dancing, climbing stairs or gardening for 15–30 minutes is strongly recommended, while overweight and obese people (BMI 25 kg/m2) should in addition reduce the quantity of the food they consume. The percentage of men and women who regularly occupy themselves with an athletic activity is presented in figure 71. According to figure 71, only a limited minority of men and women in the Greek population are regularly involved in some athletic activity. The higher levels of RIIA observed in the eldest group of the EPIC cohort may be due to the selected survival of persons regularly involved in some athletic activity.
20 10 0 25–34
35–44
45–54
55–64
65–74
75
Percentages
Age (years) 100 90 80 70 60 50 40 30 20 10 0
Women (total) : 16,379 Non-smokers (total): 11,947 Ex-smokers (total): 1,264 Current smokers (total): 3,168
25–34
35–44
45–54
55–64
65–74
75
Age (years) Current smokers
Non-smokers
Ex-smokers
Fig. 70. Smoking habits of Greek men and women, by age group. Source: EPIC Newsletter Issue 3, 2002.
Annexes
Conclusion The information presented in this report refers to nutrient intakes and health in the Greek population, based on data collected through two large cohort studies conducted among Greek children and adolescent, and among adult and elderly people, respectively. To date, a single population-based study examining nutrient intake and health status among all age groups of the Greek population has not been undertaken. Instead, several small studies have been conducted, but with limited scope and various methodologies that sometimes impair comparisons. The evidence provided reveals that overall macronutrient and micronutrient intake among children, adolescents, adults, the elderly, and athletes is adequate. Moreover, the Greek population and in particular the elderly retain a strong adherence to the nutrient composition of the traditional Greek Mediterranean diet. 149
25.0
Percentages
20.0
Men (total): Men RIAA (total):
1,1545 1,147
Women (total): Women RIAA (total):
16,469 1,235
15.0 10.0 5.0
Fig. 71. Percentage of Greek men and women regularly involved in some athletic activity (RIAA) by age group. Source: EPIC Newsletter Issue 3, 2002.
0
With respect to breastfeeding practices in the country, the lack of data collected through national, regular and comparable surveys is a serious limitation in monitoring breastfeeding in the population. The information currently available has been compiled from various studies of different population samples and methodology, thus explaining the observed inconsistencies of the findings. While cohort studies have provided adequate evidence concerning nutrient intake in children, adolescents, adults, and the elderly, much remains to be done. Specifically, the nutrient intake of special population groups, such as pregnant and lactating women, has not yet been assessed in sufficiently large samples. In addition, to date, nutritional status of various population groups has not been comparatively investigated. The most alarming evidence presented in this report is that of the apparent excess intake of energy among both Greek children and adults. This evidence, in conjunction with low physical activity levels and the elevated rates of smoking has ominous implications for the health of adults and the elderly. It is hoped that the evidence presented in this report, will be useful for the formulation of future nutrition policy priorities in Greece.
Hungary Children In 1995 a non-representative nutrition survey on primary school children of 6th form (12–13 year old) was carried out in 3 different regions of Hungary: (1) North, (2) West and (3) Budapest and a village near to Budapest [Zajkás, 1998]. 150
Annexes
25–34
35–44
45–54
55–64
65–74
75
Age (years)
Men
Women
Table 130. Sources of the data on energy and nutrient intake (none of them was representative) Population group
Data collection
n
Date
Primary school students 12–13 years 14–15 years
3 24 hour record 3 24 hour record
414 412
1995 1997
Adults (18 years) 18–34 years 35–59/54 years
3 24 hour record 3 24 hour record
2,559 731 1,668
1992–1994
Elderly people 60/55 years 70–75 years
3 24 hour record FFQ
160 47
1992–1994 1988
The obtained data shows that the average energy intake was below the Hungarian Recommended Dietary Intake (HRDI) [Bíró and Lindner, 1995] in boys and girls by 8 and 5%, respectively. Also the average protein (3 and 2%, respectively) and carbohydrate intake (19 and 14%, respectively), and the mean share of carbohydrates in total energy (13% both girls and boys) were below the HRDI (table 131). The mean share of added sugar in total energy intake was above the recommended level in boys and girls (by 19% both). The average fat intake was above the recommendations in regard of both total fat intake (by 15 and 29%, respectively) and relative share in total energy intake (by 22% in both girls and boys). The average share of SFA in total energy intake was only slightly above the recommended upper level. The mean cholesterol intake was in boys clearly above the HRDI for this nutrient. As to the micronutrient intake, the vitamin content of the diet of 12–13 year old children involved in the survey
Table 131. Mean daily intake of energy and macronutrients in Hungarian primary school children of 6th form (12–13 years)
Table 132. Mean daily vitamin intake in Hungarian primary school children of 6th form (12–13 years)
Energy, nutrient
Girls
HRDI
Mean SD
HRDI
Mean SD
Energy (MJ) Protein (g) %E Carbohydrates (g) %E Sucrose (added) (g) %E Dietary fibre (g) Fat (g) %E SFA %E MUFA %E PUFA %E Cholesterol (mg)
11.3 86 13 375 57 – 10 – 87 30 10 12 6–8 300
10.3 2.7 83 23 13.6 1.9 304 81 49.6 4.9 74 38 11.9 4.9 19.9 6.6 100.4 30.8 36.6 4.5 10.8 12.2 8.4 359 148.4
10.0 76 13 324 57 – 10 – 77 30 10 12 6–8 300
9.5 2.3 75 20 13.3 1.8 279 67 49.7 5.5 67 30 11.9 4.6 19.5 6.5 99.4 31.0 36.7 5.3 11.1 12.3 8.2 317.1 138.2
Nutrients
Boys
Retinol (g) -Carotene (mg) Vitamin A1 (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Vitamin B6 (mg) Cobalamin (g) Niacin3 (mg) Folic acid (g) Ascorbic acid (mg) 1 2
3
Girls
HRDI
Mean SD
HRDI
Mean SD
– – 1 10 8 1.4 1.6 1.8 2.0 18 150 60
786 1,131 1.9 1.4 1.1 1.2 2.6 1.3 14.8 5.8 0.9 0.4 1.1 0.4 1.4 0.5 3.4 3.3 28.3 8.3 120 49.5 57.4 42.2
– – 0.8 10 8 1.3 1.3 1.8 2.0 15 150 60
578 792 1.8 1.3 0.9 0.9 2.2 1.3 13.3 5.7 0.8 0.3 1.0 0.4 1.4 0.5 2.8 2.5 25.5 7.6 109 41.6 61.1 43.3
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), Niacin equivalent ( 1 mg niacin 60 mg tryptophan).
was rather inconsistent. The average vitamin D, thiamine, riboflavin, vitamin B6 and folic acid intakes were between 20 and 78% below the HRDI (table 132). As to the minerals the average sodium intake of boys and girls was higher (by 195% in boys and 170% in girls) than the HRDI (table 133). The mean magnesium, potassium, zinc, iron and calcium intakes in boys and girls were below the HRDI for these nutrients (by 8– 40%).
Annexes
Boys
Two years later a similar dietary survey in 412 primary school students of 8th form was accomplished [Zajkás et al.]. In this non-representative study dietary data from school children of Budapest were assessed, in different parts of the town, according to social differences. The method was the same as in the survey above. Energy and nutrient intake of boys and girls of the 8th form in primary schools (12–14 year old) were similar to the dietary intake of primary school children of 151
Table 133. Mean daily mineral intake in Hungarian primary school children of 6th form (12–13 years)
Table 134. Mean daily intake of energy and macronutrients in Hungarian primary school children of 8th form (14–15 years)
Nutrients
Mean SD
HRDI
Mean SD
Sodium (g) Potassium (g) Na/K Calcium (mg) Magnesium (mg) Iron (mg) Copper (mg) Zinc (mg)
2.0 3.1 – 1,000 350 12 1.0 9.0
5.9 1.7 2.4 0.8 2.6 0.7 612 264 321 97 9.7 3.0 1.5 1.6 7.7 2.5
2.0 3.1 – 1,000 350 15 1.0 9.0
5.4 1.5 2.3 0.7 2.5 0.7 596 264 309 94 9.3 3.0 1.5 1.6 7.0 2.3
Energy, nutrients
Boys
6th form, as the data above show. The mean energy intake of boys and girls was slightly below the HRDI (table 134). The mean total and relative protein intake was above the recommended levels of the HRDI. On average, a sufficient supply can be assumed. The mean absolute and relative carbohydrate intake of boys and girls was below the recommended level, that of added sucrose was above it. Both the mean total fat intake and the average intake of SFA were too high. Also the average cholesterol intake was above the HRDI. Among the examined vitamins, the vitamin D intake in boys and girls was of most concern. It was lower than the HRDI by 80 and 75%, respectively (table 135). The intakes of thiamine, riboflavin, vitamin B6 and folic acid in boys and girls were below the recommendations for these nutrients as well (15–45%).
Annexes
Girls
HRDI
Energy (MJ) Protein (g) %E Carbohydrates (g) %E Sucrose (added) (g) %E Dietary fibre (g) Fat (g) %E SFA %E MUFA %E PUFA %E Cholesterol (mg)
152
Boys
Girls
HRDI
Mean SD
HRDI
Mean SD
11.7 89 13 389 57 – 10 – 90 30 10 12 6–8 300
11.1 3.2 93.4 28.3 14.3 1.8 320.9 99.5 49.1 5.8 78.5 51.4 11.7 6.0 20.4 7.2 107.5 36.6 36.4 5.6 11.4 2.3 11.2 2.1 8.8 2.7 394 160.5
9.6 73 13 320 57 – 10 – 74 30 10 12 6–8 300
9.3 2.4 77.5 20.9 14.0 1.8 274.5 74 49.7 5.4 70.8 36.1 12.6 5.5 18.5 5.5 89.7 27.1 36.0 4.9 11.4 2.0 10.9 2.0 8.8 2.4 319.5 118.4
The examined boys and girls had a large sodium intake excess which was higher than the HRDI by 215 and 150%, respectively (table 136). In contrast, the mean potassium, calcium, iron and zinc intakes were in these examined children clearly below the recommended levels. One of the purposes of these two studies was to see whether the cardiovascular risk factors (high total fat, saturated fat, cholesterol, salt intake) characteristic of the diet of the Hungarian adult population are present in the dietary pattern of adolescent boys and girls. The answer is positive, the risk factors are present, but in a smaller degree than in the diet of adults. The other reason for these surveys was to check the proportion of children with increased risk of nutrient deficiency. In order to answer this question the number of children
Table 135. Mean daily vitamin intake in Hungarian primary school children of 8th form (14–15 years)
Nutrients
Retinol (g) -Carotene (mg) Vitamin A1 (mg) Vitamin D (g) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Vitamin B6 (mg) Cobalamin (g) Niacin3 (mg) Folic acid (g) Ascorbic acid (mg) 1 2
3
Sodium (g) Potassium (g) Na/K Calcium (mg) Magnesium (mg) Iron (mg) Copper (mg) Zinc (mg)
Boys
Girls
HRDI
Mean SD
HRDI
Mean SD
– – 1 10 10 1.4 1.7 2.0 2.0 18 200 60
523 827 1.7 1.8 0.8 0.9 2.5 1.5 15.0 6.3 1.0 0.4 1.3 0.5 1.6 0.6 3.2 2.2 31.5 9.7 132 65 77 67
– – 0.8 10 12 1.3 1.3 2.0 2.0 15 200 60
473 584 1.7 1.6 0.75 0.6 2.3 1.4 13.0 5.0 0.8 0.3 1.1 0.4 1.4 0.5 2.6 1.9 26.2 7.9 110 50 72 57
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33), Niacin equivalent ( 1 mg niacin 60 mg tryptophan).
Table 136. Mean daily mineral intake in Hungarian primary school children of 8th form (14–15 years) Nutrients
Boys
Table 137. Proportion of children of 6th form of primary schools (12–13 year old) with energy and macronutrient intake 70, and 50% of HRDI
Girls
HRDI
Mean SD
HRDI
Mean SD
2.0 3.5 – 1,000 350 12 1.2 10
6.3 1.8 2.6 0.8 2.6 0.7 777 365 365 127 10.3 3.1 1.4 1.2 9.0 2.9
2.0 3.5 – 1,000 350 15 1.2 9.0
5.0 1.4 2.3 0.6 2.3 0.6 667 267 305 87 9.0 2.4 1.3 1.3 7.2 2.2
with nutrient intake less than 70% and 50% of the HRDI was identified as follows. The energy intake was 70% of the HRDI in 17.9% of boys and 13.8% of girls aged 12–13 years, 4.2% of boys had an intake 50%. The proportion of moderate protein intake insufficiency was similar, between 12–15% in this group of pupils. The moderate fat intake deficiency was close to 10% among boys, and it was 12% among girls. The prevalence of insufficient carbohydrate intake was relatively high (table 137). Data on micronutrient intake indicate an even more serious situation. 50% of boys and 40% of girls had a mean intake of vitamin A, thiamine and riboflavin below
Annexes
70% of HRDI
50% of HRDI
Boys
Girls
Boys
Girls
13.8 12 12 24
4.2 4.2 1.9 6.1
0.9 1.8 1.3 2.7
% Energy Protein Fat Carbohydrates
17.9 13.7 7.5 30.2
70% of HRDI (table 138). The vitamin B6 and vitamin C intake was deficient in more than 35% of boys and 40% of girls, and the rate of severe vitamin C deficiency was close to 30% in boys. The proportion of children with low calcium intake was over 60% among boys, and 70% among girls, and serious deficiency was found in 34% of boys and 40% of girls. The prevalence of insufficient iron intake was rather high in the group of girls (68%). An insufficient zinc intake was found in 30% of the examined boys and 44% of the girls. Data from the survey of children in 8th form of primary schools (14–15 year old) in 1997 showed a similar situation. The rate of deficient energy and carbohydrate intake was rather high (table 139). Different reasons for 153
Table 138. Proportion of children of 6th form of primary schools (12–13 year old) with micronutrient intake of 70, and 50% of HRDI
Table 140. Proportion of children of 8th form of primary schools (14–15 year old) with micronutrient intake of 70, and 50% of HRDI
70% of HRDI
50% of HRDI
70% of HRDI
50% of HRDI
Boys
Boys
Boys
Girls
Boys
Girls
Girls
Girls
%
%
Vitamins Vitamin A1 Vitamin E2 Thiamine Riboflavin Vitamin B6 Cobalamin Ascorbic acid Niacin3
48.1 3.8 62.7 50.0 36.8 16.0 40.6 2.4
41.8 6.2 65.8 41.3 46.7 25.3 40.9 0.4
26.1 1.4 31.1 24.1 10.4 6.6 28.8 0.5
16.9 2.7 28.4 12.9 14.7 10.2 24.4 –
Minerals Calcium Magnesium Iron Zinc
63.2 17.9 34.9 27.4
70.2 24.9 68.0 44.0
34.3 4.7 8.0 9.9
40.0 4.4 29.3 13.8
1
2
3
Retinol equivalent (1 mg retinol 6 mg all-trans-carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg tocotrienol 0.33), Niacin equivalent (1 mg niacin 60 mg tryptophan).
Table 139. Proportion of children of 8th form of primary schools (14–15 year old) with energy and macronutrient intake 70, and 50% of HRDI 70% of HRDI
50% of HRDI
Boys
Girls
Boys
Girls
13 10 6 26
4.2 1.8 1.8 9.0
1.2 – 0.8 5.3
% Energy Protein Fat Carbohydrates
19 11 8 29
that were identified: the first was the lack of knowledge of healthy nutrition among children and their families, the second was not participating in the school feeding programme, and the third was the insufficient care of families (mothers) to the eating habits of their children. The prevalence of micronutrient deficient nutrition was rather high in the examined population group 154
Annexes
Vitamins Vitamin A1 Vitamin D Vitamin E2 Thiamine Riboflavin Vitamin B6 Cobalamin Ascorbic acid Niacin3 Folic acid
57 98 6 49 45 35 10 35 1 60
48 99 12 63 31 48 20 32 – 71
34.7 93.4 2.4 17.4 17.4 13.2 4.2 21 – 30
20.4 97.1 3.7 28.6 6.5 22.4 8.6 18.8 – 40.4
Minerals Calcium Magnesium Iron Zinc Potassium
47 14 29 23 41
60 26 75 38 56
25.1 3 7.8 5.4 25.1
29 5.3 27.3 7.8 19.2
1
2
3
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), Niacin equivalent (1 mg niacin 60 mg tryptophan).
(table 140). The prevalence of low vitamin D intake (70% of HRDI) was particularly high with 98% in boys and 99% in girls. In 48% of girls and 57% of boys the retinol equivalent intake was below 70% of the HRDI. A thiamine intake below 70% of HRDI was found in 49% of boys and 63% of girls, a low riboflavin intake in 45 and 31%, a low vitamin B6 intake in 35 and 48%, and a low ascorbic acid intake in 35 and 32%, respectively. The prevalence of low folic acid intake was even higher with 60% of boys and 71% of girls. The prevalence of deficient calcium (47 and 60%) and potassium (41 and 56%, respectively) intake in boys and girls was relatively high as well. The iron intake was insufficient in 75% of girls. Adults Between 1992 and 1995 a non-representative nutrition survey [Bíró et al., 1996a] was carried out on
2,559 adults (18 years). Data have been presented in 3 age groups: (1) 18–34 year old people; (2) 35–59 year old males, and 35–54 year old females; and (3) 60 year old males and 55 year old females. The reason why the cut-off point was made in different years on males and females was the different year of pension age at that time: it was 60 for men, and 55 for women. The energy intake of the first age group was above the HRDI, by 15% in men and by 3% in women (table 141). The protein intake was particularly high in the group of young men and was 43% above the HRDI. In young women it was 27% above the recommended level. The Table 141. Mean daily intake of energy and macronutrients (mean SD) in Hungarian young adults (18–34 years)
Table 142. Mean daily vitamin intake (mean SD) in Hungarian young adults (18–34 years)
Energy, nutrients
Men (n 388)
Women (n 343)
HRDI
Mean SD
HRDI
Mean SD
Energy (MJ) Protein (g) %E Carbohydrates (g) %E Sucrose (added) (g) %E Alcoholic drinks %E Fat (g) %E SFA (g) MUFA (g) PUFA (g) Cholesterol (mg)
13.0 91 12 440 58 – 10 – 100 30 – – – 300
14.8 3.9 130 38 14.7 2.0 393 113 44.6 6.3 129 66.4 14.6 6.0 2.6 4.0 151.4 50.5 38.0 5.8 56.0 19.9 59.7 20.7 15.5 6.7 655.4 296.5
9.6 67 12 325 58 – 10 – 74 30 – – – 300
9.9 2.7 85 24.6 14.3 2.0 278 81 47.5 6.6 103 47.6 17.8 7.5 0.6 1.5 100 33 37.4 5.8 37.0 12.4 38.7 13.4 10.9 5.2 406.8 170.4
Vitamins
Men (n 388)
-Carotene (mg) Vitamin A1 (mg) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Vitamin B6 (mg) Niacin3 (mg) Cobalamin (g) Ascorbic acid (mg) 1 2
3
Annexes
carbohydrate intake of men and women was below the recommendations. The added sugar intake was too high and by 45 and 78%, in young men and women respectively, higher than the HRDI. In this age group the absolute and the relative fat intake was very high as well and above the recommended level. Consequently, the cholesterol intake of young men was more than twice as high as the HRDI. In young women it was 35% higher. Apart from vitamin E the average intake of vitamins in young men was above the HRDI recommendations (table 142). The average intake of vitamin E was 25% below the recommended level. In the group of young
Women (n 343)
HRDI
Mean SD
HRDI
Mean SD
– 1.0 12 1.4 1.8 2.2 – 2.0 60
2.6 1.8 1.2 1.4 9.0 5.1 1.5 0.5 1.9 0.8 2.4 0.7 26.1 9.6 7.9 9.3 100.9 69.6
– 0.8 12 1.3 1.5 2.0 15 2.0 60
2.4 1.7 0.9 0.8 7.3 3.9 1.0 0.4 1.3 0.5 1.7 0.6 16.8 6.1 4.3 4.3 97.1 64.3
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25mg -tocotrienol 0.33), Niacin equivalent (1 mg niacin 60 mg tryptophan).
155
Table 143. Mean daily mineral intake (mean SD) in Hungarian young adults (18–34 years)
Minerals
Men (n 388) HRDI
Sodium (g) Potassium (g) Na/K Calcium (mg) Magnesium (mg) Iron (mg) Copper (mg) Zinc (mg)
Table 144. Mean daily intake of energy and macronutrients (mean SD) in Hungarian middle-aged adults (males 35–59 years, females 35–54 years)
Energy, nutrients
Energy (MJ) Protein (g) %E Carbohydrates (g) %E Sucrose (added) (g) %E Alcoholic drinks %E Fat (g) %E SFA (g) MUFA (g) PUFA (g) Cholesterol (mg)
2.0 3.5 800 350 12 1.4 10
Women (n 343)
Mean SD 9.5 3.0 3.5 1.0 2.8 0.7 868.2 452.2 482.0 133.1 16.2 6.6 2.9 2.5 13.5 4.7
Men (n 730)
HRDI 2.0 3.5 800 300 15 1.4 9
Mean SD 6.1 2.1 2.7 0.8 2.4 0.8 630.5 298.0 331.3 92.9 10.8 3.3 1.7 1.7 8.6 3.0
Women (n 938)
HRDI*
Mean SD
HRDI*
Mean SD
12.5 88 12 424 58
13.3 3.2 114 30.9 14.5 2.1 339 97.5 43.0 6.3 105.3 55.6 13.4 5.8 4.3 4.7 134.5 40.8 38.0 5.8 49.0 15.4 53.8 17.1 13.6 5.4 556.3 235.1
9.2 64 12 311 58
10.0 2.8 86.4 24.9 14.7 2.2 271.2 83.5 45.9 6.1 96 44 16.3 6.2 0.9 2.0 102.5 34.6 38.3 5.4 37.5 12.9 40.3 14.2 11.0 5.1 415.2 181.0
10 97 30
300
10 71 30
300
*HRDI 31–60 age group (but the results concern to 35–59 year old men, and 35–54 year old women).
women the average intake of vitamin E, thiamine, riboflavin and vitamin B6 was lower than the recommended value. There was a high excess sodium intake both in the male and female group. In the male participants the average intake of all other minerals was sufficient. In the female group the calcium intake was too low, and also the iron intake was below the Hungarian recommendation (table 143). In the group of middle aged men and women the average energy intake was slightly higher than the HRDI (table 144). The mean intake of protein in men and women was 30% and 35% higher than the recommended level; the mean intake of fat was 39 and 44% above it. 156
Annexes
As a result of this high protein and fat intake, the average intake of carbohydrates was below the Hungarian recommendation. There was a huge excess of cholesterol intake in this population group. In this age group the rate of overweight and obese men was 46.6 and 26.9%, and the rate of overweight and obese women was 30.7 and 24.6%. The average intake of vitamin E and thiamine was too low in the male group. In the female group the average intake of vitamin E, thiamine, riboflavin and vitamin B6 was below the Hungarian recommendations (table 145). The mineral intake of men was characterised by a sodium intake four times higher than the recommendation, and by an insufficient calcium intake (18% below the
Table 145. Mean daily vitamin intake (mean SD) in Hungarian middle-aged adults (males 35–59 years, females 35–54 years) Vitamins
Men (n 730)
Women (n 938)
Table 147. Mean daily intake of energy and macronutrients (mean SD) in Hungarian elderly (males 60 years and females 55 years) Energy, nutrients
-Carotene (mg) Vitamin A1 (mg) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Vitamin B6 (mg) Niacin3 (mg) Cobalamin (g) Ascorbic acid (mg) 1
2
3
HRDI
Mean SD
1.0 12 1.3 1.8 2.2 18 2.0 60
2.7 1.8 1.0 1.2 7.8 4.2 1.3 0.7 1.6 0.7 2.3 0.6 24.8 8.2 6.3 6.9 104.1 75.6
HRDI
Mean SD
0.8 12 1.2 1.5 2.0 15 2.0 60
2.8 2.1 1.0 1.0 7.4 4.0 1.0 0.3 1.3 0.5 1.8 0.6 17.8 6.3 4.8 6.5 94.6 56.3
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), Niacin equivalent ( 1 mg niacin 60 mg tryptophan).
Table 146. Mean daily mineral intake (mean SD) in Hungarian middle-aged adults (males 35–59 years, females 35–54 years) Elements
Men (n 730) HRDI
Sodium (g) Potassium (g) Na/K Calcium (mg) Magnesium (mg) Iron (mg) Copper (mg) Zinc (mg)
2.0 3.5 800 350 12 1.4 10
Mean SD 8.8 2.8 3.2 0.9 2.8 0.8 659 347.7 429 114.4 14.4 4.7 2.9 2.8 11.9 3.7
Women (n 938) HRDI 2.0 3.5 800 300 15 1.4 9
Mean SD 6.4 2.0 2.7 0.7 2.5 0.7 579 275.5 328 91.4 11.1 3.8 1.9 1.8 8.8 2.9
HRDI). The nutrient intake of middle aged women was insufficient in potassium, calcium, iron and zinc (23, 28, 26 and 2% below the recommended value; table 146). Elderly People There are two data sources to show the nutrition of elderly people in Hungary: one from the Dietary Survey in 1992–1994 [Bíró et al., 1996], the other data is from the Hungarian participation of the Euronut-Seneca Study 1989 [Moreiras et al., 1991; Amorim et al., 1991]. In the Hungarian Dietary Survey of 1992–1994 the average energy intake was in both the group of men and women higher than the HRDI (by 28%) (table 147). Also
Annexes
Energy (MJ) Protein (g) %E Carbohydrates (g) %E Sucrose (added) (g) %E Alcoholic drinks %E Fat (g) %E SFA (g) MUFA (g) PUFA (g) Cholesterol (mg)
Men (n 55)
Women (n 105)
HRDI
Mean SD
HRDI
Mean SD
9.2 75 14 301 56
11.8 3.5 102.8 28.2 14.8 2.1 310 96.2 44.3 6.4 98.2 53.9
7.9 65 14 260 56
9.7 2.6 86 24.7 14.7 2.2 272 75 47.1 7.3 95.4 42.9
10
13.7 5.5 2.2 3.2
10
16.5 6.4 0.6 1.6
71 30
123 49.8 74 38.6 5.6 30 45.5 18.5 48.4 20.8 12.5 5.8 474 212 300
300
99.4 35 37.4 6.2 36.4 13.2 39.0 14.5 10.5 4.7 375 169
the average protein intake was above the recommended level, by 37 and 32% in men and women respectively. The mean carbohydrate intake was too low. The average added sugar intake was above the Hungarian recommended value. The fat intake of men and women was particularly high, especially in men. Consequently the mean cholesterol intake was 58 and 25% above the HRDI. The mean intakes of vitamin E, thiamine, riboflavin and vitamin B6 were below the Hungarian recommendations in both men and women (table 148). The average intake of vitamin E was 40 and 41%, in men and women, respectively, below the HRDI. The average thiamine intake was 15 and 10%, the riboflavin intake 22 and 20% and the vitamin B6 intake 9 and 10%, respectively, below the recommended levels. The vitamin A intake was in the group of men too low by 20%. The average sodium intake of elderly people involved into the nutrition survey in 1992–1994 was almost 4 times higher, and that of the women was more than 3 times higher than the HRDI (table 149). The mean potassium intake of men and women was 17 and 23% below the HRDI, the average calcium intake 30 and 39%. The mean iron intake was slightly too low in the female group. Data from the Euronut-Seneca Study are similar. The mean energy intake of men and women between 70–75 years was below the HRDI by 22% (table 150). 157
Table 148. Mean daily vitamin intake (mean SD) in Hungarian elderly (males 60 years and females 55 years)
Table 150. Mean daily intake of energy and macronutrients (mean SD) in Hungarian elderly (70–75 years)
Vitamins
Energy, nutrients
-Carotene (mg) Vitamin A1 (mg) Vitamin E2 (mg) Thiamine (mg) Riboflavin (mg) Vitamin B6 (mg) Niacin3 (mg) Cobalamin (g) Ascorbic acid (mg) 1
2
3
Men
Women
HRDI
Mean SD
HRDI
Mean SD
1.0 12 1.3 1.8 2.2 18 2.0 60
2.5 2.1 0.8 0.6 7.2 3.4 1.1 0.4 1.4 0.5 2.0 0.7 19.3 7.7 4.7 4.2 91 63.6
0.8 12 1.1 1.5 2.0 15 2.0 60
2.9 1.8 0.8 0.6 7.1 3.7 1.0 0.4 1.2 0.4 1.8 0.6 17.0 6.0 3.8 4.8 93.5 62.2
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), Niacin equivalent (1 mg niacin 60 mg tryptophan).
Table 149. Mean daily mineral intake (mean SD) in Hungarian elderly (males 60 years and females 55 years) Minerals
Sodium (g) Potassium (g) Na/K Calcium (mg) Magnesium (mg) Iron (mg) Copper (mg) Zinc (mg)
Men
Energy (MJ) Protein (g) %E Carbohydrates (g) %E Fat (g) %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol (g) %E
Mean SD
HRDI
Mean SD
2.0 3.5 – 1,000 350 12 1.4 10
7.4 1.9 2.9 0.8 2.6 0.7 699 365 381 112 12.4 3.8 1.8 1.7 9.9 3.3
2.0 3.5 – 1,000 300 12 1.4 9
6.2 1.8 2.7 0.8 2.4 0.7 613 264 328 96.4 10.8 3.3 1.4 1.3 8.5 3.2
Females (n 26)
HRDI
Mean SD
HRDI
Mean SD
9.2 75 14 301 56 71 30 10
11.2 4.7 82.9 38.5 12.4 2.2 315 128 48.8 11.6 98 49 32 8 11.8 3.3 11.7 3.3 5.4 2.7 333 200 30.5 39.6 7.0 8.6
7.2 65 14 260 56 61 30 10
9.7 2.9 79.5 21.2 14.2 1.7 296 110 51.4 7.0 88 29 35.2 6.7 13.3 3.0 12.4 2.9 6.1 2.1 328 108 1.5 4.7 0.5 1.5
6–8 300
6–8 300
Source: EURONUT-Seneca, 1989.
Table 151. Mean daily vitamin and mineral intake (mean SD) in Hungarian elderly (70–75 years) Men
Women
HRDI
Mean SD
HRDI
Mean SD
Vitamins -Carotene (mg) Vitamin A1 (mg) Thiamine (mg) Riboflavin (mg) Vitamin B6 (mg) Ascorbic acid (mg)
1.0 1.3 1.8 2.2 60
1.7 0.8 0.28 0.09 0.64 0.46 0.94 0.43 1.32 0.79 66 31
0.8 1.1 1.5 2.0 60
2.0 0.8 0.35 0.18 0.76 0.48 1.20 0.74 1.42 0.86 56 34
Minerals Calcium (mg) Iron (mg)
1,000 12
638 220 9.7 2.8
1,000 12
838 527 9.8 5.1
Women
HRDI
Males (n 21)
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids) Source: EURONUT-Seneca, 1989. 1
The average protein intake was above the recommended level in men and women. The mean carbohydrate intake was too low. The absolute and the relative fat and SFA intake was above the recommended value. Consequently also the average cholesterol intake was too high. The prevalence of insufficient vitamin intake was rather high. In the group of men and women the average vitamin A intake was below the HRDI by 72 and 56%, the average thiamine intake by 51 and 31%, the average riboflavin intake by 48 and 20%, the average vitamin B6 intake by 41 and 30%, and the average vitamin C intake in the female group by 7%. The mean calcium and iron 158
Annexes
intakes were below the Hungarian recommended intake levels in both men and women as well (table 151). Nutritional Status of the Hungarian Population In the Hungarian Nutrition Survey between 1992–1994 biochemical analytical examinations were made as well according to the following: As to the biochemical markers of average vitamin status there were no data out of normal range except
Table 152. Biochemical markers of vitamin supply in the Hungarian population (mean SD); dietary survey in 1992–1994
Serum retinol (mol/l) Mean SD
Serum -tocopherol (mol/l) Mean SD
-ETK Mean SD
Serum folate (mmol/l) Mean SD
Ascorbic acid in leucocytes (g/108) Mean SD
Men Young Middle-aged Older Total average
2.6 0.7 3.1 1.0 3.0 0.8 2.9 0.9
28.3 8.4 34.5 12.0 36.8 8.9 32.6 11.2
1.1 0.1 1.1 0.1 1.1 0.1 1.1 0.1
20.8 8.9 20.0 8.8 17.6 6.1 20.2 8.7
34.9 9.9 32.9 10.4 33.9 11.0 33.6 10.3
Women Young Middle-aged Older Total average
2.3 0.8 2.4 0.7 2.7 0.7 2.4 0.7
28.6 6.5 32.0 11.5 38.4 10.7 31.8 10.8
1.1 0.1 1.1 0.1 1.1 0.1 1.1 0.1
22.7 9.8 21.1 9.7 19.2 7.6 21.3 9.6
36.2 9.8 36.9 10.3 35.6 13.7 36.6 10.5
Altogether Normal range
2.6 0.9 1.05–2.8
32.2 11.0 12–42
1.1 0.1 0.97–1.27
20.8 10.5 11–45
35.3 10.5 21–54
Sex, age group1
1
Young: 18–34 years (men: n 388; women: n 343), middle-aged: 35–59 years (men: n 730; women: n 938), older: 60 years (men: n 55; women: n 105), total: men: n 1,173; women: n 1,386.
Table 153. Serum levels of some macro- and microelements in the Hungarian population (mean SD) Sex, age group
Potassium (mmol/l) Mean SD
Calcium (mmol/l) Mean SD
Magnesium (mmol/l) Mean SD
Zinc (mol/l) Mean SD
Copper (mol/l) Mean SD
Selenium (mol/l) Mean SD
Men Young Middle-aged Older Total
3.9 0.9 3.9 0.3 3.9 0.4 3.9 0.6
2.4 0.1 2.4 0.1 2.4 0.2 2.4 0.1
0.8 0.1 0.8 0.4 0.8 0.1 0.8 0.3
17.2 2.6 17.2 2.6 16.5 3.3 17.2 2.6
17.1 2.9 17.3 2.8 18.1 3.3 17.3 2.9
1.3 0.4 1.3 0.4 1.4 0.4 1.3 0.4
Women Young Middle-aged Older Total
3.9 0.3 3.9 0.4 3.8 0.4 3.9 0.4
2.4 0.1 2.4 0.1 2.4 0.1 2.4 0.1
0.8 0.2 0.8 0.1 0.9 0.8 0.8 0.3
17.0 2.7 16.8 2.7 17.1 3.1 16.9 2.7
18.6 3.3 18.7 3.2 19.4 2.9 18.7 3.2
1.3 0.4 1.3 0.4 1.2 0.4 1.3 0.4
Altogether Normal range
3.9 0.5 3.4–4.5
2.4 0.1 2.1–2.65
0.8 0.3 0.65–1.05
17.0 2.7 10.7–22.9
18.1 3.1 Men: 11–22 Women: 12.5–22.9
1.3 0.4 0.63–1.89
middle and old age groups (their serum retinol value was a little higher than the normal) (table 152). There were no data of average mineral status (potassium, calcium, magnesium, zinc, copper, selenium) out of normal range (table 153). There were no data of average haematological biomarkers out of normal range (table 154). There were no data of average biomarkers of iron metabolism out of normal range (table 155).
Annexes
There were no data of average biochemical markers of protein metabolism out of normal range (table 156). Increased cardiovascular risk was indicated by the serum lipid values. The average total cholesterol and LDL-cholesterol levels were above the normal range in both the group of men and women, except for the youngest age group. The average HDL-cholesterol level was within the normal range in all age groups, the average serum triglyceride level was above the normal value 159
in the group of young adult men (table 157). The Apo A-I, A-II and Apo B lipoproteins were within the normal range (table 158). In the Euronut Seneca Study some laboratory analysis was done as well: haematology, serum albumin, serum lipids and plasma vitamins (tables 159 and 160). The haemoglobin, haematocrit and serum albumin values were within the normal range, but serum total cholesterol and the serum triglyceride levels were higher than the normal value both in the group of men and women [Dirren et al., 1991; Kafatos et al., 1991].
Table 154. Haematological parameters in the Hungarian population (mean SD) Sex, age group
Haemoglobin (mmol/l) Mean SD
Haematocrit Mean SD
Men Young Middle-aged Older Total
9.5 0.7 9.4 0.8 9.1 0.9 9.4 0.8
0.47 0.03 0.47 0.04 0.45 0.04 0.46 0.04
Women Young Middle-aged Older Total
8.4 0.9 8.4 0.8 8.7 0.9 8.4 0.8
0.42 0.03 0.42 0.04 0.42 0.03 0.42 0.04
8.9 0.9 Men: 8.4–11.2 Women: 7.4–9.9
0.44 0.04 Men: 0.43–0.49 Women: 0.37–0.45
Altogether Normal range
Table 155. Biochemical markers of iron metabolism in the Hungarian population (mean SD)
Sex, age group
Annexes
Retinol Pyridoxal-5-phosphate Folic acid -tocopherol Cobalamin
1.35 mol/l 20 nmol/l 6.8 nmol/l 11.5 mol/l 111 pmol/l
According to the above criteria there were no plasma vitamin values below the high risk deficiency level in the Hungarian group participating in the Euronut Seneca Study (table 160). Anthropometric Data There are data of BMI and waist/hip rate from the Nutrition Survey of 1992–1994 [Bíró et al., 1996]. It can be seen, that 10 years ago the proportion of obese men and women was 21 and 21.2%, in the total population in the study. The percentage of overweight men was rather high, almost 42%, and it was close to 30% among women. The highest prevalence of obesity was found in the group of 60 year old men, and in the group of 55 year old women. The highest proportion of W/H higher than the upper limit was in the group of young men and women (table 161). Smoking Habits in the Hungarian Population In Hungary 19.1% of 15 year old adolescents and 42% of the population older than 15 years is smoking
Serum iron (mol/l) Mean SD
TIBC (mol/l) Mean SD
Transferrin (g/l) Mean SD
Transferrin (sat. %) Mean SD
Men Young Middle-aged Older Total
15.9 6.4 16.0 6.2 15.9 5.6 15.9 6.2
62.5 8.2 59.2 8.3 61.5 9.0 60.5 8.4
3.2 0.5 3.2 0.6 3.1 0.5 3.2 0.5
25.8 10.7 27.5 11.3 26.8 10.6 26.9 11.1
Women Young Middle-aged Older Total
15.3 6.3 14.4 5.9 14.0 5.3 14.6 6.0
64.2 10.6 63.0 9.6 62.6 11.2 63.3 10.0
3.5 0.6 3.3 0.6 3.3 0.6 3.3 0.6
24.3 10.3 23.5 10.3 22.7 8.5 23.6 30.2
15.2 6.1 Men: 11.6–31.3 Women: 9.0–30.4
62.1 9.5 44.8–80.6
3.3 0.6 2.0–4.0
25.0 10.7 15–50
Altogether Normal range
160
In the Euronut Seneca study the criteria for definition of high risk vitamin deficiency was the following [Haller et al., 1991]:
Table 156. Biochemical markers of protein metabolism in the Hungarian population (mean SD)
Sex, age group
Total serum protein (g/l) Mean SD
Serum albumin (g/l) Mean SD
Serum urea (mmol/l) Mean SD
Serum uric acid (mol/l) Mean SD
Men Young Middle-aged Older Total
76.6 4.1 76.0 4.3 75.9 6.1 76.2 4.4
47.2 2.6 46.7 2.9 45.3 7.8 46.7 3.4
5.8 1.4 6.0 1.7 6.3 1.7 5.9 1.6
330.9 74.5 341.7 74.5 347.6 107.0 338.8 76.8
Women Young Middle-aged Older Total
74.1 4.7 73.2 4.9 74.1 4.9 73.5 4.9
46.8 2.9 45.9 2.8 46.9 3.3 46.2 2.9
5.1 1.6 5.5 1.7 5.8 2.2 5.5 1.7
233.3 52.1 251.0 63.1 281.1 68.9 249.5 62.4
Altogether Normal range
74.6 4.9 60–80
46.4 3.2 38–50
5.7 1.1 2.1–8.9
287.2 81.7 Men: 210–420 Women: 150–350
Table 157. Serum lipids in the Hungarian population (mean SD)
Table 158. Serum lipoproteins (mean SD)
Sex, age group
Sex, age group
TC LDL-C HDL-C TG (mmol/l) (mmol/l) (mmol/l) (mmol/l) Mean SD Mean SD Mean SD Mean SD
Apo A-I (g/l) Mean SD
Apo A-II (g/l) Mean SD
Apo-B (g/l) Mean SD
Men Young Middle-aged Older Total
5.1 1.1 6.0 1.2 6.0 0.9 5.7 1.2
3.1 1.0 3.8 1.0 3.9 0.8 3.6 1.1
1.4 0.3 1.4 0.4 1.4 0.3 1.4 0.4
1.5 1.4 2.4 2.5 1.8 1.4 2.1 2.2
Men Young Middle-aged Older Total
1.5 0.3 1.6 0.4 1.6 0.3 1.6 0.3
0.3 0.1 0.3 0.1 0.3 0.1 0.3 0.1
0.8 0.3 1.0 0.3 1.0 0.3 0.9 0.3
Women Young Middle-aged Older Total
5.0 1.0 5.7 1.1 6.6 1.2 5.6 1.2
3.1 1.0 3.6 1.0 4.5 1.1 3.6 1.1
1.6 0.4 1.6 0.3 1.6 0.4 1.6 0.4
1.1 0.6 1.4 1.5 1.7 1.2 1.3 1.3
Women Young Middle-aged Older Total
1.6 0.3 1.7 0.3 1.8 0.3 1.7 0.3
0.3 0.1 0.3 0.1 0.4 0.1 0.3 0.1
0.8 0.2 0.9 0.3 1.1 0.3 0.9 0.3
Altogether 5.6 1.2 Normal range 5.2
3.6 1.1 3.4
1.5 0.4 Men: 0.9 Women: 1.1
1.7 1.8 2.0
Altogether Normal range
1.6 0.3 1.0
0.3 0.1 0.25
0.9 0.3 1.2
[WHO Europe, 2002a]. Other data show that more than 50% of men, and around 30% of women aged 15 years and over are daily smokers [WHO Europe, 2002b]. In 1999 the proportion of boys and girls smoking at the age of 15–18 years was 44.9 and 46.9%, respectively. The proportion of smokers in the groups of 15, 16, 17 and 18 year old adolescents was 37.2; 43.0; 49.4 and 51.8%, respectively. Most of the smokers – 45.7% – smoked 2–10 cigarettes/day, and 23.5% smoked 11 or more cigarettes [Népegészségügy, 2000].
Annexes
Table 159. Haematology, serum albumin and serum lipids of people 70–75 year old
Haemoglobin (g/l) Haematocrit (%) Serum albumin (g/l) Total cholesterol (mmol/l) HDL-cholesterol (mmol/l) HDL-C/TC Serum triglyceride (mmol/l)
Males Mean SD
Females Mean SD
157 10 48.5 2.7 44.3 2.9 5.94 1.09 1.37 0.38 0.24 0.09 1.82 2.54
150 11 46.4 3.2 43.2 2.5 6.50 1.09 1.43 0.38 0.23 0.07 1.89 1.73
Source: Euronut Seneca Study, 1989.
161
Table 160. Plasma vitamin levels of people 70–75 year old Hungarians
Carotene (mol/l) Retinol (mol/l) Vitamin E (mol/l) Vitamin B6 Folic acid (nmol/l) Cobalamin (pmol/l)
Overall Mean SD
Males Mean SD
Females Mean SD
0.21 0.14 1.7 0.4 20 12 33 23 14.0 11.7 224 108
0.22 0.18 1.8 0.4 21 9 33 20 12.8 4.2 217 91
0.20 0.12 1.6 0.3 24 11 34 28 15.0 15.5 229 123
Source: Euronut Seneca Study, 1989.
Table 161. BMI and W/H values in the Hungarian Nutrition Survey 1992–1994
Italy Infants At three months, 40–70% of the infants are exclusively breastfed, with higher rates in northern Italian regions, while at 6 months only 12–41% are exclusively breastfed, with lowest values in Calabria and Sicilia (12–13%; table 162, Grandolfo et al., 2002). The PUER 1 [Bellù et al., 1991] and PUER 2 studies [Scaglioni et al., 2000] indicated that mixed feeding using infant formula and cow’s milk is common after the age of 3 months (fig. 72). Complementary feeding is started on average at 4.3 months (range: 1.6–6.5), with fruit and vegetable products being introduced first, respectively at 4.3 months (range: 1.6–7.7) and 5.0 months
Males, %
BMI 20 20–25 25–30 30 W/H ratio 0.95 0.80
Females, %
18–34 years
34–59 years
60 years
Total
18–34 years
35–54 years
55 years
Total
9.8 48.4 32.7 9.1
1.1 25.4 46.6 26.9
3.6 23.6 45.5 27.3
4.1 33.0 41.9 21.0
19.8 55.4 16.6 8.2
5.4 39.2 30.7 24.7
0.9 25.7 40.1 33.3
8.7 42.2 27.9 21.2
80.7
46.3
54.5
58.1 68.8
42.3
19.0
47.1
n
3 months %
6 months %
PIEMONTE LOMBARDIA BOLZANO TRENTO EMILIA R. TOSCANA MARCHE UMBRIA LAZIO SARDEGNA CAMPANIA PUGLIA BASILICATA CALABRIA SICILIA
185 481 374 384 179 1,685 785 486 688 489 816 415 190 137 346
57.8 62.4 70.1 69.8 73.2 62.0 61.0 62.6 67.0 66.3 57.1 61.2 67.4 42.3 41.6
20.5 23.3 41.2 31.3 22.3 27.1 19.9 23.3 24.9 22.5 16.4 17.3 25.8 12.4 13.6
162
Annexes
Percentage of infants
Table 162. Exclusive breastfeeding in different Italian regions Breast milk Infant formula Cow's milk
100 90 80 70 60 50 40 30 20 10 0 0
1
2
3
4
5
6
7
8
9
10 11 12
Months
Fig. 72. Proportion of Italian infants on breast milk, infant formula and cow’s milk.
Children A nationwide food intake survey was conducted in 1994–1996 on a representative sample of 1,200 households (1,978 individuals) using a 7-day diary [D’Amicis et al., submitted]. Survey data on children aged 1–9 years and 10–14 years and on adults (18–64 year old) was collected. Another study on food consumption and meal distribution in school children in Italy, was conducted on a representative sample of 1,036 children aged 6–14 years [D’Amicis et al., 2002a]. The nutrient intakes are described in tables 163 and 164. In the first study 16 %E was obtained from protein, 35% from fat and 49% from carbohydrates at all ages; in the second study the energy from fat was slightly lower (33%) and that from carbohydrates slightly higher (52%), but in both studies protein intake was much higher than the reference values. Dietary protein was mainly from animal sources. A mean intake of sugars above the recommended level was also observed, while complex carbohydrates were below the recommendations.
(range: 2.3–8.1 months). Cereals not containing gluten are introduced at 5.2 months (range: 2.3–8.4 months), while those containing gluten are introduced later, at 5.7 months (range: 3.3–9.5 months). Meat is introduced on average at 5.5 months, dairy products at 6.2 months, eggs at 8.5 months and fish at 9.1 months. In one-year-old children macronutrient requirements were met, but protein intake was more than double the requirements (fig. 73).
Energy Protein Lipids Carbohydrates
250
LARN
200 150 100 50 0 Energy
Protein
Lipids
Carbohydrates
Adolescents For adolescents, there are no nationally representative studies. A food intake survey was carried out on a
Fig. 73. Intake of macronutrients in one-year-old Italian infants. Source: Bellù et al., 1991. Table 163. Energy and nutrient intake in Italian children Nutrients
Unit
Energy Total protein Animal protein Vegetable protein Total lipids Animal lipids Vegetable lipids Saturated fatty acids Monounsaturated fatty acids Polyunsaturated fatty acids Available carbohydrates (monosaccharides) Starch (polysaccharides) Soluble carbohydrates (monosaccharides) Alcohol Fibre Water
Children (1–9 years )
Children (10–14 years )
Mean SD
% EU PRI
% energy
Mean SD
% EU PRI
% energy
kcal g g g g g g g g g g
1,717 461 68.4 18.3 44.2 12.4 23.7 9.2 65.9 19.9 36.0 11.8 27.8 13.0 20.75 6.28 22.26 7.78 7.55 4.80 226.2 69.4
109 271
2,365 545 93.0 23.8 57.2 16.2 35.1 11.7 91.1 24.0 46.2 15.7 42.1 15.7 27.35 8.19 33.67 10.72 12.83 5.58 310.0 82.2
106 164
85
100% 16% 10% 6% 35% 19% 15% 11% 12% 4% 49%
87
100% 16% 10% 6% 35% 18% 16% 10% 13% 5% 49%
g g
119.2 47.8 90.5 32.2
61 168
29% 20%
187.0 61.5 100.0 34.8
72 141
33% 16%
g g g
0.2 0.6 14.2 5.6 1,174 321
0% 0% 0%
1.5 4.8 20.2 7.4 1,501 448
126
123
0% 0% 0%
Source: D’Amicis et al., submitted.
Annexes
163
Table 164. Energy and nutrient intake in 6–14 year old Italian children
Table 166. Energy and nutrient intake in 18–64 year-old Italian adults
Nutrients
Unit
Mean
% LARN Mean SD
% EU PRI
Nutrients
Unit Mean SD
Energy Protein Fats Saturated fats Available carbohydrates Starch (polysaccharides) Sugars Alcohol Fibre
kcal g g g g
1,915 73.8 69.4 23.4 263.0
100 38 167 65 109 49 112 56 82 30
96 221
g
181.3
78 31
81.3 0.2 16.5
126 55 56 23
kcal 2,206 474 106 g 89.1 21.0 152 g 55.7 16.7 g 33.1 9.0 g 83.6 24.1 121 g 41.6 15.6 g 40.2 16.8 g 25.47 8.40 g 32.47 10.78
g g g
Energy Total protein Animal protein Vegetable protein Total lipids Animal lipids Vegetable lipids Saturated fatty acids Monounsaturated fatty acids Polyunsaturated fatty acids Available carbohydrates Starch Soluble carbohydrates Alcohol Fibre Water
Source: D’Amicis et al., 2002a.
Table 165. Energy and macronutrient intake in adolescents in Rome
g
11.56 6.11
g g g g g g
271.6 68.3 165.9 49.6 85.9 34.4 11.2 16.0 20.1 6.5 1,643 509
% PRI % energy 100% 16% 10% 6% 34% 17% 16% 10% 13% 5% 83 70 132
46% 31% 15% 4% 0% 0%
Source: D’Amicis et al., submitted. Nutrients
Unit
Energy Total Protein Total Fats Saturated fatty acids Total carbohydrates Starch (polysaccharides) Sugars Alcohol Fibre
kcal g g g g g g g g
Females (n 108) Mean SD
Males (n 125) Mean SD
2,055 577 77 22 91 28 29 10 245 72 151 51 80 29 11 14 5
2,711 721 103 28 117 30 36 11 328 99 204 62 103 42 35 17 6
Source: INRAN Study 2001.
sample of 233 students of the second and third year of nine secondary public schools of Rome, aged 16–18 years [Leclercq et al., 2004]. The energy and macronutrient intake in this group is reported in table 165. The proportion of energy from protein was 15%, from lipids 40% and from carbohydrates 45%. Adults The 1994–1996 nationwide household survey provides nationally representative data on energy and nutrient intakes of adults and elderly. 16% of total energy was obtained from protein, 34% from fat, 46% from carbohydrates and 4% from alcohol. Although energy from fat 164
Annexes
was above the recommended 30%, the SFA recommendation was not exceeded, as the additional fat was mainly derived from unsaturated fat. Despite a relatively high proportion of carbohydrates in total energy intake, starch intake was lower than recommended and soluble carbohydrate intake higher (table 166). Elderly In adults above 64 years energy intake was higher, but the proportion of macronutrients was at about the same level compared to younger adults: 16% from protein, 32% from fat, 46% from carbohydrates and 5% from alcohol (table 167). The excess of soluble carbohydrates was reduced in this age group. The survey revealed an insufficient vitamin D intake in this age group. Lactating Women Nationally representative data on energy and nutrient intake of lactating women are not available. The results of a small study carried out in three centres [Giammaroli et al., 2002] are reported in table 168. There is no apparent peculiarity in this group, compared to the general adult population. There is a north-south gradient as far as the total fat intake and soluble carbohydrates are concerned, with more fat and sugars in the North than in the Centre and South.
Table 167. Energy and nutrient intake of Italian adults 64 years Nutrients
Unit Mean SD
Energy Total protein Animal protein Vegetable protein Total lipids Animal lipids Vegetable lipids Saturated fatty acids Monounsaturated fatty acids Polyunsaturated fatty acids Available carbohydrates Starch Soluble carbohydrates Alcohol Fibre Water
kcal g g g g g g g g
1,970 481 109 80.3 20.3 143 49.4 15.3 30.8 9.5 70.3 21.0 117 33.2 12.4 36.5 15.2 21.28 7.29 28.94 10.60
g
10.22 5.60
g g g g g g
244.2 67.0 154.4 55.1 72.5 26.8 14.2 18.3 19.9 6.6 1,622 590
% PRI % energy 100% 16% 10% 6% 32% 15% 17% 10% 13% 5% 88 77 131
46% 32% 14% 5% 0% 0%
Source: D’Amicis et al., submitted.
Table 168. Energy and nutrient intake of a sample of Italian lactating women
Energy (MJ/day) Total protein (g/day) Animal protein Vegetable protein Total protein (g/kg) Protein (% energy) Fat (g/day) Animal lipids Vegetable lipids Fat (% energy) SFA (% energy) PUFA (% energy) Cholesterol (mg/day) Total carbohydrates (g/day) Total carbohydrates (% energy) Soluble carbohydrates (% energy) Fibre (g/day)
Nutritional status The SCARPS study [D’Amicis et al., 2002] provides information on weight and height of Italian school age children in different regions. In boys BMI was higher in the Centre and South than in the North, while in girls it was more homogeneous (table 169). A multi-centre study on 5,479 children in the third year of primary school was carried out in 2001 (INRAN, 2003). Overweight and obesity was present in 23–51% of the boys (fig. 74) and 24–63% of the girls (fig. 75), with large variability across regions, southern regions being more affected than northern regions. A nationally non-representative study in adolescents in Rome indicated that the average BMI in boys is slightly above the expected 22.5, but it is lower in girls, pointing out a possible issue of underweight in adolescent girls (table 170). Nationally representative data on self reported weight and height of adolescents are also available [ISTAT 1999–2000] and indicate a prevalence of overweight of 17.8% in boys and 7.6% in girls (table 174). For the adult population there are two sources of data: measurements of weight and height were carried out on more than 7,000 men and women aged 50–64 in the
Italy (n 125)
North (n 36)
Centre (n 30)
South (n 59)
9.9 2.5 91.3 27.6 65% 35% 1.5 0.5 15.7 2.9 82.4 24.9 56% 44% 31.8 5.8 11.1 3.2 3.2 3.0 362.3 191.0 324.4 94.4
10.0 1.9 80.6 19.0 65% 35% 1.3 0.4 14.1 2.0 92.2 21.9 57% 43% 36.3 5.2 12.7 3.1 3.9 1.0 360.9 189.6 300.2 69.6
8.7 2.1 80.7 20.8 61% 39% 1.3 0.4 15.6 2.6 67.4 20.5 48% 52% 29.1 4.7 9.2 2.5 3.0 0.5 303.2 185.4 304.7 80.0
10.6 2.8 103.3 30.4 66% 34% 1.7 0.5 16.7 3.0 83.9 25.7 60% 40% 30.5 5.2 11.1 3.0 3.0 1.0 393.8 190.7 349.2 108.3
52.0 6.6
49.2 5.7
54.9 6.5
52.3 6.5
15.6 5.0
17.3 5.6
16.0 4.2
14.3 4.5
20.0 6.5
17.8 5.9
20.7 5.8
21.0 6.9
Source: Giammaroli et al., 2002.
Annexes
165
Table 170. Physical characteristics of a sample of adolescents in Rome
Table 169. BMI (kg/m2) of school age children in Italy Boys
Girls Boys (n 125)
Age group (years) 6–8 9–11 12–14 All ages
17.0 3.8 18.8 3.8 19.9 3.9 18.8 4.0
16.5 3.9 18.0 3.7 18.9 4.5 17.9 4.2
Geographical area North Centre South ITALY
18.0 2.9 19.4 3.2 19.2 3.6 18.9 3.3
18.1 3.1 18.7 3.3 18.0 2.8 18.3 3.1
Source: D’Amicis et al., 2002.
Normal/Underweight
Overweight
Obesity
23.3
11.8 9.6
64.9
Totale
67. 7
Toscana (tutta)
22.8
51.7
Calabria (lamezia terme)
25.8
22.5
22.3
28.4
49.3
Campania (pomigliano D’Arco)
77
Lombardia (lodi)
15.2
62.6
Emilia romagna (bologna)
63.1
Puglia (brindisi) 0
20
21.6
40
60
7.9 10.2 15.3
27.2
80
100
%
Fig. 74. Prevalence of overweight and obesity in eight-year-old boys (n 2,829).
Normal/Underweight
Totale
65.1
Toscana (tutta)
69 36.1
Calabria (lamezia terme)
Overweight
34.7
29.2 34.2
17.9 17.2
64.8
Emilia romagna (bologna)
24.6
61.2
Puglia (brindisi) 0
20
8.4
22.6
76.9
Lombardia (lodi)
10.3
24.5
47.9
Campania (pomigliano D’Arco)
Obesity
27.6 40
60
80
5.9 10.6 11.2 100
%
Fig. 75. Prevalence of overweight and obesity in eight-year-old girls (n 2,650).
context of the European Prospective Investigation into Cancer and Nutrition [Slimani et al., 2002]. Nationally representative data are also available for all geographical areas and in different age groups but are based on self reported weight and height [ISTAT 1999–2000]. The data from the EPIC study (tables 171 and 172) indicate 166
Annexes
Age (years) Weight (kg) Height (cm) BMI (kg/m2)
17.1 1.1 70.2 12.8 174 6 23.2 4
Girls (n 108) 16.8 1.1 57 9.6 162 6 21.8 3.5
Source: Leclercq et al., 2004.
that the combined prevalence of overweight and obesity ranges between 63 and 80% in men and between 48% and 73% in women, with a remarkable north-south gradient. Obesity occurs more in women in southern regions. The prevalence figures obtained from the self reported weight and height are lower, as one may expect, but are useful to describe an age trend of overweight (tables 173 and 174): in men it increases steadily from the third decade, while in women it triples between the third and the fifth decade of life, most probably in coincidence with menopause. The self reported data indicate that the overweight and obesity problem affects one third of the Italian adult population of all ages (table 174). Underweight may be a problem in elderly people. Conclusions Exclusive breastfeeding is practiced by a substantial number of mothers, but only up to the age of 3 months. Mixed feeding takes place early (i.e. at 4–5 months) in the majority of Italian children. After that, a sizeable excess of protein, particularly animal protein, is observed. At all ages proteins are mainly derived from animal foods (10% of total energy) and 6% from plant foods (ratio: 1.5:1). Fats are also in excess at all ages (32–35%), although a greater excess is observed in adolescents (39–40% of energy), but SFA account for 10–11% of total energy intake. Unsaturated fat accounts for most fat intake at all ages : children (S:11%; M:12%; P:4%); adolescents (S:10%; M:13%; P:5%); adults (S:10%; N:13%; P:5%); elderly (S:10%; M:13%; P:5%). Animal fat is contributing more to total fat intake than vegetable fat at all ages, except in elderly. Carbohydrate intake is below the Eurodiet recommendation, and most worryingly simple carbohydrates are in excess at all ages.
Table 171. BMI in men and women aged 50–64 years in the EPIC study City
Ragusa Florence Turin Varese
Men
Women
n
Mean
SE
P10
P50
P90
n
Mean
SE
P10
P50
P90
1,057 1,708 2,841 1,587
28 26.6 26.3 26.7
0.1 0.1 0.1 0.1
23.7 22.7 22.4 22.9
27.8 26.3 26 26.3
32.5 30.8 30.4 30.9
943 2,304 6,505 2,413
27.9 27.9 26 25.4
0.1 0.1 0.1 0.1
22.6 22.9 21.5 20.7
27.3 27.3 25.4 24.8
34 33.6 31.5 30.5
Source: Slimani et al., 2002. Table 172. BMI distribution in 50–64-year-old in the EPIC study City
Ragusa Naples Florence Turin Varese
Men
Women
n
18.5
18.5–24.9
25–29.9
30
n
18.5
18.5–24.9
25–29.9
30
1,057 – 1,708 2,841 1,587
0 NA 0.2 0.2 0.4
20.2 NA 31.9 36.8 32.1
54.8 NA 53.5 50.9 53.4
25 NA 14.2 12.1 14.1
943 2,304 6,505 2,413 4,469
0.3 0.4 0.7 1.6 1.3
26.7 27.2 44.6 50.4 41.9
44.8 45.6 39.5 35.8 40.4
28.2 26.8 15.2 12.2 16.4
Source: Slimani et al., 2002.
Table 173. Distribution of BMI in Italian adults from reported weight and height by age group Age group
BMI 18.5
Thousands of people 18.5–25
25.1–30
30
Men 18–24 25–34 35–44 45–54 55–64 65–74 75 and above Total
3.1 1.3 0.3 0.5 0.5 0.7 3.2 1.1
77.5 61.3 46.9 36.1 34.6 33.9 44.3 47.9
17.7 32.9 44.5 49.7 50.5 52.2 44.3 41.8
1.7 4.4 8.3 13.8 14.5 13.2 8.1 9.1
2,516 4,460 4,408 3,753 3,253 2,582 1,552 22,525
Women 18–24 25–34 35–44 45–54 55–64 65–74 75 and above Total
17.8 10.5 4.5 2.4 1.9 1.8 5.8 6
72.6 74.7 69.4 54.9 44.9 45.4 46.9 59.2
7.8 11.9 20.3 30.0 37.9 38.6 35.2 25.7
1.8 2.9 5.8 12.8 15.3 14.2 12.1 9.1
2,387 4,395 4,349 3,862 3,422 3,186 2,728 24,329
Source: ISTAT 1999–2000.
Annexes
The requirement for water soluble and fat soluble vitamins is met at all ages, with the notable exception of vitamin D which may be insufficient among elderly people. There is a low risk of deficiency for most minerals, with the exception of calcium in adolescents and elderly and of iron in adolescent girls. The data on weight and height indicate that Italy is also involved in the epidemic of obesity in men, an increasing prevalence after adolescence; in women, menopause is the critical period. One third of the adult Italian population is affected by overweight and obesity. Updated and nationally representative data on anthropometry and biochemistry of different age groups are however missing. Norway The National Council on Nutrition and Physical Activity has carried out dietary surveys among nationally representative groups at three different ages: Babies and children aged 6 months to 2 years (Spedkost 1998–1999), 3–5 years (Ungkost, 2000), school pupils aged 13–18 (Ungkost 1993), and the age group 167
Table 174. Overweight in adolescents and adults from reported weight and height by geographical area and age
Geographical areas
Age groups
Standardised rate1
15–24
25–44
45–64
65 and over
Total
Males North Centre Islands South ITALY
15.1 14.3 20.4 21.7 17.8
34.6 35.3 42.7 43.8 38.0
49.4 51.3 50.3 51.7 50.6
48.8 46.2 50.2 50.0 48.6
40.2 40.3 43.3 44.2 41.6
37.2 37.3 41.6 42.6 39.2
Females North Centre Islands South ITALY
6.3 6.5 6.7 9.1 7.6
12.9 14.4 18.9 20.9 16.0
31.3 32.1 36.3 38.3 33.7
35.1 38.4 37.7 41.7 37.9
23.6 25.3 26.7 29.0 25.8
21.6 23.0 25.7 28.2 24.2
Males Females North west 11.7 North east 9.5 Centre 10.6 Islands 13.7 South 15.5 ITALY 12.8
22.4 26.0 24.9 30.7 32.3 27.1
39.5 41.3 41.4 43.1 44.9 42.0
39.1 42.6 41.7 43.1 45.2 42.3
30.6 33.0 32.5 34.7 36.3 33.4
28.3 30.3 29.9 33.4 35.1 31.4
1
Standardized rates have been calculated using Italian resident population aged 15 years and over – Census 1991. Source: ISTAT 1999–2000.
16–79 years (Norkost 1993–1994 and 1997). In all of these surveys, self-administered questionnaires were used, asking what the individual usually eats. There are plans to repeat the studies. Children (4 years) The nutrient intake of this sample was calculated with and without considering the intake of supplements. Both results are presented here. The mean share of protein in total energy intake was within the normal range indicated by the WHO (2003). Also the absolute protein intake numbers show a sufficient supply of protein in this population group (table 175). The mean proportion of carbohydrates in total energy intake was satisfactory. It was only slightly below the recommended level of Eurodiet (2000). However, the share of sugar in carbohydrate intake was relatively high with 15 %E. The proportion of fat in the daily diet of Norwegian 4 year old children was higher than the upper level recommended by Eurodiet. The share of SFA in total fat intake was in general relatively high which indicates a relative high proportion of 168
Annexes
animal products in the daily diet of this age group. The average intake of PUFA can on average be regarded as sufficient. The effects of supplements on nutrient intake particularly become obvious in vitamin and mineral intake (table 176). The recommendation for vitamin A was already reached without supplements, in both girls and boys. The average vitamin A intake was in both groups about 20% higher if the supplement intake was considered as well. The mean vitamin D intake without supplements was relatively low in Norwegian children of this age group. Especially in winter this low supply may be insufficient as the sun irradiation in the Nordic regions during this period is very low. The mean intake which was calculated including vitamin D derived from supplements was about two to three times as high as the average intake without supplements. On average, the vitamin E intake of Norwegian children of this age group can be regarded as sufficient even without the intake of supplements. Both, girls and boys were above the recommended level of the SCF. When considering the
Table 175. Mean daily intake of energy and macronutrients (mean SD) in Norwegian children (4 years)
Children (4 years)
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg)
Male (S) (n 206) 6.3 1.4 14 4 52 15 52 13 15 6 12 5 33 10 14 4 10 3 62 180 81
Female (S) (n 185) 6.0 1.2 14 3 50 12 53 11 15 7 12 4 33 9 15 4 10 3 62 168 65
Male (S) (n 206) 6.3 1.5 14 4 52 15 53 13 15 6 12 5 34 10 15 4 10 3 62 180 81
Female SCF (S) (n 185) M 6.1 1.2 14 3 50 12 52 11 15 7 12 4 34 9 15 4 10 3 63 174 65
F
6.7 6.3 10–15** 19 55* 10* 30* 10* 6–10*
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids; (S) without supplements; (S) with supplements. * Eurodiet (2000); ** WHO (2003)
Table 176. Mean daily vitamin and mineral intake (mean SD) in Norwegian children (4 years)
Children (4 years) Male (S) Female (S) Male (S) Female (S) SCF (n 206) (n 185) (n 206) (n 185) M Vitamin A1 (mg) Vitamin D (g) Vitamin E2 (mg)
0.9 0.5 2.7 2.1 4.6 1.6
1.0 1.0 2.4 1.5 4.4 1.3
Thiamine (mg) Riboflavin (mg) Ascorbic acid (mg) Calcium (mg) Iron (g)
0.9 0.2 0.8 0.2 1.2 0.4 1.2 0.3 66 32 68 30 684 215 667 208 6.8 2.2 6.4 2.0
1.1 0.6 6.8 5.3 9.0 5.4
1.2 1.0 7.1 5.6 9.8 7.3
1.2 0.5 1.2 0.5 1.6 0.7 1.6 0.7 81 44 88 41 687 217 673 212 7.8 3.8 7.4 3.9
F
0.4 0–10 (0.4 g PUFA) 4.1/4.2 4.0/4.1 0.7 1.0 25 450 4
(S) without supplements; (S) with supplements. Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33). 1
vitamin E intake by supplements the average intake was about twice as high as without supplements. Also the mean intake of thiamine, riboflavin and ascorbic acid in these Norwegian population groups was sufficient without the use of supplements, in both male and female. The contribution of supplements in total intake was between 20 and 40% for these vitamins. The average calcium intake in both girls and boys was sufficient. The contribution of supplements in total mean intake was very low. Also the average intake of iron can be considered as sufficient in this population group even
Annexes
without the use of supplements. The supplement intake increased the average iron intake by 1 g/day in both girls and boys. Children of 4th and 8th Grade of School (9 and 13 years) The interviewed Norwegian children of both school grades and both sexes had a mean energy intake which corresponded to the average requirements indicated by the SCF for these age groups (table 177). The proportioning of protein, carbohydrates and fat was very good 169
Table 177. Mean daily intake of energy and macronutrients (mean SD) in Norwegian children (9 and 13 years)
Children (9 and 13 years)
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg)
4th grade (9 years)
8th grade (13 years)
SCF
Male (n 404)
Male (n 492)
M
Female (n 411)
Female (n 517)
8.6 2.0 7.7 2.0 9.5 3.5 8.0 2.6 14 2 14 3 15 3 14 3 73 21 63 20 82 34 67 25 54 6 55 6 54 7 55 6 16 6 18 6 18 8 19 7 16 7 14 6 16 8 14 7 32 5 31 5 31 6 31 5 14 3 14 3 13 3 14 3 10 2 10 2 10 2 10 2 62 62 52 52 221 102 197 105 239 134 196 105
F
8.4/9.6 7.5/8.4 10–15** 27/43 27/42 55* 10* 30* 10* 6–10*
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Table 178. Mean daily vitamin and mineral intake (mean SD) in Norwegian children (9 and 13 years)
Children (9 and 13 years)
4th grade (9 years)
8th grade (13 years)
SCF
Male (n 404)
Female (n 411)
Male (n 492)
Female (n 517)
M
Vitamin A1 (mg) Vitamin D (g) Vitamin E2 (mg)
1.3 0.7 3.1 3.0 6.5 2.4
1.1 1.5 2.6 2.1 5.7 2.0
1.2 2.4 2.8 3.0 7.4 4.1
1.0 1.2 2.4 2.5 6.4 3.4
Thiamine (mg) Riboflavin (mg) Ascorbic acid (mg) Calcium (mg) Iron (g)
1.2 0.4 1.6 1.0 87 48 914 339 9.3 3.0
1.0 0.3 1.2 0.5 1.3 0.4 1.6 0.7 81 42 94 64 751 271 933 497 8.2 3.5 10.2 4.3
1 2
Annexes
0.5/0.6 0–10/0–15 (0.4 g PUFA) 5.5/5.5 4.8/4.6 1.0 0.4 0.8/1.0 0.8/0.9 1.3 0.5 1.2/1.31.2/1.2 85 52 20/35 785 359 550/1,000 8.7 3.3 6/10 6/18
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent ( mg -tocopherol mg -tocopherol 0.5 mg
-tocopherol 0.25 mg -tocotrienol 0.33).
in all these groups as well. The average share of protein as well as of carbohydrates in total energy intake was within the normal range indicated by the WHO and Eurodiet, respectively. However, the share of sucrose in total carbohydrate intake was relatively high, especially in boys and girls of the 8th grade, and girls of the 4th grade. This high consumption of sugar should be reduced and the proportion of complex carbohydrates should in exchange be increased. The average fat intake of the interviewed Norwegian children was only slightly above the normal range 170
F
indicated by Eurodiet (2000). The proportion of SFA in total fat intake was relatively high in girls and boys of both grades and was clearly above the upper level indicated by Eurodiet (2000). Table 178 shows that the mean intake of vitamin D was relatively low in the interviewed sample. As mentioned before, the vitamin D supply by food is very important in Nordic countries especially in winter due to a low amount of sun irradiation. The mean calcium intake in girls and boys of 4th grade was above the recommended level of SCF. Boys and girls at the age of 13 years have clearly higher
requirements. The intake was slightly below the requirements in boys, and it was significantly lower in girls of this age group. The average iron intake was sufficient in the boys of both school grades and in girls of 4th school grade. The girls of the 8th grade showed an average intake which was significantly below the population reference intake for this age group. Adolescents The proportioning of macronutrients was good in Norwegian adolescents as well. The average share of protein, carbohydrates and fat approximately corresponded to the recommendations of Eurodiet (2000). The mean intake of SFA was however above the indicated upper level, as well as the cholesterol intake in male adolescents. The average alcohol intake was relatively low in Norwegians of this age group (table 179). The mean intake of vitamin D in Norwegian male adolescents was relatively high with more than 5 g/day (table 180). In the female sample it was lower with an average of only 3.4 g/day. The average supply of calcium was relatively high in Norwegian adolescents and far above the recommendation of Eurodiet (2000), particularly in the male group. The supply of iron can on average be regarded as sufficient in the male sample.
Table 179. Mean daily intake of energy and macronutrients (mean SD) in Norwegian adolescents (16–19 years) Adolescents (16–19 years)
Male (n 92)
Female (n 86)
SCF M
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
13.9 14 114 54 16 26 31 14 11 5 362 1 4
9.1 15 80 55 12 21 29 12 10 5 228 1 5
F
11.7 8.8 10–15** 56 55* 10* – 30* 10* – 6–10* 300** – –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Annexes
Table 180. Mean daily vitamin and mineral intake (mean SD) in Norwegian adolescents (16–19 years) Adolescents (16–19 years)
Male (n 92)
Female (n 86)
SCF M
Vitamin A1 (mg) Vitamin D (g) Thiamine (mg) Riboflavin (mg) Niacin2 (mg) Ascorbic acid (mg) Calcium (mg) Iron (g)
1.6 5.4 1.9 2.4 20 129 1,400 13.7
1.3 3.4 1.3 1.7 15 119 1,000 9.8
F
0.7
0.6 0–10
1.1 1.6 18
0.9 1.3 14
45 700/800* 9 16*
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 Niacin equivalent ( 1 mg niacin 60 mg tryptophan). * Eurodiet (2000). 1
In female adolescents the iron intake was below the recommendation of 16 mg/day [Eurodiet, 2000]. Adults The share of protein in total energy intake was in both men and women between 15 and 16% and thus slightly above the recommended normal range of the WHO (2003) (table 181). The mean proportion of carbohydrates was above 50% in both age groups, and in women slightly higher than in men. The average intake of sucrose was relatively low in Norwegian adults, especially in those of the second age group. On average, the proportion of fat in the daily diet of the interviewed sample was relatively low compared to other industrial countries. It was in both men and women only slightly above the normal range indicated by Eurodiet (2000). Also the proportion of SFA was slightly too high, as well as the mean cholesterol intake in men. The mean alcohol intake in Norwegian adults was relatively low. The average supply of vitamin D was relatively good in Norwegian male adults with nearly 6 g/day (table 182). The mean intake of vitamin D was much lower in Norwegian women with an average of 3.4–4.2 g/day. In regard of the low amount of sun irradiation in Norway, this amount of vitamin D may especially in winter not be sufficient. A higher intake of this vitamin would thus be recommendable, particularly for Norwegian female adolescents and adults. 171
Table 181. Mean daily intake of energy and macronutrients (mean SD) in Norwegian adults (20–59 years)
Adults (20–59 years)
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
Men
Women
SCF
20–29 years (n 248)
30–59 years (n 721)
20–29 years (n 268)
30–59 years (n 774)
M
F
12.6 15 108 51 12 24 32 13 11 6 358 2 9
10.6 16 97 50 8 25 31 12 11 6 334 3 9
8.7 15 76 53 13 20 30 13 11 6 239 2 4
7.8 16 75 51 9 21 31 13 11 6 260 2 4
9.2–12.8 7.7–9.0 10–15** 56 55* 10* 30* 10* – 6–10* 300** – –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Table 182. Mean daily vitamin and mineral intake (mean SD) in Norwegian adults (20–59 years)
Adults (20–59 years)
Vitamin A1 (mg) Vitamin D (g) Thiamine (mg) Riboflavin (mg) Niacin2 (mg) Ascorbic acid (mg) Calcium (mg) Iron (g)
Men
Women
SCF
20–29 years (n 248)
30–59 years (n 721)
20–29 years (n 268)
30–59 years (n 774)
M
1.6 5.6 1.7 2.3 21 124 1,300 13.0
1.6 5.9 1.6 1.9 20 120 1,000 12.1
1.3 3.4 1.2 1.6 14 111 900 9.7
1.5 4.2 1.2 1.5 14 119 800 9.6
0.7
F
0.6 0–10
1.1 1.6 18
0.9 1.3 14
45 700/800* 9 16*
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), Niacin equivalent ( 1 mg niacin 60 mg tryptophan). * Eurodiet (2000). 1 2
The average supply of calcium in Norwegian adults seems to be very good as well. In both men and women in all age categories the mean intake was higher than the recommended level of 800 mg/day [Eurodiet, 2000]. The supply of iron was on average sufficient in the male sample. In women, who have higher requirements than men, the mean intake was not sufficient. Only in women after the menopause this average intake of iron might be sufficient. 172
Annexes
Elderly The energy intake in Norwegian elderly approximately corresponded to the average requirements indicated for this population group (table 183). The proportion of protein in total energy intake was slightly above the recommended normal range of the WHO (2003). The mean carbohydrate intake was relatively high in the examined sample with more than 50 %E in both men and women. Furthermore, the proportion of sucrose in total
carbohydrate intake was notably low. The mean dietary fibre intake in Norwegian elderly corresponded on average to the recommended level, in women it was too low. The average share of fat was within the normal range of Eurodiet (2000), that of SFA was slightly too high. The mean cholesterol intake was below the indicated upper level in both male and female elderly. Table 183. Mean daily intake of energy and macronutrients (mean SD) in Norwegian elderly (60–79 years) Elderly (60–79 years)
Men (n 237)
Women (n 246)
SCF M
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Sucrose %E Dietary fibre (g) Fat %E SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
8.8 16 84 52 8 25 30 12 11 5 292 2 5
7.1 17 70 53 8 22 29 12 11 5 222 1 2
F
8.0 7.3 10–15** 56 55* 10* – 30* 10* – 6–10* 300** – –
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003).
Table 184. Mean daily vitamin and mineral intake (mean SD) in Norwegian elderly (60–79 years) Elderly (60–79 years)
Men (n 237)
Women (n 246)
SCF M
Vitamin A1 (mg) Vitamin D (g) Thiamine (mg) Riboflavin (mg) Niacin2 (mg) Ascorbic acid (mg) Calcium (mg) Iron (g)
1.6 5.8 1.5 1.7 17 117 900 11.0
1.6 4.0 1.2 1.5 14 123 800 9.0
F
0.7
0.6 10*
1.1 1.6 18
0.9 1.3 14
45 700/800* 9
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), 2 Niacin equivalent (1 mg niacin 60 mg tryptophan). * Eurodiet (2000). 1
Annexes
The average alcohol intake was relatively low in this group as well. The average intake of vitamin D was – compared to other European countries – relatively high in Norwegian elderly men with about 5.8 g/day, in women it was lower with only 4 g/day (table 184). These intakes were however clearly below the recommended level of 10 g/day indicated by Eurodiet (2000). Portugal Apart from the periodic FBS and HBS food data, that can only allow for a gross estimation of food consumption, Portugal has no other recent representative data on this subject. In Portugal, the last and only survey assessing food and nutrient intake at a national level was held in 1980. Since then no other food consumption data has been collected at a national representative level. For these reasons, the presented information has been derived from several recent national studies that have been held within this scope. It is important to highlight that these data were collected for different investigation purposes with different methodological approaches and that the samples are not nationally representative (table 185). Children Table 186 shows that the energy intake of Portuguese children was higher than the recommended values for their age, especially in male subjects. On the contrary, carbohydrates were lower than the ideal minimum intake. The mean intake of protein, fat, SFA and sugars was higher than the recommended levels. The calcium intake was also satisfying. Adolescents The average energy intake was below the recommended intake in both male and female adolescents. Also the mean intake of carbohydrates was lower than the recommended level, whereas the mean protein and fat intake was above the RDI. As a consequence of the relatively high fat intake, the mean cholesterol intake was above the recommended upper level as well. The mean calcium intake was especially in male children and adolescents not satisfying, in the female group it corresponded to the recommended intake (table 187). Adults On average the mean energy intake in Portuguese adults approximately corresponded to the average 173
Table 185. Method and period of dietary assessment in Portugal by age group
Age group Children Adolescents
7–9 years 11–15 years
Adults
18–29 years 40 years
Elderly
70–79 years
Table 186. Mean daily intake of energy and nutrients (mean SD) in Portuguese children (7–9 years)
Energy (kcal) Carbohydrates (%E) Sugars (%E) Protein (%E) Fat (%E) SFA (%E) MUFA (%E) PUFA (%E) Fiber (g) Calcium (mg)
Male (n 2,184)
Female (n 2,113)
2,449 608 49.2 8.0 22.6 7.3 16.7 3.8 35.3 6.8 12.7 3.4 14.6 3.5 4.9 1.7 18.7 7.9 1,104 426
2,284 573 49.0 7.9 22.2 7.1 16.7 3.8 35.2 6.9 12.8 3.3 14.6 3.5 5.0 1.6 17.8 7.8 1,049 414
Source: Data taken from Moreira P, Fernandes T, Mourão I, Padez C, Rosado V: Dietary calcium and body mass in Portuguese school children. Clinical Nutrition 2004;23:901–902.
requirements indicated by the SCF for this population group. The mean protein intake in Portuguese young adults as well as in adults older than 40 years was relatively high with about 18 %E in men and 19 %E in women and was thus above the recommendations of the WHO (2003). Also the absolute numbers of protein intake show a sufficient supply. The average intake of carbohydrates was too low with only 48 %E in young adults, both male and female. In adults older than 40 years the average share of carbohydrates in total energy intake was only 45% in men, but 50% in women. The mean intake of dietary fibre was in young adults below the recommended level of Eurodiet (2000) as well, with 23 g/day in men and 22 g/day in women. In the older age group the average dietary fibre intake can be regarded as 174
Annexes
Method
N
Year
24 hour recall Quantitative 24-hourrecall Semi-quantitative FFQ (validated with 4-dayrecord) Semi-quantitative FFQ (validated with 7-dayrecord) FFQ (validated with 3-dayrecord)
4,297 272
2000–2002 2000
246
2001
726
1995–1998
157
1993
Table 187. Mean daily intake of energy and nutrients indicated as % of recommended intake (mean SD) in Portuguese adolescents (11–15 years)
Energy (% of RDI1) Carbohydrates (%of RDI1) Protein (%of RDI1) Fat (% of RDI1) Cholesterol (% of RDI1)2 Calcium (% of RDI1)3
Male (n 124)
Female (n 148)
90.6 25.4 92.3 13.1 118.7 27.0 115.6 22.9 143 25 77
91.8 28.9 89.4 14.5 124.7 34.3 117.4 22.0 158 25 99
1
National recommendations, Source: Calado, 1995 (n 81m, 104 f), 3 Source: Perdigão, 1996 (n 28m, 40 f). Source: Data taken from Viana V: Food behaviour, nutritional status and some psychological and social related factors in an adolescent group. PhD dissertation, Faculty of Nutrition and Food Science from Porto University. Porto, 2000. 2
sufficient. The mean fat intake in Portuguese young adults was slightly above the normal range indicated by Eurodiet, with 33 %E in both men and women. In Portuguese adults older than 40 years it was within the normal range. The average intake of SFA in Portuguese adults approximately corresponded to the guideline of Eurodiet (2000). Despite the quite good proportion of SFA, the average intake of cholesterol was relatively high especially in young Portuguese men (444 mg/day) and in women of this age group (382 mg/day). The mean alcohol consumption in young Portuguese adults was relatively low. In Portuguese men older than 40 years it was very high with 10 %E. (table 188). According to table 189 the supply of vitamins seems to be very good in Portuguese adults. For vitamin D the SCF
Table 188. Mean daily intake of energy and macronutrients (mean SD) in Portuguese adults (18–291 and 402 years)
Adults
Male 18–29 years (n 159)
Energy (MJ) 10.9 1.9 Protein %E 18 3 Protein g 21 21 Carbohydrates 48 10 %E Dietary fibre (g) 23 7 Fat %E 33 6 SFA %E 11 2 MUFA %E 14 3 PUFA %E 61 Cholesterol (mg) 444 91 Alcohol %E 11 Alcohol (g) 4.2 5.4
Female
SCF
40 years (n 310)
18–29 years (n 87)
40 years (n 416)
11.1 2.8 17 5 115 31 45 13
8.9 1.4 19 3 105 18 48 9
8.8 2.3 18 5 97 28 50 14
10–15** 56 47 55*
26 9 28 9 93 12 4 52 364 132 10 9 40 34
22 7 33 7 11 3 14 3 6 1.3 382 85 0.3 1 1.1 2.5
25 10 30 10 94 13 6 52 303 120 24 7 12
25* 30* 10* – 6–10* 300** – –
M
F
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003). Source: data taken from 1 Moreira P, Daniel S, de Almeida MDV: Validity assessment of a Food Frequency Questionnaire by comparison with a 4-day diet record. Acta Médica Portuguesa 2003; 16:412–420, and 2 Lopes C: Food and ischaemic heart disease, community-based case-control study. PhD dissertation, Faculty of Medicine from Porto University. Porto, 2000.
Table 189. Mean daily vitamin intake (mean SD) in Portuguese adults (18–29A and 40B years) Male
Vitamin A1 (mg) Vitamin D (g) Vitamin E2 (mg) Vitamin B1 (mg) Vitamin B2 (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Folate4 (g) Vitamin B12 (g) Vitamin C (mg)
Female
SCF
18–29 years (n 159)
40 years (n 310)
18–29 years (n 87)
40 years (n 416)
M
F
1.5 0.8 4.8 1.8 8.2 2.2
1.5 0.8 – 8.7 2.4
1.7 1.0 4.6 1.6 7.8 2.2
1.7 1.0 – 8.2 2.8
0.6
2.1 0.4 2.4 0.6 27 5 6.0 1.2 2.4 0.5 305 93 10.6 4.1 125 48
– – – – – 296 90 – –
1.8 0.3 2.1 0.5 23 4 5.3 1.0 2.1 0.5 277 96 9.2 3.8 133 53
– – – – – 282 106 – –
0.7 0–10 (0.4 g PUFA) 6.6/5.8 1.1 1.6 18 3–12 1.5 200/400* 1.4 45
5.5/4.7 0.9 1.3 14 1.1
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). Source: Data taken from A Moreira P, Daniel S, de Almeida MDV: Validity assessment of a Food Frequency Questionnaire by comparison with a 4-day diet record. Acta Médica Portuguesa 2003; 16: 412–420, and B Lopes C: Food and ischaemic heart disease, community-based case-control study. PhD dissertation, Faculty of Medicine from Porto University. Porto, 2000. 1 2
Annexes
175
does not give any absolute recommendation, only a range of 0–10 g/day. The requirements of vitamin D depend on the amount of sun exposure. Like the other countries of South Europe, Portugal has – compared to the countries of North and Central Europe – a relatively high amount of sun exposure, particularly in summer. Thus, the bodily production of vitamin D in this region might be high and the supply in young adults can probably be valuated as sufficient. The average folate intake in Portuguese adults was below the recommended level of 400 g/day indicated by Eurodiet (2000). A sufficient supply with this vitamin can thus on average not be assumed. On average the supply of minerals was very good in Portuguese adults. Only the mean intake of iron in women older than 40 years and the iodine intake in young adults were below the indicated guidelines (table 190). Elderly As it can be seen from table 191, Portuguese male elderly had an energy supply within the recommended range but female elderly had an insufficient supply. The macronutrient energy distribution was not ideal, with an excessive supply of protein in both men and women and an insufficient supply of carbohydrates in men. The energy proportion of alcohol was high for male subjects. Apart from vitamin C supply, that was higher than the recommendations for both gender, the other vitamins
supply values were either smaller or similar to the reference values (table 192). As stated in table 193, both iron and calcium intakes are lower than the reference values for female subjects. Overweight and Obesity Despite different methodological approaches, all the available studies on Portuguese BMI data showed quite high values for overweight and obesity for both gender in all age groups (table 194). Spain Preschoolers EnKid Study: Methods: Cross-sectional study utilising face-to-face interviews. A random sample of 3,534 Spanish people aged 2–24 were interviewed by a team of 43 dieticians in the subjects’ homes. Interviews included two 24-hour recalls (a second 24-hour recall in 25% of the sample) administered throughout the year, in order to avoid the influence of seasonal variations. To avoid bias brought on by day-to-day intake variability, the questionnaires were administered homogeneously from Monday to Sunday. In order to estimate volumes and portion sizes, the household measures found in the subjects’ own homes were used. The administration of two questionnaires in a sub sample allowed adjustment
Table 190. Mean daily mineral intake (mean SD) in Portuguese adults (18–29A and 40B years) Male
Sodium (g) Calcium (mg) Phosphorus (mg) Potassium (g) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Iodine (g) Selenium (g)
Female
SCF
18–29 years (n 159)
40 years (n 310)
18–29 years (n 87)
40 years (n 416)
2.5 0.6 998 318 1,689 339 3.6 0.8 363 74 15.6 3.4 15.2 3.0 1.8 0.5 104 53 151 92
– 862 337 – – – 19 5 – – – –
2.1 0.4 897 269 1,467 277 4.0 0.9 317 69 18.0 3.7 12.8 2.4 1.6 0.4 92 43 135 27
– 896 399 – – – 15 5 – – – –
M
F
0.6–3.5 700/800* 550 3.1 300 9 9.5
16* 7 1.1 130/150* 55
* Eurodiet (2000). Source: Data taken from A Moreira P, Daniel S, de Almeida MDV: Validity assessment of a Food Frequency Questionnaire by comparison with a 4-day diet record. Acta Médica Portuguesa 2003;16:412–420, and B Lopes C: Food and ischaemic heart disease, community-based case-control study. PhD dissertation, Faculty of Medicine from Porto University. Porto, 2000.
176
Annexes
Table 191. Mean daily intake of energy and macronutrients (mean SD) in Portuguese elderly (70–79 years) Adults
Energy (MJ) Protein %E Protein (g) Carbohydrates %E Carbohydrates (g) Mono and disaccharides % Carbohydrates Fat %E Fat (g) SFA %E MUFA %E PUFA %E Cholesterol (mg) Alcohol %E Alcohol (g)
Male
Female
SCF
(n 77)
(n 80)
M
8.0 2.5 16.4 2.9 76.0 24.4 52.4 9.4 247 97 35.7 11.9
5.5 1.6 17.0 3.0 55.1 18.8 56.2 7.3 182 52 36.5 10.2
– 10–15** – 55* – –
25.7 5.7 54 19 8.6 2.6 10.5 2.6 3.8 1.3 223 85 6.5 8.7 18.9 26.8
27.7 6.2 41 17 9.2 2.8 11.1 3.1 4.4 1.5 178 87 0.3 1.8 0.7 3.8
30* – 10* – 6–10* 300** – –
F
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids. * Eurodiet (2000); ** WHO (2003). Source: Data taken from SENECA investigators: Longitudinal changes in the intake of energy and macronutrients of elderly Europeans. European Journal of Clinical Nutrition 1996;50(suppl 2): S67–S76.
Table 192. Daily vitamin intake (median) in Portuguese elderly (70–79 years)
Vitamin A1 (mg) -carotene (g) Vitamin B1 (mg) Vitamin B2 (mg) Vitamin B6 (mg) Vitamin C (mg)
Male
Female
SCF
(n 77)
(n 80)
M
F
0.63 1.95 1.08 1.65 1.38 87
0.51 1.43 0.62 1.24 0.93 62
0.7 – 1.1 1.6 1.5 45
0.6 – 0.9 1.3 1.1 –
Retinol equivalent (1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids). Source: Data taken from SENECA investigators: Longitudinal changes in the intake of vitamins and minerals of elderly Europeans. European Journal of Clinical Nutrition 1996:50(suppl 2):S77–S85. 1
for random intra-individual variation. Food composition table: The nutrient database software used for the study consisted of the Spanish database from Mataix et al., 1998 (3 ed), completed with information from the Annexes
Table 193. Daily mineral intake (median) in Portuguese elderly (70–79 years)
Calcium (mg) Iron (mg)
Male
Female
SCF
(n 77)
(n 80)
M
766 12.8
548 7.0
9
F 700/800 9
Source: Data taken from SENECA investigators: Longitudinal changes in the intake of vitamins and minerals of elderly Europeans. European Journal of Clinical Nutrition 1996:50(suppl 2):S77–S85.
French [Favier et al., 1995] and British [Holland et al., 1991] food composition tables. For the identification of under-reporting of food intake the EI/BMR (Energy intake/Basal Metabolic Rate) ratio was used: less than 1.14 classified the individual as under-reported [Goldberg et al., 1991]. The reference nutrient values utilised were those elaborated by CSIC (Centro Superior de Investigaciones Científicas, 1994) which represents the recommended nutrient and energy daily intake for the Spanish population. Underreporters (18%) were excluded. The questionnaire included other questions such as lifestyle variables. Weight and height were measured in all subjects. Total energy consumption was 1,547.1 164.2 kcal for children from 2 to 5 years old (n 192; table 195). Cereals (25%) and milk (14%) were the main sources of energy. 17% of the energy came from proteins, 44% from carbohydrates, and 38% from lipids. Proteins came mainly from milk (18%) and cereals (17%). Cereals (44%) and fruits (11%) were the main sources of carbohydrates. More than 20% of the lipids came from vegetable oils. Eggs and cereals were the main sources of cholesterol and dietary fibre respectively. Vitamin A intake was above 130% of RDIs for both sexes (table 196). 0.4% of females were at risk of inadequate intake. Dairy products and vegetables are the main sources of this vitamin. Vitamin D intake among pre-school children was between 12% and 14% of the RDIs and 100% of population of that age were at risk of inadequate intake. The main source of vitamin D came from fish (58%). 24% of males and 52% of females had suboptimal intakes for vitamin E. Vegetable oils are the main source of this vitamin (30%). 177
Table 194. Portuguese BMI percentages for overweight and obesity in different age groups Age Group Children
7–9 years1
Adolescents
11–15 years2
Adults
15 years3 18–65 years4 18 years5
Elderly
65 years6
N
Method
Overweight (%)
Obesity (%)
Year
4,511 (2,234 M, 2,274 F) 6,131
Measured [T. Cole criteria, 2000] Measured [T. Cole criteria, 2000] Self-reported Measured
M – 19.1 F – 21.4 M – 16.6 F – 12.9 M F – 33 M – 41.1 F – 30.8 M – 51.3 F – 34.4 M – 50.7 F – 29.2
M – 10.3 F – 12.3 M – 3.6 F – 2.7 MF–9 M – 12.9 F – 15.4 M – 21.8 F – 22.4 M – 8.2 F – 13.5
2000–2002
1,007 4,330 (1,843 M, 2,485 F) 1,500 (665 M, 853 F) 171 (73 M, 98 F)
Measured Self-reported
2002 1997 1995–2000 2001 1997
Source: Data taken from 1 Padez C, Fernandes T, Mourão I, Moreira P, Rosado V: Prevalence of overweight and obesity in 7–9 years Portuguese children – trends in BMI from 1970 to 2002. Am J Human Biol (in press); 2 HBSC – Portugal, 2002; 3 European Comission: A Pan-EU survey on consumer attitudes to physical activity, body-weight and health. Luxembourg, 1999; 4 Carmo I, Carreira M, de Almeida MDV, Lima Reis JP, Medina JL, Galvão Teles A: Estudo da prevalência da obesidade em Portugal. Boletim da SPEO Jan/Jun 3–5, 2000; 5 Instituto de alimentação BECEL: Estudo epidemiológico de caracterização do perfil lipídico da população portuguesa; 6 Afonso C, Graça P, de Almeida MDV: Obesity, body weight changes and weight loss practices in Portuguese seniors. V congreso de la sociedad Espanola de nutricion comunitaria – III congreso iberoamericano de nutrition y salud publica. Libro de resumens. P301: 223. Madrid, 2002.
Table 195. Mean daily intake of energy and macronutrients (mean SD) and risk of inadequate intake in Spanish preschoolers (2–5 years)
Preschoolers (2–5 years)
Mean SD
Energy (kcal) Energy (MJ) Carbohydrates (g) Proteins (g) Lipids (g) SFA (g) MUFA (g) PUFA (g) Cholesterol (mg) Fibre (g) Carbohydrates (%E) Proteins (%E) Lipids (%E) SFA (%E) MUFA (%E) PUFA (%E)
Thiamine intake was higher than the RDIs for the Spanish population, with no male or female at risk of inadequate intake for this vitamin. Average riboflavin intakes were more than 200% of the RDI in males and 193% in females with no risk of inadequate intakes for this vitamin. 178
Annexes
Boys
Girls % RDI
1,596.5 146.5 112.8 6.7 0.6 187.5 11.6 66.1 8.7 257.5 68.0 10.3 24.7 3.8 27.3 5.9 7.8 2.2 290.4 101.2 11.2 0.9
%2/3 RDI
Mean SD
0.4
1,495.6 166.3 104.0 0.8 6.3 0.7 179.7 21.0 63.9 9.4 245.9 0.0 63.6 9.7 23.5 6.3 24.9 4.7 7.1 1.4 253.7 96.1 10.1 2.8
0.0
44.2 2.5
45.1 2.7
16.6 1.6 38.3 3.7 13.9 1.5 15.3 2.5 4.4 1.0
17.1 1.6 38.2 3.0 14.0 2.7 14.9 1.9 4.2 0.6
% RDI
%2/3 RDI
Niacin intake was 172% of RDI for males, with none of them being at risk of inadequate intakes. 1% of females were at risk of inadequate intakes and had an average intake of 159% of the RDI. Cereals and meat were the main sources of this vitamin for both males and females.
Table 196. Mean daily vitamin intake (mean SD) and risk of inadequate intake in Spanish preschoolers (2–5 years)
Preschoolers (2–5 years)
Vitamin A (mg RE) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Vitamin C (mg)
Table 197. Mean daily mineral intake (mean SD) and risk of inadequate intake in Spanish preschoolers (2–5 years)
Preschoolers (2–5 years)
The average intake of vitamin B6 was 171% of RDI for males and 150% of RDI for females. 0.4% of girls were at risk of inadequate intakes. Cereals (30%) and fruits (11%) for males, and cereals (27%) and milk (11%) for females were the principal sources for this nutrient. 0.7% of males and 5% of females were at risk of inadequate folate intakes. The mean intake was greater than 130% of the RDI for males and 108% for females. In females the main sources of folate were fruits (21%), cereals (18%) and vegetables (16%). The mean intake of vitamin B12 was greater than 400% for both genders and not one single male nor female was at risk of inadequate intakes. 2% of males and 11% of females showed risk of inadequate intakes for vitamin C. Dietary sources of this vitamin covered 146% of the RDI for males and 131% for females. Fruits were the main source, contributing more than 60% of this nutrient. There was no evidence of risks for inadequate mineral intakes in male children.
Girls
Mean SD
% RDI
% 2/3 Mean SD RDI
0.5 0.04 1.4 0.4 4.7 0.5 1.2 0.3 1.8 0.3 15.7 2.8 1.4 0.4 131.5 28.3 5.1 0.7 80.5 29.0
163.7 13.8 73.0 208.5 206.5 172.1 171.4 131.5 471.4 146.4
0.0 100.0 24.0 0.0 0.0 0.0 0.0 0.7 0.0 2.4
Boys Mean SD
Sodium (g) Potassium (g) Phosphorus (mg) Calcium (mg) Magnesium (mg) Iron (mg)
Annexes
Boys
1.6 0.2 2.4 0.3 1,201 151 897 67 227 27 10.3 2.4
0.4 0.2 1.2 0.6 4.6 1.6 1.0 0.2 1.7 0.5 14.7 3.1 1.3 0.2 108.8 24.2 5.5 0.7 72.2 31.6
% RDI % 2/3 RDI 138.0 12.2 71.4 180.6 193.2 159.1 150.1 108.3 498.0 131.2
0.4 100.0 52.0 0.0 0.0 1.0 0.4 5.1 0.0 11.0
Girls % RDI
112.1 151.7 132.5
% 2/3 RDI
0.0 0.0 0.0
Mean SD
% RDI
% 2/3 RDI
1.6 0.1 2.2 0.5 1,170 201 876 214 213 37 9.0 1.6
109.4 138.5 113.8
3.2 0.8 0.4
3% of girls had suboptimal intakes of calcium, with a mean intake of 109% RDI (table 197). Milk (46%) was the main source of this mineral. The mean intake of magnesium was suboptimal for 1% of females. Milk was also the principal source of this nutrient. 0.4% of females had inadequate iron intakes, with cereals (25%) comprising the main source or this group. Children Data for children were derived from the EnKid study. Energy consumption in Spanish children was 2,143 Kcal and 1,886 Kcal for males and females, respectively (table 198). Cereals, milk and vegetable oils were the main sources of energy. 44% of the energy came from carbohydrates, 17% from proteins and 39% from lipids. Cereals were the main source of carbohydrates and proteins. Vegetable oils were the main sources of fats. Eggs and milk 179
represented the main sources of cholesterol. Dietary fibre came from cereals and fruits. Dietary intakes of vitamin A were less than 90% of RDI for both males and females (table 199). 51% of males and 48% of females showed suboptimal intakes. Milk and vegetables constituted the main sources of this nutrient. Almost 100% of the sample were at risk of inadequate intake for vitamin D. Mean intakes of this vitamin met 41% of the RDIs for the Spanish population in men and 35% in women. Fish was the main source of
Table 198. Mean daily intake of energy and macronutrients (mean SD) and risk of inadequate intake in Spanish children (6–13 years)
Children (6–13 years)
Carbohydrates (%E) Proteins (%E) Lipids (%E) SFA (%E) MUFA (%E) PUFA (%E)
Children (6–13 years)
Vitamin A (mg RE) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Vitamin C (mg)
180
Annexes
Boys Mean SD
Energy (kcal) Energy (MJ) Carbohydrates (g) Proteins (g) Lipids (g) SFA (g) MUFA (g) PUFA (g) Cholesterol (mg) Fibre (g)
Table 199. Mean daily vitamin intake (mean SD) and risk of inadequate intake in Spanish children (6–13 years)
this nutrient, providing more than 50% of the total contribution. 37% of males and 54% of females were at risk of inadequate intake of vitamin E. Vegetable oils were the main source of vitamin E. There were no risks of inadequate intake for thiamine. 0.2% of male Spanish children were at risk of inadequate intake for riboflavin. No males or females were at risk of suboptimal niacin intakes. Cereals represented the main source of this vitamin.
Girls % RDI
% 2/3 RDI
2,143.3 300.0 94.2 0.2 9.0 1.3 252.4 53.5 89.9 16.4 217.9 0.0 93.3 13.2 33.3 5.2 37.0 6.8 11.7 2.2 363.1 117.2 16.0 3.2 43.9 4.7 16.8 1.7 39.2 2.8 14.0 1.5 15.5 1.7 4.9 0.6
Mean SD
% RDI
% 2/3 RDI
1,885.8 241.0 86.4 1.6 7.9 1.0 214.3 26.9 77.5 8.6 198.1 0.0 83.2 11.9 29.0 5.5 33.3 4.8 10.5 2.2 329.4 117.7 13.6 2.0 42.8 3.3 16.6 1.6 39.8 3.2 13.8 1.9 16.0 1.6 5.0 0.8
Boys
Girls
Mean SD
% RDI
% 2/3 RDI
Mean SD
% RDI
% 2/3 RDI
0.5 0.1 2.1 0.5 6.7 1.4 1.4 0.3 1.9 0.4 22.8 3.7 1.8 0.4 152.4 33.2 7.9 1.2 72.7 34.3
88.5 41.4 72.6 156.5 136.2 153.4 111.5 138.6 450.8 126.6
51.0 96.7 37.4 0.0 0.2 0.0 1.9 3.2 0.0 12.1
0.5 0.1 1.7 0.5 6.4 2.2 1.2 0.2 1.6 0.2 19.5 2.9 1.5 0.3 137.4 22.4 6.4 0.9 69.5 23.6
85.2 34.6 69.9 143.7 124.1 136.6 95.2 120.8 364.8 120.8
47.7 98.3 54.0 0.0 0.0 0.0 4.7 15.6 0.0 7.5
The mean intake of vitamin B6 was 112 and 95% of the RDI for males and females, respectively. 2% of male and 5% of female had suboptimal intakes of this nutrient. Cereals and meat were the main contributors. 16% of female and 3% of males had inadequate folate intakes. The main sources of folate were cereals, fruits and vegetables. There were no risks of suboptimal intakes of vitamin B12. 12% of males and 7% of female children had inadequate vitamin C intakes. Fruits and vegetables were the main sources of this nutrient. The mean intake of calcium was below 2/3 the RDI for 1% of males and 3% of females. Milk and cereals were the main calcium sources. Table 200. Mean daily mineral intake (mean SD) and risk of inadequate intake in Spanish children (6–13 years)
Children (6–13 years)
Sodium (g) Potassium (g) Phosphorus (mg) Calcium (mg) Magnesium (mg) Iron (mg)
Table 201. Mean daily intake of energy and macronutrients (mean SD) and risk of inadequate intake in Spanish adolescents (14–24 years)
Adolescents (14–24 years)
Adolescents Adolescent data was derived from the EnKid study. The mean energy intakes were 2,509 Kcal for males and 1,940 Kcal for females, respectively (table 201). Cereals contributed more than 20% and were the main source of energy. 3 and 5% of males and females had energy intakes falling below 2/3 of the RDI.
Boys
Carbohydrates (%E) Proteins (%E) Lipids (%E) SFA (%E) MUFA (%E) PUFA (%E)
Girls
Mean SD
% RDI
% 2/3 RDI
Mean SD
% RDI
% 2/3 RDI
2.5 0.6 2.8 0.4 1,453 198 983 164 283 46 14.0 2.0
– – – 109.5 92.9 128.9
– – – 0.9 4.6 0.0
2.1 0.4 2.5 0.3 1,288 138 866 147 251 29 12.1 1.4
– – – 96.8 90.1 96.4
– – – 2.8 0.7 13.8
Men Mean SD
Energy (kcal) Energy (MJ) Carbohydrates (g) Proteins (g) Lipids (g) SFA (g) MUFA (g) PUFA (g) Cholesterol (mg) Fibre (g) Alcohol (g)
Annexes
5% of males and 1% of females had suboptimal magnesium intakes, a mineral found mainly in milk and cereals. 14% of females had suboptimal intakes of iron, especially girls aged 10–13 years (26%). Cereals (25%) and meat were the main sources of this nutrient (table 200).
Women % RDI
% 2/3 RDI
2,509.1 353.5 84.9 2.6 10.5 1.5 271.3 38.4 107.5 12.3 196.5 0.0 109.5 21.3 35.4 7.7 45.1 9.3 14.0 2.7 478.6 159.8 18.6 3.5 8.0 29.1 41.8 5.1 17.7 2.1 40.2 4.6 13.0 1.8 16.5 2.3 5.2 0.8
Mean SD
% RDI
1,939.6 270.9 83.2 8.1 1.1 213.6 38.3 82.5 10.5 195.1 84.6 14.2 27.6 4.8 34.8 6.3 11.0 2.7 370.4 136.0 15.3 3.0 3.6 15.6
% 2/3 RDI 4.1
0.0
41.9 5.5 17.4 2.0 39.8 4.0 13.0 1.6 16.4 2.1 5.2 1.0
181
42% of the energy came from carbohydrates, 18% from proteins and 40% from fats. Meat and cereals were the main sources of proteins. Meat and cereals were the primary contributors of lipids except for males aged 14–17, where vegetable oils, sausages and bakery were the main sources of this nutrient. Cereals supplied more than 40% of total calories, being the principal source of carbohydrates. The mean intake of dietary fibre was below 20 g for both genders, with cereals, fruits and vegetables constituting the primary sources. More than 80% of adolescents had suboptimal vitamin A intakes. This vitamin is mainly found in vegetables and milk. Almost 100% of adolescents had inadequate intakes of vitamin D, primarily in the form of fish (55–60%). More than 50% of males and 80% of females had suboptimal intakes of vitamin E which came from vegetable oils (25%) and from nuts in female adolescents aged 18–24 (11%). There were no inadequate intakes either for thiamine or niacin. 2% of male adolescents and 0.3% of females had inadequate riboflavin intakes. The mean intake of vitamin B6 was 94% RDI in female, with 6% of them with suboptimal intakes (table 202). Cereals and meat were the main source of that vitamin in females. 100% of female Spanish adolescents and 15% of male adolescents had suboptimal intakes of folate. The main sources of folate were vegetables, fruits and cereals. There were no inadequate intakes observed for vitamin B12.
Table 202. Mean daily vitamin intake (mean SD) and risk of inadequate intake in Spanish adolescents (14–24 years)
Adolescents (14–24 years)
Vitamin A (mg RE) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Vitamin C (mg)
182
Annexes
79% of female adolescents and 8% of males had inadequate intakes of vitamin C, which came mainly from fruits and vegetables. 2 and 6% of male and female adolescents had inadequate intakes of calcium. The main sources were milk and cereals. The mean intake of magnesium was below 85% of the RDI (table 203), with 6% of males and 7% of females having intakes below 2/3 RDI. Cereals and milk were the main sources for this mineral. 35% of female adolescents had inadequate intakes for iron, with the mean intake corresponding to 71% RDI. Cereals (23%) and meat (11%) were the main sources of iron for females aged 14–17, cereals (20%) and vegetables (9%) were the main sources in females aged 18–24. Adults In Spain there is a lack of nutritional studies evaluating individuals in a representative sample of the entire Spanish adult population. Existing data are derived from population based studies conducted in various regions of Spain. The Eve Study was designed to take advantage of this data so as to assess vitamin intake in the totality of the Spanish population. The Eve Study considers cross-sectional data from regional population nutrition surveys carried out between 1990 and 1998 in random samples from Alicante, Andalucia, The Balearic Islands, The Canary Islands, Catalonia, Galicia, Madrid and the Basque country. All samples were obtained via multi-step stratified random sampling procedures by age, gender and habitat, proportional to population density. Adult
Men
Women
Mean SD
% RDI
% 2/3 RDI
Mean SD
% RDI % 2/3 RDI
0.5 0.1 2.3 0.5 8.2 1.6 1.6 0.2 1.9 0.3 26.7 2.4 1.9 0.2 179.5 44.4 9.1 1.4 79.4 32.7
54.6 46.5 69.0 132.3 104.2 136.0 99.6 89.7 453.8 132.3
88.6 94.0 50.4 0.0 1.7 0.0 0.2 14.8 0.0 8.2
0.5 0.1 1.7 0.5 6.8 1.6 1.3 0.2 1.6 0.2 22.0 3.3 1.6 0.3 161.2 28.9 7.3 1.0 81.0 32.5
58.0 33.7 57.5 137.8 110.3 144.3 94.0 40.3 365.9 135.0
79.6 99.3 79.6 0.0 0.3 0.0 5.9 99.8 0.0 79.0
Table 203. Mean daily vitamin intake (mean SD) and risk of inadequate intake in Spanish adolescents (14–24 years)
Adolescents (14–24 years)
Mean SD
Sodium (g) Potassium (g) Phosphorus (mg) Calcium (mg) Magnesium (mg) Iron (mg)
people from each representative sample within the age range 25–60 years were included in the pooled analysis of this study. The pooled sample was post stratified by region, age group and gender following the procedures described by Hansen and Cochran. In order to estimate the prevalence of diet inadequacy in Spain, a homogeneous distribution of this issue in every region was assumed. The sample was weighted according to the distribution of the Spanish population in the 1991 population census by age, gender and region. Methodology for food consumption analyses: the nutritional surveys included in this study used a combination of diet assessment methods. Repeated 24-hour recall was the method used in most studies. One study used 3-day food diaries. The information was completed by a food-frequency questionnaire in a number of studies. This pooled analysis was performed based on the repeated 24-hour recall and food diary data. Photographic models including local and regional dishes or household measures were used in all of the studies to estimate portion sizes. Results are based only on dietary intake data, excluding supplements. Estimates for individual food consumption in each regional survey were pooled into a single database. In order to estimate intake of energy and nutrients, a tailor-made food composition database was developed containing 1,200 food items. Main sources used for this purpose were McCance & Widdowson’s food composition tables (fifth edition), Spanish food composition tables by Moreiras et al. and those elaborated by Mataix et al. The database was completed with information supplied by food industries for frequently used products. Vitamin intakes were adjusted for intra-individual variability. Underreporters were excluded from the analysis for estimating inadequate intakes.
Annexes
Men
3.0 0.5 3.1 0.4 1,656 224 1,006 223 316 45 16.3 2.5
Women % RDI
112.3 84.2 134.2
% 2/3 RDI
1.8 6.4 0.0
Mean SD
% RDI
% 2/3 RDI
2.2 1 .4 2.6 0.4 1,341 167 838 145 264 36 12.8 1.8
94.5 80.1 70.9
6.4 7.1 34.6
Table 204. Mean daily intake of energy and macronutrients (mean) in Spanish adults (25–60 years) Adults (25–60 years)
Men
Women
Total
Energy (kcal) Energy (MJ) Carbohydrates (g) Proteins (g) Lipids (g) SFA (g) MUFA (g) PUFA (g) Cholesterol (mg) Fibre (g) Alcohol (g)
2,514.2 10.5 262.5 102.0 104.7 32.9 46.0 15.2 450.4 19.7 21.4
1,885.9 7.9 203.2 79.6 82.7 25.9 32.6 12.3 349.8 17.4 4.5
2,185.4 9.1 231.7 90.2 91.9 29.1 40.9 13.6 399.6 18.5 12.7
Source: Data derived from weighted results of published studies. Pooled analysis.
The pooled sample consisted of 10,208 individuals aged 25–60 years, 4,728 men and 5,480 women. Mean age of the sample was 41 11 years. Eve Study: Estimated energy intake (excluding alcohol) in the sample was 2,409 753 kcal (median: 2,290) for men and 1,909 567 kcal (median: 1,802 kcal) for women (table 204). The analysis of individual intakes in a representative sample of the Spanish population has demonstrated dietary patterns typical of the Mediterranean Diet (table 205). Energy intake was distributed as follows: 17% from protein; 38% from fat in the male group, 40% in the female group; and 44% from carbohydrates. Alcohol intake accounted for 5% of calorie intake among men and for 1.5% in the female group. Mean vitamin A intakes met 67% of the RDI in men and 83% in women (table 206). The percentage of the
183
Table 205. Mean daily intake of energy and macronutrients (mean) in adults of different Spanish regions Study
Energy (kcal)
Proteins
CHO
Lipids
SFA
MUFA
PUFA
Alcohol
% Energy Basque Country 1990 Murcia region 1990 Catalonia 1992–1993 Madrid community 1993 Andalucia 1997 Canary Islands 1997–1998 Balearic Islands 1999–2000
2,485.0 2,267.2 2,013.9 2,398.0 2,218.5 1,799.7 1,722.8
15.0 15.2 18.0 15.9 16.2 17.5 17.6
41.9 46.1 39.6 42.4 43.1 50.0 42.0
34.6 36.3 37.8 40.3 37.8 33.1 38.9
11.7 11.0 12.6 11.8
14.6 16.8 17.2 18.5
8.3 5.0 4.6 6.0
8.0 3.0 3.5 4.0
11.9 13.2
13.0 16.9
4.6 4.9
2.6 1.7
Weighted Mean RDI
2,185.4 2,300–2,900
16.6 10–15
42.4 55–60
37.8 30–35
12.1 7–8
16.9 15–20
5.5 5.0
4.0 1.0
RDI: Moreiras et al., 1999 and Food and Nutrition Scientific Committee of the European Union 1993.
Table 206. Mean daily vitamin intake (mean SD) and risk of inadequate intake in Spanish adults (25–60 years)
Adults (25–60 years)
Mean SD
Retinol (g) -Carotene (mg) Vitamin A (mg RE) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Biotin (g) Pantothenic acid (mg) Vitamin C (mg) 1 2
Annexes
293 260 1.8 1.5 0.7 0.5 2.4 2.6 9.1 6.1 1.8 0.8 1.8 1.0 40 15 2.3 0.9 267 108 9.5 8.5 31 15 5.3 2.0 123 85
Women % RDI1
67 58 76 162 105 222 125 133 476 2042 1772 205
% 2/3 RDI2
38.6 15.0 2.3 9.5 0.2 2.1 8.1 0.6 1.8 0.9 8.7
Mean SD 276 253 2.0 1.8 0.7 0.5 2.0 2.3 8.3 5.2 1.5 0.6 1.7 0.8 33 13 2.0 0.8 252 103 7.1 7.1 26 11 4.7 1.6 136 88
% RDI1 % 2/3 RDI2
83 48 69 165 126 233 122 126 355 1732 1552 226
30.0 17.3 0.9 5.4 0.6 1.4 10.0 1.4 2.8 1.9 6.9
Spanish RDI; European RDI.
population at risk for inadequate intakes was estimated to be 61% of males and 49% of females. As a whole, the principal dietary contributors of this vitamin in terms of retinol equivalents were vegetables (40%) and dairy products (30%). 76% of the RDIs for vitamin E were met in males and 69% in females. According the Reference values for the Spanish population, 50% of the target population had suboptimal intakes for this nutrient. Middle184
Men
aged men and women older than 55 years had the highest risk of inadequate intakes. Vegetable oils (44%) and vegetables (15%) were the main sources of this vitamin. Mean vitamin D intakes met 58% of the RDIs for the Spanish population in men and 48% in women. 70% of the study population were at risk of suboptimal dietary intakes. Fish 27%, eggs 26% and cereals 23% were the primary contributor of this nutrient.
Thiamine intake was higher than the RDIs for the Spanish population in all age and gender groups. 2.8% of males and 1.1% of females are at risk of inadequate intake for this vitamin, with males having significantly higher risk. Vegetables (36%), meat (30%) and cereals (20%) are the main sources of thiamine in the Spanish population. Average riboflavin intakes were 115% of the RDI in men and 126% in women. However, 12.6% of males and 5.7% of females were at risk of inadequate intakes for this vitamin. Women aged 25–34 were those who showed the highest percentages of inadequate intake. Milk and dairy products are the main contributors of riboflavin in the Spanish diet, for 36% of men and 45% of women, followed by the meat group with an average contribution of 18%. The average intakes of niacin were greater than 200% of the RDIs in both sexes. Based on niacin equivalents, 0.4% of men and 0.6% of women were at risk of inadequate intakes for this nutrient. Meat accounted for 36% of the intake of this vitamin, followed by fish and cereals, with the latter two groups each contributing 17% of niacin intake. 125% of the RDIs for vitamin B6 were met in men and 122% in women. 8.6% of females were at risk for inadequate intakes for this vitamin, and men and women over 55 years of age were especially at risk. 23% of vitamin B6 comes from the meat group, with potatoes contributing 18% and cereals 13%. Intakes of vitamin B12 maintained stable over time with the mean intakes in both sexes for all age groups surpassing the Spanish RDIs. The subgroup of men and women over 55 years old showed the highest percentages for risk of inadequate intakes: 2% in males and 4% in females. Fish (32%), meat (30%) and dairy products (24%) were the main dietary sources of vitamin B12. Mean intakes of folate were greater than 100% of the Spanish RDIs for all age and gender groups. However, 8% of men and 10% of women had chronic risk of inadequate intakes. The youngest and oldest age subgroups were those who more frequently exhibited suboptimal intakes. Vegetables (20%), cereals (20%), fruits (12%) and pulses (12%) were the main dietary sources for this nutrient. 2% of the population showed risk of inadequate intakes for biotin, with younger males and older women being especially vulnerable. Dairy products (23%) and eggs (22%) are the principle food sources of this vitamin.
Annexes
Risk of inadequate intakes for pantothenic acid was seen in less than 2% of the population. Meats contributed 24% of this nutrient and milk and dairy products provided 21%. Dietary intakes of vitamin C were greater than 200% of the RDIs for the Spanish population. However risk of suboptimal intakes were seen in 14% of males and 11% of females, and especially those in the youngest age subgroups. Fruits (67%) and vegetables (22%) are the main dietary sources of this micronutrient. Based on assessment of current intakes for four vitamins (folate, vitamin C, vitamin A and vitamin E), 23% of men and 25% of women had good quality diets meeting amounts for these nutrients. 43% of males and 37% of females showed diets of moderate to poor quality. A higher percentage of diets of low nutritional quality were seen in the youngest cohorts and in elderly women. In relation to the influence of sociodemographic factors and diet quality, it was demonstrated that risk factor determinants included older subgroups, women with lower education and socioeconomic levels and widows/widowers or those living alone. Higher risks of inadequate intakes were observed in medium sized settings, most frequently seen in the Autonomous Communities of Andalucia and the Canary Islands. Smoking, alcohol consumption, lack of physical activity and overweight status (in women) were observed to be determinants of a lower quality diet. The mean intake of iron in females was 12 mg, below the reference dietary value for Spanish population (21 mg; table 207). Nutritional Status in Spanish Adults Biochemical Indicators: (Canary Islands, Catalonia, Andalucia, and Basque Country) The biochemical analysis showed that 5% of the population had low blood values for vitamin B1, vitamin B2 Table 207. Mean daily mineral intake (mean) in Spanish adults (25–60 years) Adults (25–60)
Men
Women
Total
Sodium (g) Potassium (g) Phosphorus (mg) Calcium (mg) Magnesium (mg) Iron (mg)
2.9 3.3 1,440.9 867.1 318.9 15.2
2.0 2.9 1,205.9 800.4 266.0 11.7
2.4 3.1 1,315.6 832.2 290.8 13.4
185
(Andalucia), vitamin B6 (Catalonia, Andalucia), vitamin B12 (Basque Country) and vitamin E (Catalonia, Basque Country). And 15% of population showed suboptimal biochemical values for folate (Andalucia, Basque
Table 208. Biochemical indicators in adult Spanish population (mean)
Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Folic Acid Tocopherol Retinol -Carotene Licopene Vitamin C Calcium Magnesium Phosphorus Iron Zinc Copper Manganese Selenium
Alfa-ETK Alfa-EGR Alfa-EGOT pg/ml ng/ml mol/l mol/l mol/l mol/l mg/l mg/dl mg/dl mg/dl g/dl g/dl g/dl g/l g/dl
Men
Women
Total
1.20 1.08 1.42 538.5 8.30 32.1 2.03 0.40 0.68 9.8 9.99 2.19 3.8 108.0 115.8 121.40 0.88 8.04
1.04 1.06 1.40 603.3 8.40 33.3 1.79 0.49 0.68 12.0 9.63 2.19 3.7 95.2 110.7 130.60 0.89 7.72
1.03 1.07 1.41 574.0 8.35 32.7 1.90 0.45 0.68 11.0 9.80 2.19 3.8 100.6 113.0 126.10 0.88 7.85
Country, Canary Islands) and tocopherol (Canary Island) (table 208). Elderly (65–75 years) The elderly nutritional data comes from nutritional surveys developed in the Autonomous Communities of Catalonia, the Basque Country, the Canary Islands and in the region of Murcia (table 209). There are some data derived from the SENECA study developed in Spain, as well as information provided by a study on the elderly in Bilbao, Basque Country. In the region of Murcia it was observed that the intakes of vitamin D and E were below the RDIs for the Spanish population (table 210). The results showed suboptimal intakes for riboflavin, vitamin C, and vitamin A in Catalan male, and inadequate intakes of vitamin A in females from Catalonia. More than 80% of that population showed inadequate intakes of vitamin D. Intakes of vitamin A (male), vitamin D (male and female), vitamin E (male and female) and folate (in both sexes) were below the RDIs in the Canary Island population. The pooled analysis of mean vitamin intake showed intakes below the RDIs for vitamin D, vitamin E and vitamin B6 (table 211).
Table 209. Mean daily intake of energy and macronutrients (mean SD) in Spanish elderly (65–75 years) Elderly (65–75 years)
Energy (kcal) Energy (MJ) Carbohydrates (g) Proteins (g) Lipids (g) SFA (g) MUFA (g) PUFA (g) Cholesterol (mg) Fibre (g) Alcohol (g) Carbohydrates (%E) Proteins (%E) Lipids (%E) SFA (%E) MUFA (%E) PUFA (%E)
186
Men
Women
Murcia
Catalonia
Canary Islands
Mean
Murcia
Catalonia
Canary Islands
Mean
1,923.1 8.0 243.8 72.9 68.2 19.3 31.4 10.2 317.7 19.7 9.1 49.2 15.7 33.0 9.3 15.2 4.9
1,880.2 7.9 199.6 83.7 71.2 21.8 33.2 9.6 360.2 18.7 11.3 44.4 18.7 35.7 10.9 16.4 4.7
1,699.9 7.1 225.5 71.5 55.5 19.9 21.9 7.4 265.2 18.5 9.8 51.9 18.0 30.2 10.5 11.9 4.1
1,862.3 7.8 208.0 80.9 68.9 21.3 31.6 9.4 343.3 18.8 10.9 45.9 18.3 34.7 10.7 15.7 4.6
1,533.4 6.4 194.2 63.0 57.4 16.6 26.7 8.3 267.7 16.1 1.9 47.9 16.6 34.0 9.8 15.8 4.9
1,555.9 6.5 172.8 73.7 59.0 18.6 26.3 7.8 323.5 16.5 2.2 45.5 19.0 33.8 10.6 15.0 4.5
1,488.6 6.2 203.1 61.3 52.8 19.2 21.1 6.9 215.7 16.4 1.1 51.3 17.2 31.6 11.2 12.7 4.3
1,545.1 6.5 178.9 71.0 58.1 18.5 25.7 7.7 304.0 16.4 2.0 46.5 18.5 33.6 10.6 14.8 4.5
Annexes
Table 210. Mean daily vitamin intake (mean) in Spanish elderly (65–75 years)
Elderly (65–75 years)
Vitamin A (mg) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Vitamin C (mg)
Men Murcia
Catalonia
Canary Islands
Mean
Murcia
Catalonia
Canary Islands
Mean
1.7 3.0 1.9 1.3 1.4 16.3 1.6 209.6 6.3 144.1
1.3 4.3 9.2 1.1 1.5 19.1 1.8 349.7 7.2 121.1
0.7 3.9 5.8 1.1 1.8 21.7 1.8 168.3 9.5 122.8
1.3 4.1 7.9 1.1 1.5 19.1 1.8 310.6 7.4 124.0
1.6 2.0 1.7 1.1 1.3 14.0 1.3 177.7 4.7 131.9
1.0 3.0 7.4 1.0 1.5 16.3 1.5 301.3 6.0 113.6
1.0 3.4 6.8 1.0 2.1 21.0 1.6 173.0 9.0 134.9
1.1 2.9 6.7 1.0 1.6 16.6 1.5 271.8 6.2 118.3
Table 211. Mean daily vitamin intake (mean SD) in Spanish elderly. Pooled analysis
Vitamin A (mg) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folate (g) Vitamin B12 (g) Vitamin C (mg)
Age group (years)
N
60–91 50–90 50–90 60–90 60–90 60–94 60–90 65–90 60–90 60–94
915 1,317 1,890 1,498 1,498 1,141 1,047 695 1,510 2,556
Mean SD
Table 212. Risk for inadequate intakes for vitamins. Intake adjusted for intra-individual variability. Bilbao nutritional study Male
RDI
%RDI* 0.8 0.3 2.07 0.6 8.4 0.9 1.1 0.4 1.6 0.6 19.6 7.6 1.47 0.4 237 5.3 9.2 91 116 72
0.8–1.0 5 12 0.7–1.0 1.0–1.4 11–16 1.6–1.8 200 2 60
The SENECA study showed vitamin D and B6 mean intakes below the RDIs. In addition, there was a high percentage of the population at risk of inadequate intakes for retinol, -carotene, vitamin E, folate, riboflavin and thiamine. Data from Bilbao showed that an important percentage of the population were at risk of inadequate intake for vitamin D, vitamin A and vitamin E (table 212). Nutrition Status Information for Vitamins and Minerals The Bilbao study showed that 18% of the study population had suboptimal biochemical values for -carotene. 1% of the sample had suboptimal vitamin E values. The biochemical values for vitamin C were below the optimal for 8% of the population.
Annexes
Women
Thiamine Riboflavin Niacin Eq. Vitamin B6 Folate Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin A
151 120 240 126 140 425 228 183 61 58
Female % 2/3 RDI*
0.65 1.5 2 2.5 5.7 44 11 34
%RDI*
163 156 265 137 139 325 240 71 63 149
Total % 2/3 RDI*
% 2/3 RDI*
0.1 0.53
0.60
1.2 0.5 1.7 3.1 61 11 20
1.3 1.2 2.1 4.4 52 11 27
* Recommended Dietary Intakes for Spanish population [Varela, 1994].
The SENECA study demonstrated that 28% of this population had deficient carotene values. 1.6% of the sample had inadequate values for vitamin E. 23% of males and 16% of females showed deficient values for folate (10 mol/ml). Pregnant Women The pooled analysis of data for pregnant women (n 491) for vitamin A yielded a total of 2.4 0.4 mg/day, which is considerably higher than the reference intakes (table 214). However, the wide range of data dispersion (as this vitamin is concentrated in certain foods and not widely distributed in the diet) explains the fact 187
Table 213. Mean daily mineral intake in Spanish elderly (65–75 years) Elderly (65–75 years)
Sodium (g) Potassium (g) Phosphorus (mg) Calcium (mg) Magnesium (mg) Iron (mg)
Men
Women
Murcia
Catalonia
Canary Islands
Mean
Murcia
Catalonia
Canary Islands
Mean
1.5 2.2 1,105.3 762.9 232.9 10.8
2.0 3.2 1,214.2 670.4 304.0 12.8
1.6 2.4 1,341.8 930.2 293.8 12.3
1.7 3.0 1,217.9 714.0 294.5 12.5
1.3 1.9 920.8 661.1 187.7 9.1
1.6 3.0 1,139.7 743.6 257.7 10.2
1.3 3.0 1,280.0 940.3 255.0 10.3
1.5 2.9 1,132.6 758.6 249.6 10.1
Table 214. Mean daily vitamin intake (mean SD) in Spanish pregnant women
Population
Granada
Guadalajara MéridaGuadalajara
Cuenca
Pooled analysis
Reference
Constant et al., 1993
Ortega et al., 1994
Ortega et al., 1996
Ortega et al., 1998
Aranceta et al., 2000
n
n Age Vitamin A (mg) Vitamin D (g) Vitamin E (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Vitamin B12 (g) Folate (g) Vitamin C (mg)
52 18–45 –
135 19–42 2.5 3.1
292 23–34 2.4 3.7
64 18–35 2.1 0.5
– – 2.4 0.4
– – 491
2.48 3.57
3.2 3.0
3.2 0.2
3.0 0.4
3.1 1.2
543
–
–
3.2 0.8
–
–
–
2.68 2.62
1.4 0.4
1.4 0.2
1.25 0.2
1.72 0.3
543
2.21 0.72
2.1 0.8
2.15 0.6
1.83 0.3
2.1 0.5
543
30.46 11.2 –
34.2 7.9 –
33.8 7.6 1.5 0.3
32 7.5 –
32.4 8.1 –
543 –
5.41 11.1
15 17
14.7 3.7
12.9 7.3
13.2 6.5
543
– 264 100 131.55 18.7 174.2 81
that although the mean intake is rather high, between 33.3 and 40.4% of pregnant women are at risk of inadequate intake. The pooled analysis of data for a pregnant population (n 543) showed an overall vitamin D intake of 3.1 1.2 g/day, which is considerably lower than the reference intake (10 g/day). In fact, more than 90% of the pregnant women studied had intakes of vitamin D that were less than the recommended. The pooled analysis of data for a pregnant population (n 543) showed an overall intake of thiamine of 188
Annexes
268 94 181 42 252 82 491 176.95 31 133.4 12 173.7 31 543
1.72 0.3 mg/day. This figure is greater than the reference intake (1 mg/day), although between 0–12% of this population don’t meet the recommendation. The pooled analysis of data for a pregnant population (n 543) showed an overall riboflavin intake of 2.1 0.5 mg/day. This result exceeds the recommended (1.6 mg/day), although between 0–23% of pregnant women are at risk of inadequate intakes. Data for pregnant women showed an overall result of 32.4 8.1 mg/day for niacin intakes, surpassing the reference intake of 17 mg/day. None of the pregnant
women studied showed intakes of this vitamin that were less than the recommended. The pooled analysis of pregnant women yielded a global intake for vitamin B12 of 13.2 6.5 g/day, which exceeds the reference intake of 2.2 g/day. Despite the fact that the mean intake is much higher than the recommended, 8–23% of the study population had suboptimal intakes. The pooled analysis conducted in 491 pregnant women demonstrated that folate intakes were much lower than the reference intake (400 g/day, and according to the latest studies this should be increased to 600 g/day). In fact, the studies analysed showed that 81–88% of pregnant women had intakes below 200 g/day. Although the dietary contribution of vitamin C is quite high (173.7 31 mg/day) in the 543 pregnant women studied (18–45 years), 12–15.4% had intakes that were less than the recommended Spanish 80 mg/day. Risk Nutrients and Risk Groups Children and Adolescents There was no risk of inadequate intakes for protein or vitamin B12 in Spanish children and adolescents. Certain minerals, mainly iron for females, and magnesium and calcium for both sexes, were consumed in inadequate amounts for most of the age groups. Vitamins which showed mean intakes below 2/3 RDI were vitamin D, vitamin A, vitamin E, folate, vitamin C and vitamin B6. Vitamins whose intakes were below 1/3 of the RDI included vitamin D and folate. Adolescents aged 14–17 had the highest risk of inadequate intakes, with females being the majority. Adults No evidence was seen for risk of inadequate protein intakes. Certain minerals like iron, magnesium (the Canary Islands), calcium (Catalonia) were considered to be at risk of suboptimal consumption. In the case of vitamins, risk of inadequate intakes was evident for riboflavin, vitamin D and vitamin C (in Catalonia) and vitamin D, vitamin A, vitamin E, folate, vitamin C and vitamin B6 (the Canary Islands). Elderly Risk of inadequate intakes was noted for vitamin D, vitamin E and vitamin B6. Annexes
Health Indicators in Spain Body Weight, Body Height, Body Mass Index Population 2–24 Years: EnKid Study Obesity is a chronic disease with a complex multifactorial nature whose onset typically begins in childhood and adolescence. It constitutes one of today’s most critical and escalating public health concerns for this segment of the population. The non-existence of obesity prevalence data at the national level prompted the undertaking of the EnKid Study (1998–2000), which was designed to evaluate the food habits and nutritional status of Spanish children and youth. Design and Subjects: Cross-sectional epidemiological study in a representative sample of the Spanish population aged 2–24 years (n 3,534). Methods: Height and weight measurements were taken using standard procedures and equipment. Obesity and overweight were established using BMI Table 215. Prevalence of overweight and obesity in Spanish children and adolescents. EnKid study (1998–2000) Gender Age (years)
Prevalence Overweight* %
Obesity* %
Overweight and obesity* %
Total 2–5 6–9 10–13 14–17 18–24 Total
18.5 24.3 21.3 15.3 16.0 18.1
9.0 9.2 4.7 5.9 4.0 5.8
27.5 33.5 26.0 21.2 20.0 23.9
Males 2–5 6–9 10–13 14–17 18–24 Total
14.3 25.8 26.7 20.0 21.6 21.7
7.6 11.2 6.6 9.2 5.9 7.6
21.9 37.0 33.3 29.2 27.5 29.3
Females 2–5 6–9 10–13 14–17 18–24 Total
23.1 22.8 15.7 10.4 10.0 14.4
10.6 7.1 2.7 2.4 2.0 3.9
33.7 29.9 18.4 12.8 12.0 18.3
*
Cut-off points: Cole et al., 2000.
189
Table 216. Prevalence of overweight and obesity in the Spanish population aged 2–24 according to sociodemographic variables. EnKid Study (1998–2000)
Variable 10,000 10,000–50,000 50,000–350,000 350,000
5.7 6.8 5.2 8.3
24.3 23.9 25.0 22.4
Region
Centre Northeast North South Levant Canary Islands
5.7 4.5 5.1 8.1 5.2 8.3
24.5 19.7 22.6 27.3 23.7 29.2
Socio-economic
Low Medium High
7.1 4.6 4.8
25.6 22.3 23.6
Parents Educational Level
Low (both parents) Medium mother/ Low-medium father High father/ Low-medium mother High mother
5.6 6.0
24.0 23.8
5.1
21.1
6.1
24.6
Cut-off points: Cole et al., 2000.
cut-off points defined by Cole, with BMI values ( 30 kg/m2 obesity and BMI 25 kg/m2 overweight) corresponding to 18 year olds being applied to the rest of the age cohorts [Cole et al., 2000]. Results: The prevalence of obesity in Spain was 5.8% and the combination of overweight and obesity 23.9% (with overweight alone constituting 18.1%; table 215). Obesity was greater in males (7.6%) than in females (3.9%), which was also true for the overweight classification. With respect to age, those between 2 and 9 years old were the most obese. As for geographic area, the Canary Islands and Andalucia showed the highest prevalence and the northeast region the lowest. Obesity was more prevalent among the lowest socioeconomic level, and in those who omitted or consumed a poor breakfast (table 216). Conclusion: Compared to other countries, Spain shows an intermediate level of obesity in children and youth. Over the past few decades, patterns indicate an increasing tendency towards overweight and obesity, which is more prominent in males and in the pre-pubertal ages. Adult Population: SEEDO 2000 Study Obesity is a major public health problem in developed countries. It is of critical importance to ascertain its magnitude and to identify the key at risk groups. For this
Annexes
Overweight and obesity* %
Population size (num. Inhabitants)
*
190
Obesity* %
reason a pooled-analysis was conducted, consisting of eight regional cross-sectional nutrition surveys carried out in representative random population samples. Randomly selected 9,885 free living subjects aged 25–60 years were included that had participated in population-based nutrition surveys carried out in eight Spanish regions (Andalucia, Balearic Islands, Basque Country, Canary Islands, Catalonia, Galicia, Madrid and Valencia) between 1990 and 2000. Weight and height were measured on each individual by trained observers following standardised procedures and measuring instruments. The samples were pooled together and weighted according to the distribution of Spanish adult population aged 25–60 years. Obesity was defined as body mass index (BMI) 30 kg/m2. The prevalence of obesity in the Spanish adult population was 14.5% (95% CI, 13.9–15.1%), significantly higher among women 15.8% (95% CI, 14.9–16.6%), than in men 13.4% (95% CI, 11.8–14.9%) (212.470; p 0.001; tables 217 and 218). Prevalence of obesity significantly increased with age in men and women. The highest rates were estimated for the age group older than 55 years, both among males 21.6% (95% CI, 18.7–24.5%), and females, 33.9% (95% CI, 32.7– 35.1%; table 219).
Table 217. Distribution of Body Mass Index (kg/m2) in the Spanish adult population Gender Age (years)
Mean (95% CI)
SD
P25
P50
P75
Men 25–34 35–44 45–54 55–60
24.9 (24.6–25.1) 26.1 (25.3–26.9) 26.8 (26.5–27.1) 27.1 (26.7–27.5)
3.4 3.4 3.7 3.4
22.6 23.9 24.6 24.8
24.4 25.9 26.6 26.6
26.9 28.0 28.7 29.2
Women 25–34 35–44 45–54 55–60
23.2 (22.9–23.4) 25.1 (24.7–25.4) 27.5 (27.1–27.8) 28.4 (28.0–28.8)
3.6 4.2 4.6 4.7
20.7 22.1 24.3 25.1
22.4 24.2 27.0 28.0
25.0 27.3 30.1 31.4
Table 218. Distribution of the Spanish adult population according to BMI. SEEDO 2000 study BMI (kg/m2)
Gender
18.50 18.50–24.99 25.00–26.99 27.00–29.99 30.00–34.99 35.00–39.99 40.00
Women % (95% CI)
Men % (95% CI)
0.7 (0.20–1.20) 41.8 (40.4–43.2) 23.4 (21.9–24.9) 24.6 (20.0–23.2) 12.4 (10.5–14.3) 0.7 (0.30–1.10) 0.3 (0.13–0.47)
1.7 (1.03–2.43) 50.5 (49.1–51.9) 15.3 (14.8–15.8) 16.9 (15.7–18.1) 12.7 (11.7–13.8) 2.3 (1.98–2.70) 0.7 (0.50–0.90)
Table 219. Prevalence of overweight and obesity in the Spanish adult population Gender Age (years)
n
Overweight (BMI 25–29.9) % (95% CI)
Obesity (BMI 30) % (95% CI)
Men (total) 25–34 35–44 45–54 55–60
4,707 1,629 1,307 1,042 729
45.0 (43.3–46.7) 35.6 (33.0–38.2) 47.7 (45.0–50.3) 51.5 (49.6–53.4) 52.3 (47.3–57.2)
13.4 (11.8–14.9) 7.5 (5.5–9.6) 12.9 (11.3–14.6) 12.6 (16.0–19.1) 21.6 (18.7–24.5)
Women (total) 25–34 35–44 45–54 55–60
5,178 1,628 1,491 1,242 817
32.0 (30.5–33.5) 20.4 (17.8–23.0) 31.7 (30.4–33.0) 42.9 (41.7–44.0) 42.1 (40.9–43.3)
15.8 (14.9–16.6) 4.8 (4.4–5.2) 11.3 (10.1–12.5) 26.0 (23.3–28.7) 33.9 (32.7–35.1)
Conclusion: Obesity is a health problem which affects an important proportion of the Spanish adult population. Considering its potential impact on public health, it is essential to design and implement effective strategies
Annexes
aimed at the early detection of at risk subjects and the provision of adequate treatment, as well as to establish suitable preventive programmes.
Mortality and Morbidity Data from Nutrition Related Diseases (See tables 220 and 221)
Blood Cholesterol Level and Lipid Profiles Biochemical assessment of cholesterol level and lipid profiles were obtained from nutrition studies carried out in adults from four Autonomous Communities. The region showing the most unsatisfactory results was the Canary Islands. In the Canary Islands, there was a high prevalence of hypercholesterolemia, with 30.4% of the Canarian population between 18 and 75 years (32% men and 29.1% women) having serum cholesterol values higher or equal to 240 mg/dl. This cohort also had the lowest values for HDL-Cholesterol (53 mg/dl) and the highest triglyceride levels (124 mg/dl), the latter also being evident for Andalucia (table 222).
Smoking Habits In developed countries smoking is considered one of the primary causes of preventable morbidity and mortality. Spain is one of the countries in the European Union with the highest prevalence of smoking. According to data from the National Health Survey of 2001, 34.4% of the population older than 16 smokes on a regular basis. 42.1% of men and 27.2% of women are smokers. Table 223 presents tobacco consumption by age groups based on National Health Survey data. The percentage of the population who smokes is greater in the age group between 25 and 44 years (48.2%), followed by the 16–24 year cohort. In the latter age group the prevalence of female smokers is greater than that of males. Figures 76, 77 and 78 show the evolution of tobacco consumption since 1987 by years, where one can see that the prevalence of male smokers has decreased from 55% in 1987 to 42% in 2001. In contrast, prevalence rates for women have been increasing, from 23% in 191
Table 220. Crude rate and European age standardised rate (EARS) per 100,000 inhabitants. Proportional mortality to the standardised rate. Spain 2000, Mortality by ICD Chapter and Gender (ICD-10) Males
Deaths
Age mean
Crude rate
EASR
(%)
I. Infections and parasites II. Tumors III. Blood, immunity IV. Endocrine, nutrition, metabolic V. Mental and behavioural disorders VI, VII, VIII. Nervous system, vision, hearing IX. Circulatory system X. Respiratory system XI. Digestive system XII. Skin and subcutaneous tissue XIII. Bone and musculoskeletal; connective tissue XIV. Genitourinary system XV. Pregnancy, birth, postpartum XVI. Conditions originating in perinatal period XVII. Congenital malformations, chromosomal abnormalities XVIII. Not elsewhere classified XX. External causes All chapters
3,672 59,061 504 4,184 3,767 4,369 56,303 24,026 9,933 301 905 3,818 0 471 576 4,197 11,587 187,674
58.84 70.58 71.56 75.2 81.63 72.71 76.11 78.66 70.83 81.59 81 79.7 0 0.91 17.93 71.72 48.06 71.99
18.79 302.29 2.58 21.42 19.28 22.36 288.18 122.97 50.84 1.54 4.63 19.54 0 2.41 2.95 21.48 59.31 960.58
16.5 259.16 2.25 17.84 16.23 18.55 241.39 100.79 44.29 1.3 3.98 16.18 0 3.88 4.01 19.36 53.97 819.69
2.01 31.62 0.27 2.18 1.98 2.26 29.45 12.30 5.40 0.16 0.49 1.97 0.00 0.47 0.49 2.36 6.58 100.00
Females
Deaths
Age mean
Crude rate
EASR
(%)
I. Infections and parasites II. Tumors III. Blood, immunity IV. Endocrine, nutrition, metabolic V. Mental and behavioural disorders VI, VII, VIII. Nervous system, vision, hearing IX. Circulatory system X. Respiratory system XI. Digestive system XII. Skin and subcutaneous tissue XIII. Bone and musculoskeletal; connective tissue XIV. Genitourinary system XV. Pregnancy,birth, postpartum XVI. Conditions originating in perinatal period XVII. Congenital malformations, chromosomal abnormalities XVIII. Not elsewhere classified XX. External causes All chapters
2,557 35,775 698 6,682 7,378 6,072 68,307 16,786 8,375 640 2,247 4,078 14 382 528 5,322 4,273 170,114
71.43 72.64 79.41 80.88 86.62 79.07 83.45 83.82 79.19 84.56 84.24 82.46 29.28 0.7 22.43 84.93 59.82 79.75
12.54 175.46 3.42 32.77 36.18 29.78 335.01 82.33 41.07 3.14 11.02 20 0.07 1.87 2.59 26.1 20.96 834.31
7.9 115 1.88 16.89 16.44 15.91 164.36 40.19 22.64 1.5 5.42 10.02 0.06 3.35 3.62 13.17 16.08 454.45
1.74 25.31 0.41 3.72 3.62 3.50 36.17 8.84 4.98 0.33 1.19 2.20 0.01 0.74 0.80 2.90 3.54 100.00
1987 to 27.2% in 2001. These tendencies have been observed in all age groups for both sexes. Tobacco consumption is associated with a range of respiratory diseases (chronic bronchitis, emphysema and asthma), cardiovascular pathologies and certain cancers (lung, oral cavity, larynx, pharynx, oesophagus, gall bladder and kidney). 85% of all cancer cases is attributed to tobacco smoking. In women, tobacco is associated with 192
Annexes
reduced fertility, increased risk of premature menopause and in postmenopausal women, increased risk of osteoporosis. In combination with oral contraceptive use, there is an increased risk for cardiovascular disease. Pregnant women who smoke are more at risk for spontaneous abortions, complications in pregnancy and at birth, as well as low birth weight babies and neonatal mortality.
Table 221. Crude rate and European age standardised rate (EASR) per 100,000 inhabitants. Proportional mortality to the standardised rate. Spain 2000, Mortality by ICD Chapter and sex (ICD-10) Male
Female Deaths
Crude rate
EASR
(%)
22,073 15,432 14,931 12,197
113.0 79.0 76.4 62.4
95.1 68.7 62.9 50.1
11.6 8.4 7.7 6.1
6,841 6,182 5,448 4,461
35.0 31.6 27.9 22.8
29.6 27.0 22.5 21.0
3.6 3.3 2.7 2.6
4,726 4,501
24.2 23.0
20.1 19.3
2.5 2.4
4,083 4,065 3,877 3,741 3,546 3,189 2,782 2,764 2,702 2,534 2,725 2,232
20.9 20.8 19.8 19.2 18.2 16.3 14.2 14.2 13.8 13.0 14.0 11.4
19.1 17.9 16.7 16.3 14.9 13.4 11.9 11.7 11.6 11.6 11.5 10.2
2.3 2.2 2.0 2.0 1.8 1.6 1.5 1.4 1.4 1.4 1.4 1.2
2,069 1,833
10.6 9.4
9.2 8.9
1.1 1.1
1,768
9.1
8.2
1.0
1,890
9.7
8.2
1.0
Respiratory failure Rectal cancer Oesophageal cancer Leukaemia Alzheimer’s
1,842 1,722 1,553 1,608 1,759
9.4 8.8 8.0 8.2 9.0
7.8 7.4 7.3 7.1 7.1
1.0 0.9 0.9 0.9 0.9
CA. in situ and unknown nature Hypertensive disorders Others acc (non traffic) and post effects AIDS and HIV Arteriosclerosis
1,555
8.0
6.7
0.8
1,569 1,403
8.0 7.2
6.7 6.6
0.8 0.8
1,382 1,466
7.1 7.5
6.5 6.3
0.8 0.8
Ischaemic heart disease Lung cancer Cerebrovascular disease Chronic obstructive pulmonary disease Heart disease, others Heart failure Prostate cancer Car accidents Colon cancer Respiratory system disease, others Cirrhosis Undefined cancer Pneumonia Gastric cancer Diabetes Bladder cancer Liver cancer Renal disease Dementia, non specify Suicide Vascular, others Cardiac arrest, death without medical attention. Unknown causes Pancreatic cancer Oral and pharyngeal cancer Larynx cancer Gastrointestinal disease, others
Annexes
Cerebrovascular disease Ischaemic heart disease Cardiac failure Heart disease, others Breast cancer Diabetes Dementia, non-defined Respiratory system disease, others Colon cancer Chronic obstructive pulmonary disease Unclassified cancer Pneumonia Alzheimer’s Hypertensive disorders Renal disease Gastric cancer Lung cancer Cirrhosis Ovarian cancer Uterine cancer Arteriosclerosis Pancreatic cancer Car accidents Cardiac arrest, death without medical attention. Unknown causes Digestive system disease, others Bone and musculoskeletal and connective tissue disease Respiratory failure Senility Liver cancer Leukaemia CA. in situ and unknown nature Vascular, others Chronic rheumatic disease Encephalic cancer Lymphoma non-Hodgkin’s Rectal cancer
Deaths
Crude rate
EASR
(%)
21,489 16,615 12,701 8,504
105.4 81.5 62.3 41.7
51.4 41.2 28.8 21.3
11.3 9.1 6.3 4.7
5,663 5,686 6,192 5,078
27.8 27.9 30.4 24.9
20.6 14.0 13.6 12.3
4.5 3.1 3.0 2.7
4,029 4,376
19.8 21.5
11.9 10.6
2.6 2.3
2,936 3,679 3,622 3,464 2,870 2,340 1,876 1,891 1,755 1,800 2,749 1,920
14.4 18.0 17.8 17.0 14.1 11.5 9.2 9.3 8.6 8.8 13.5 9.4
8.9 8.8 8.3 8.2 7.1 6.9 6.7 6.5 6.3 6.3 6.1 5.9
1.9 1.9 1.8 1.8 1.6 1.5 1.5 1.4 1.4 1.4 1.3 1.3
1,354 2,078
6.6 10.2
5.9 5.5
1.3 1.2
2,062
10.1
5.5
1.2
2,247
11.0
5.4
1.2
1,975 2,077 1,468 1,255 1,333
9.7 10.2 7.2 6.2 6.5
4.8 4.5 4.3 4.1 3.9
1.0 1.0 0.9 0.9 0.8
1,521
7.5
3.8
0.8
1,264 959
6.2 4.7
3.8 3.6
0.8 0.8
1,101 1,155
5.4 5.7
3.6 3.5
0.8 0.8
193
Table 221. (Continued) Male
Female Deaths
Encephalic cancer Malignant cancer, others Lymphoma no Hodgkin’s Wrongly classified, others Renal cancer Nervous system disease, others Gastrointestinal bleeding Intestinal vascular failure Septicaemia Respiratory disease for external causes
Crude rate
EASR
(%)
1,224 1,251 1,234 1,122
6.3 6.4 6.3 5.7
5.7 5.6 5.4 5.0
0.7 0.7 0.7 0.6
1,097
5.6
4.8
0.6
1,034
5.3
4.8
0.6
1,037
5.3
4.6
0.6
1,094 1,052 1,031
5.6 5.4 5.3
4.6 4.5 4.3
0.6 0.5 0.5
Deaths Malignant cancer, others Suicide Septicaemia Intestinal vascular failure Nervous system disease, others Wrongly classified, others Endocr, nutr, metab., others Gall bladder CA Gastrointestinal bleeding Urinary tract disease, others
Table 222. Blood lipid levels in nutritional population Spanish studies
Gender Age Chol (mg/dl) Chol 200 mg/dl Chol 240 mg/dl LDL-C (mg/dl) LDL-C 130 mg/dl LDL-C 160 mg/dl HDL-C (mg/dl) HDL-C 35 mg/dl HDL-C 60 mg/dl Triglycerides (mg/dl)
Table 223. Prevalence of smoking per 100 inhabitants by age Age groups (years)
Men (%)
Women (%)
Total (%)
16–24 25–44 45–64 65 Total
40.8 52.6 42.6 19.2 42.1
42.7 43.5 17.5 2.1 27.2
41.7 48.2 29.7 9.3 34.4
Source: National Health Survey 2001.
194
Annexes
Years Mean % % Mean % % Mean % % Mean
Crude rate
EASR
(%)
1,162 807 1,180 1,333
5.7 4.0 5.8 6.5
3.5 3.3 3.2 3.1
0.8 0.7 0.7 0.7
920
4.5
3.1
0.7
1,141
5.6
2.9
0.6
996
4.9
2.9
0.6
904 1,087 1,056
4.4 5.3 5.2
2.6 2.6 2.5
0.6 0.6 0.6
Basque Country 1990
Catalonia 1992–1993
Andalucia 1997
Canary Islands 1997–1998
Total 25–60 210.0
Total 18–75 203.9 48.6 19.1 127.5 54.0 17.2 55.8 3.0 35.1 103.9
Total 25–60 202.8 45.0 15.0 133.9 40.0 20.0 56.7
Total 18–75 216.3 36.9 30.4 138.8 43.0 32.4 52.7 11.5 29.9 123.6
129.0
56.0
119.0
122.7
The non-smoking population that is exposed to tobacco smoke has increased risks for respiratory and cardiovascular diseases as well as lung cancer. In the case of exposed children, there is a greater incidence of upper respiratory infections, otitis media, sinusitis, bronchitis, pneumonias, asthma and sudden infant death syndrome. In Spain during the period from 1978 to 1992, 14% of total mortality was due to tobacco smoking, causing the death of 621,678 persons over the age of 34. The majority of these deaths were premature with the concomitant loss of potential life years. Although the greater part of these deaths were in men (93% in 1992), the increased
Total
15.0
14.5
20
13.0
12.0
30
48.7
49.2
50.0
16.8
34.4
35.7
36.9
40
38.0
50
49.0
60
48.5
70
36.0
Percentage of Spanish population 16 years and older
80
10 0 Smokers
Fig. 76. Trends in smoking prevalence of Spanish population 16 years and older (1987–2001).
Non-smokers
80
1995
1997
2001
Men
20
33.0
32.6
30.3
26.0
24.8
22.5
22.4
19.0
30
21.0
40
30.0
42.1
44.8
48.0
50
47.7
60
10 0 Non-smokers 1997
2001
63.3
Women
70
1995
64.8
80
1993
70.0
1987
68.0
Ex-smokers
65.6
Smokers
60
7.9
7.1
10
7.0
6.0
20
9.4
27.2
27.2
30
25.0
40
27.2
50
23.0
Percentage of Spanish female population 16 years and older
1993
70 55.0
Percentage of Spanish male population 16 years and older
1987
Fig. 77. Trends in smoking prevalence of Spanish male population 16 years and older (1987–2001).
0
Fig. 78. Trends in smoking prevalence of Spanish female population 16 years and older (1987–2001).
prevalence of smoking in women has also considerably increased their mortality rates. Attributable mortality due to smoking in Spain has been estimated to have increased in 1998 to 55,613
Annexes
Ex-smokers
Smokers
Non-smokers
Ex-smokers 1987
1993
1995
1997
2001
individuals (92.5% males, 7.5% females). Causes of death included lung cancer (26.5%), chronic obstructive pulmonary diseases (21%), ischaemic cardiopathy (13%) and cerebrovascular disease (9%). 195
Physical Activity
In addition, the EnKid study included questions about physical activity during school and leisure time. Table 224 shows the distribution of the Spanish children and adolescent population according to the number of days a week that some kinds of sport during leisure time are done. The results show that more than 35% of males and more than 50% of females do not do any kind of sports during leisure time.
In Spain there is no existing data on physical activity as measured by the IPAQ questionnaire except for Catalonia. The National Health Survey developed periodically by the Health Ministry includes some questions about physical activity during leisure time. The questions include: ‘What kind of exercise do you do during leisure time?: (1) I do not exercise. I am sedentary during my leisure time. (2) I occasionally do physical activity or sports. (3) I regularly do physical activity, several times a month and (4) I do physical training several times a week’. According to these questions people are classified into four categories: inactive, moderate activity, regular activity, high activity. Figure 79 shows the results of the last four National Health Surveys. The results show that although the percentage of inactive people has diminished since 1987, the percentage of people who exercise regularly (every week) is very low (6% in 1987 and 9% in 1993, 1997 and 2001) showing minimal changes in the trend (fig. 79).
IPAQ Questionnaire: Catalonia The last Catalan nutritional survey, developed during 2002 and 2003, introduced the short IPAQ questionnaire for the first time to evaluate the level of physical activity in the population. A total of 1,564 people from 18 to 65 years old answered the questionnaire. The sample was classified according to their level of physical activity as: highly active (at least 3 days of vigorous activity accumulating at least 1,500 MET-min/week, or 7 or more days of any combination of walking, moderateintensity or vigorous intensity activities achieving at least 1,500 MET-min/week); sufficiently active (3 or
Fig. 79. Distribution of the Spanish population (16 years and older) according to the percentage of people that exercise during leisure time. Source: National Health Survey, Spain, 1987, 1993, 1997, 2001.
Table 224. Distribution of Spanish children and adolescent population according to the number of days a week that physical activity during leisure time is done. EnKid study 1998–2000
Age group (years)
2–5 6–9 10–13 14–17 18–24 Total
196
Annexes
Percentage of Spanish population 16 years and older
100
Inactive
Moderate
Regular
High
90 80 70
62.6
60
55.1
40 30
46.6
45.7 38.6
50
38.3
31.9
28.6
20 10
6.2
8.9 2.6
8.8 6.9
4.1
8.5
6.1
0 1987
1993
Male
1997
2001
Female
No sport
2 days/week
2 days/week
No sport
2 days/week
2 days/week
81.6 33.0 19.8 27.3 33.3 36.6
13.7 34.7 28.2 21.6 24.2 24.4
4.6 32.2 51.9 51.1 42.4 39.0
84.2 50.2 43.0 54.2 58.3 57.5
10.5 32.3 28.4 18.6 21.4 22.0
5.3 17.5 28.6 27.2 20.3 20.5
Table 225. Physical activity level of Catalan population aged 18–65 years Gender
Male
Female
Total
Age group (years)
18–24 25–44 45–65 Total 18–24 25–44 45–65 Total 18–65
Physical activity level (%) Insufficiently active
Sufficiently active
Highly active
10.7 14.8 21.9 16.8 12.6 20.4 18.5 18.1 17.5
70.5 70.0 60.6 66.5 78.3 70.4 73.0 73.0 70.1
18.9 15.2 17.5 16.7 9.1 9.2 8.5 8.9 12.4
Source: Catalan Nutrition Survey, 2002–2003.
more days of vigorous activity of at least 20 minutes per day or 5 or more days of moderate intensity activity or walking of at least 30 minutes per day or 5 or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving at least 600 MET-min/week); or insufficiently active when the activity reported was below the categories cited before. Table 225 shows the preliminary results for gender and age. 17.5% of the Catalan population were insufficiently active. The percentage of people in the lowest category increased with age except for women from 45 to 65 who were more active than males of the same age group. In the highly active cohorts, males of all ages were almost twice that of females. Females from 45 to 65 years were more active (including both sufficiently active and highly active as a whole) than males of the same age group.
European countries and is on the increase, particularly among men, accompanied by low physical activity levels. Smoking prevalence is high, decreasing in men and increasing in women, with cancer being the primary cause of mortality in men. Nutrients showing the highest risk of inadequate intakes include folate, vitamins A, D and E. Biochemical assessment of vitamin and nutritional status, conducted in several Autonomous Communities studied, showed that suboptimal levels exist affecting more than 5% of the population for vitamin B1 and B2 (Andalucia), vitamin B6 (Catalonia and Andalucia), Vitamin B12 (Basque country) and vitamin E (Catalonia and Basque country). Deficient biochemical indicators affecting more than 15% of the population for serum folate were observed in Andalucia, Basque Country and the Canary Islands as well as tocopherol in the Canary Islands. The help of Joy Ngo in the supervision in the English translation of the Spanish national report is acknowledged.
Sweden Swedish National Food Survey 1997–1998 In 1997–1998, the Statistics Sweden in co-operation with the National Food Administration (NFA) carried out the second nation-wide Swedish dietary survey, Riksmaten. The study was a follow-up of the previous survey (Hulk) carried out in 1989, using similar design and methods. In Riksmaten a representative sample of 2000 households was examined (table 226). In each household one person aged 18–74 years filled in a Table 226. Age of participants in Riksmaten 1997–1998 and Hulk 1989
Conclusions Spain, compared to other Mediterranean countries, has a unique monitoring system of nutritional status that pools different data obtained at regional levels, thus permitting data analysis of the country as a whole. Data obtained for children and adolescents has been carried out at the national level. This effort was co-ordinated by the Spanish Society of Community Nutrition. The nutritional status of the Spanish population is conditioned by dietary habits that are clearly and characteristically Mediterranean. The prevalence of obesity shows an intermediate value compared with other
Annexes
Mean Median Min Max 25 percentile 75 percentile
Riksmaten 1997–1998 (18–74 years)
Hulk 1989 (18–74 years)
Men (n 589)
Women (n 626)
Men (n 769)
Women (n 804)
43 42 17 79 31 53
43 43 17 75 32 53
44 43 18 74 31.5 56
43 42 18 74 29 55
197
pre-coded 7-day record book. The participants also filled in a questionnaire with information on body weight, height, education, occupation, physical activity, smoking habits and other lifestyle factors. About 1,200 persons completed the study with a participation rate of approximately 60%. Participation was lower in larger cities and surrounding areas than in rural areas and lower among young as well as older households. The average daily energy intake in the Riksmaten survey was similar or somewhat higher than in the Hulk survey (table 227). The dietary fat content was on average 34 %E, which was lower than in the Hulk-survey, but still higher than the recommended level of 30 %E. The differences among different sex and age groups were generally small, but the youngest age group (18–24 years) tended to have a lower fat percentage. The proportion of saturated fatty acids was 14 %E, also lower than in Hulk. Together with trans-fatty acids
Table 227. Mean daily intake of energy and macronutrients (mean SD) in Swedish adults (18–74 years)
‘hard fat’ contributed 15 %E, considerably higher than the recommended level of 10%. Carbohydrates provided on average 47 %E and 46 %E among women and men, respectively. The proportion of sucrose in the diet was higher among women than among men. The average intake of dietary fibre was 17–18 g/day, corresponding to 1.8 g/MJ among men and 2.0 g/MJ among women. The intake has not changed compared to the Hulk-survey. The average alcohol intake was higher among men than women and provided on average 4 %E and 3 %E among men and women, respectively. Average intakes of individual fatty acids are given in table 228. The ration of n-6 and n-3 fatty acids was around 5:1. An evaluation of under-reporting using the Goldberg technique (7) showed that around 20% of the subjects reported an energy intake below cut-off. Underreporters had a somewhat lower fat proportion and
Women
Men
SCF
Riksmaten Hulk Riksmaten Hulk F (n 626) (n 804) (n 589) (n 769) Energy1 (MJ) 7.81 Protein %E 16 Protein (g) 73 Fat %E 34 Fat (g) 72 SFA %E 14.2 SFA (g) 30 MUFA %E 12.3 MUFA (g) 26 PUFA %E 4.7 PUFA (g) 10.0 Cholesterol (mg) 292 Carbohydrates1 %E 47.5 Carbohydrates1 (g) 218 Monosacch. (g) 32 Disacch. (g) 62 Sucrose %E 9.0 Sucrose (g) 42 Dietary fibre (g) 16.4 Dietary fibre (g/MJ) 2.1 Alcohol %E 2.9 Alcohol (g) 7.6
7.36 15.5 66 37 74 16.5 33 12.4 25 5.2 10.5 297 46 199 28 63 9.4 42 15.4 2.1 1.8 4.5
1
Excl. fibre, * Eurodiet (2000); **
198
Annexes
WHO 2003.
9.90 15.5 90 34 92 14.6 40 12.6 34 4.6 12.5 350 46 270 33 76 8.5 51 18.1 1.8 3.8 12.7
9.57 15.5 85 37.5 98 16.8 44 12.7 33 5.4 14.2 380 44 249 30 73 7.7 45 18.0 1.9 3.3 10.4
M
7.7–9.0 9.2–12.8 10–15** 47 56 30* 10*
6–10* 300** 55*
10** 25*
Table 228. Mean intake (g/day) of individual fatty acids in Riksmaten 1997–1998 Abbrevation
Name
Women
Men
F4:0–10:0 F12:0 F14:0 F16:0 F18:0 F20:0 F16:1 F18:1 F18:2 F18:3 F20:4 F20:5 F22:5 F22:6
Butyric, caprylic, capronic acid Lauric acid Myristic acid Palmitic acid Stearic acid Arachidic acid Palmitoleic acid Oleic acid Linoleic acid Linolenic acid Arakidonsyra Eicosapentaenoic acid, EPA Docosapentaenoic acid Docosahexaenoic acid, DHA
2.1 1.6 3.3 15.6 6.7 0.19 1.2 23.4 7.8 1.2 0.08 0.10 0.03 0.21
2.7 2.0 4.3 20.4 8.7 0.24 1.5 30.8 9.7 1.6 0.10 0.10 0.04 0.24
Table 229. Mean daily vitamin and mineral intake (mean SD) in Swedish adults (18–74 years)
somewhat higher carbohydrate proportion compared to acceptable reporters. The average intakes of vitamins and minerals (table 229) were generally close to or above the recommended daily intakes (RI). The intake of vitamin D was lower than recommended for older persons, while the intake of folate corresponds to approximately 75% of the RI. The intake of iron among women in fertile ages was only two thirds of the RI. The selenium intake was three fourths of the RI. The intake of retinol was lower in Riksmaten than in Hulk, mainly due to a lower consumption of spreads and liver. The intake of vitamin C was higher in Riksmaten than in Hulk. The iron intake was lower than in Hulk due to the termination of iron fortification of flour in 1995. The intake of sodium from food and drinks (excl. salt added at the table) was 2.8 g/day and 3.6 g/day among women and men respectively.
Women
Retinol (g) -Carotene (mg) Vitamin A1 (mg) Vitamin D (g) -Tocopherol (mg) Ascorbic acid (mg) Thiamine (mg) Riboflavin (mg) Niacin, pref. Niacin2 (mg) Vitamin B6 (mg) Vitamin B12 (g) Folate3 (g) Calcium (mg) Phosphorous (mg) Iron (mg) Magnesium (mg) Sodium (g) Potassium (g) Zinc (mg) Selenium (g)
Men
SNR*
Riksmaten (n 626)
Hulk (n 804)
Riksmaten (n 589)
Hulk (n 769)
1997
775 1.9 1,110 4.9 6.8 93 1.30 1.60 16 31 1.87 6.0 217 925 1,290 10.4 295 2.9 3.1 9.9 32
970 2.0 1,300 4.6 6.3 74 1.15 1.65 – 26 1.65 6.6 194 990 1,275 12.1 295 2.6 3.1 9.0 29
1,000 1.7 1,310 6.2 7.8 80 1.60 1.89 20 39 2.24 6.9 232 1,070 1,570 12.3 345 3.6 3.5 12.6 36
1,270 1.8 1,580 6.3 7.7 71 1.50 2.07 – 34 2.11 8.6 226 1,190 1,620 15.9 375 3.4 3.8 11.7 36
– – 800; 900 5 – 60 1.1; 1.4 1.3; 1.6 – 15; 18 1.2; 1.5 2.0 300 800 600 10–18 280; 350 2,000 3,100; 3,500 7; 9 40; 50
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 3 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * Swedish Nutrition Recommendations. 1 2
Annexes
199
Sociodemographic Differences Pronounced age differences in dietary habits were seen. Older people ate more of ‘traditional’ foods like potatoes, root vegetables, fish, offals and blood, porridge and sweet bakery products, while young people eat and drink more of ‘modern’ foods, e.g. pasta, rice, pizza, sweets, nuts and snacks, and soft drinks. Older people also ate more fruit and vegetables. Women eat more fruit and vegetables than men do. There were generally small differences in the nutrient composition of the diet between men and women. Low education was among men linked to a lower consumption of fruit and vegetables and a higher intake of spreads. Men with low education consumed a diet with higher fat content compared to high-educated men (35 and 33 %E, respectively). No such difference was observed for women. High education was linked to a higher alcohol intake, in both sexes. Further, high education was linked to a higher intake of -carotene (women only), vitamin C and folate compared to low education. Similar tendencies, although less pronounced, were seen when the participants were classified into socioeconomic groups. Smokers, especially men, had poorer dietary habits than non-smokers had, with e.g. a lower consumption of fruit and vegetables. Smoking men ate a diet with a higher fat content than non-smokers did (36 and 34 %E, respectively). Men that snuffed drank more alcohol compared to those that never had snuffed. Regional differences were identified but generally were minor. The consumption of fruit and vegetables were lower in the Northern Sweden compared to that in the Stockholm region, while the consumption of spreads and milk was higher. The proportion of saturated fatty acids in the diet was higher in Northern Sweden than in the Stockholm area, while the consumption of alcohol was higher in Stockholm. The intake of calcium was higher in Northern Sweden than in the Stockholm region and Southern Sweden, while the intake of vitamin C was higher in the Stockholm region than in Northern Sweden. Nordic Comparisons National food consumption surveys have been carried out in all Nordic countries during the last decade. Differences in dietary assessment methods, food composition data and calculation systems have to be taken into account when comparing the results. The nutrient intake has therefore been adjusted for energy intake and the 200
Annexes
same energy calculation factors have been used. The data indicate that the Swedish diet has no particular specific feature in terms of nutrients, except for a somewhat lower selenium level. However, more recent analytical data for market baskets, dairy products and meat indicate that the selenium intake is somewhat higher than calculated. General Comments Although certain improvements in the dietary pattern in the Swedish population have occurred since the late 1980s, the main problem remains with an imbalance between fat (and fat quality) and complex carbohydrates. Factors like smoking and low education are still associated with poorer dietary habits, especially among men, while a certain equalisation seems to have occurred among women in this respect. For the population as a whole the general advice, that part of the dietary fat, mainly hard fat, should be replaced by complex carbohydrates, is still valid. On a food level this means increased consumption of fruit, berries, vegetables, bread and cereal products, to replace high fat meat and dairy products with fat-reduced alternatives, and to limit the consumption of high fat bakery products and sugar containing products like soft-drinks and sweets. Soft or fluid edible fats should replace hard fats to a larger degree. An increased physical activity in the population is equally important. It should be stressed, however, that the degree and magnitude of desirable changes in dietary habits varies between different groups and individuals. Methods and advice to promote changes should be adapted according to the context, conditions and prerequisites relevant for the group or individual. Health in Sweden – Sweden’s Public Health Report 2001 Summary Life Expectancy Continues to Increase. The first national Swedish public health report, which was published in 1987, showed that life expectancy in Sweden had increased by one year during the first half of the 1980s – a larger increase than at any other time during the post-war period. Since then men’s life expectancy has increased by 3.3 years and women’s by 1.9 years. Men’s life expectancy, after stagnating during the 1970s, has thus increased more quickly than women’s and the difference between men’s and women’s life expectancy has decreased from 6 years to 4.6 years. Since 1983/1984, moreover, infant mortality has halved – in
2000 it was as low as 3.2 deaths during the first year of life per 1,000 live births. Life Expectancy and Health Unevenly Distributed. The 1987 Report drew attention to the fact that health was unevenly distributed. Even though class differences in material welfare had decreased, blue-collar workers’ risk of illness was greater than white-collar workers’. In addition, a number of factors of significance for health development proved to be distributed in such ways as to cause concern that class differences in health were going to increase. None of the three subsequent public health reports, nor the present one, the fifth, have found otherwise than that the social differences in health persist. Now as then they are greatest among men. Male upper white-collar workers at age 35 are expected to live 2 years longer than unskilled male blue-collar workers and female upper white-collar workers 0.7 years longer than female unskilled blue-collar workers. Health differences between social groups, however, appear to have shrunk somewhat among men but instead are increasing among women. The Report also notes that health development is favouring those aged 45 or older rather than younger adults. Children and young people in Sweden have long had a very favourable health development but among them, too, there are disquieting signs. Cardiovascular Diseases Decreasing. Cardiovascular disorders are the group that causes most premature deaths, at the same time they often entail long-term health problems and functional impairments. During the 1990s the risk of developing coronary diseases, primarily myocardial infarction, decreased by about 20% and the risk of dying from coronary disease decreased even more. This is the most important reason why life expectancy has increased so much in recent years. The risk of dying of stroke has also decreased. The decreased risks of developing cardiovascular disease are due to improvements in the life habits that affect health, predominantly reduced smoking and improved dietary habits, while the reduced risks of dying from them may be ascribed chiefly to medical care efforts. An estimated 3,000 people’s lives are saved annually thanks to improved coronary care. Mortality from cardiovascular diseases is considerably higher among men than among women, but it is the men who have gained most in life expectancy as these diseases have become less common and less deadly. Slower Increase in and Reduced Mortality from Cancer. Tumours cause half of all deaths before age 65
Annexes
among women and one third among men. Cancer is otherwise a disease of old age and two thirds of all cancers occur after 65. The risk of developing a cancer disease increased by just over 1% during the 1980s but the rate of increase fell to half a per cent during the 1990s. Every third cancer case is explained by tobacco, dietary habits and sunbathing habits. Mortality from cancer has decreased by an average of 1.5% per year during the past twenty years. The two commonest forms — breast cancer among women and prostate cancer among men – constitute a third of all cancer. Both forms increased somewhat during the 1990s but there has been no corresponding increase in mortality. Both lung cancer and mortality from lung cancer are increasing among women but decreasing among men. Reduced Mortality from Accidents. Accidental injuries are the largest cause of death for the ages up to 45 years. Mortality due to accidents has declined by 37% for men and almost halved for women since 1980. Two thirds of those who die of their injuries are men. Traffic predominates as the cause of fatal accidents, causing one fifth of all accidental deaths. Mortality from accidents is greatest in sparsely-populated areas. Falls are the commonest cause of accidents for all ages but particularly among the elderly. Suicide Decreasing. The frequency of suicide continues to decrease and during the past two decades suicide mortality has decreased by 38% for both sexes. Suicide is commoner among men: during 1998 three times as many men as women committed suicide. On the other hand, suicide attempts are commoner among women than among men. Alcohol-Related Mortality Down. Alcohol-related mortality has declined by one third since the beginning of the 1980s. Changed drinking habits with reduced consumption of spirits have probably contributed to this. Elderly People Healthier but Varying Development for Other Ages. Middle-aged and elderly people appear to have had the most favourable health development in Sweden during the past twenty years. People over 45 increasingly consider their health as good. For ages 16–44 the proportion did not change for most of the 1980s and during the 1990s it gradually decreased. Particularly mental ill-health such as anxiety, worry and anguish, and sleep problems, became more common during the 1990s. These problems had decreased for all ages during the 1980s but increased again somewhat during the 1990s, except for women over 65 for whom the improvement continued. At the end of the 1990s 201
these problems were most common among those born abroad, predominantly from countries outside Europe. Mobility among the elderly has been improving for some time. This is probably partly an effect of knee and hip arthroplasty. The proportion of elderly people with impaired vision is shrinking, almost certainly due to the large number of cataract operations. Locomotive Pain – A Problem for Many. During the 1990s disorders of the locomotive organs increased among female lower white-collar workers up to pensionable age and among male aged 45–64 years. For male blue-collar workers, however, they declined. Aches and pains in the locomotive organs are very common: half of men and 70% of women have back, neck, shoulder, elbow, leg or knee pain. Various types of ache have become more common since the beginning of the 1980s, notably among women. These problems are also more widespread among those born abroad than among native Swedes, particularly women from non-European countries. Allergies Continue to Increase. Other major health problems are asthma, allergies and other hypersensitivity – complaints that have grown enormously during the past few decades and which afflict children and young people in particular. Diabetes Increasing among Children. The incidence of juvenile diabetes (type 1) increased during the 1990s particularly in the younger age groups. The causes have not been established, but the shift towards an increase at younger ages indicates that environmental factors and/or life style factors play a part. Infectious Diseases Still a Great Social Problem. In days gone by infectious diseases were a dominating cause of death but during the twentieth century they declined drastically. Recently, however, resistant bacteria and antibiotics resistance have made it harder to treat infections. Through travel, there is a continual import of resistant bacteria from other parts of the world. A particular problem is resistant tuberculosis, for which in some cases there is no treatment. Sexually Transmissible Diseases Increasing Again. Chlamydia is now the largest sexually transmissible disease in Sweden. A disquieting increase in reported cases was seen at the end of the 1990s chiefly among young people; but gonorrhoea in the large cities, and syphilis and HIV, both mainly among homosexual men, are increasing. In Sweden HIV and syphilis present a relatively limited problem but the increasing frequencies may be a signal that prevention is not fully functioning. 202
Annexes
Social Differences in Dental Health Still Large. Dental health has improved appreciably during the past 25 years, particularly for children and those over 65. The social differences in dental health are still large and are not decreasing. More and more people visit a dentist during a two-year period, except for fairly young people and male white-collar workers at middle and upper levels. Heavy Manual Labour Still a Health Risk. Formerly, many people worked in very unhealthy workplaces. Blue-collar workers, in particular, risked accidents or were exposed to hazardous substances. For decades, efforts to improve the work environment have had a high priority in Sweden and work-environment risks no longer affect public health to the same extent as earlier. The work environment now plays a relatively small part in, among other things, the occurrence of cancer. However, heavy manual labour and monotonous work tasks are still causing a great deal of back and neck complaints and disorders of the locomotive organs. The latter underlay almost half women’s and a third of men’s newly-granted disability pensions in 1999. Computer work is increasing continuously and between 60 and 70% of both sexes are now using computers in their jobs. This may be one explanation of why complaints in the neck and other parts of the back have increased. Stress – A Growing Work-Environment Problem. Awareness of the psychosocial work environment is growing. Working tempo and time pressure continue to increase. Stressed work increased continuously in the 1990s, especially for women. The proportion of those who work overtime also grew during the late 1990s and the proportion who feel reluctant to go to work has also increased. The health lead enjoyed by gainfullyemployed is shortening: the proportion who judge their health as good has decreased more since 1993 among those who are in work than among those who are without gainful employment. Stress Both Good and Bad. It may be hard to decide whether stress at work is positive for health or negative. A number of research results show that negative stress – e.g. in work that makes heavy demands on getting the job done but allows little opportunity for affecting how it is organised – increases the risk of e.g. myocardial infarction. Positive stress, i.e. heavy demands on performance but with much opportunity of affecting one’s work situation, is not considered equally dangerous, or is perhaps even a protective factor. Economic stress,
however, may be more negative for people who have no paid work, than the demands and loads to which the gainfully-employed are subjected. Even though developments in working life are most frequently described as negative, almost three quarters of gainfully-employed people in Sweden are in general very content with their work. Where time pressure and overtime increase, however, opportunities of combining working life and private life shrink, and this can in the long run entail both health problems and social problems. Negative Development for Care Staff and Teachers. Health development during the 1990s appears to have been especially negative for municipal and county-council employees, mainly women. Particularly in the nursing and educational sector, both work environment and well-being seem to have deteriorated. Reorganisations and cutbacks have increased the load on people working in these sectors, who are predominantly women. Better Habits of Life Less Smoking. While smoking is still perhaps the greatest health risk, it has declined in all socioeconomic groups and both sexes since the beginning of the 1980s. For men, the decline has been more rapid than for women. Note, however, that men born abroad smoke to a considerably larger extent than men born in Sweden. A study showed that young male immigrants from Chile, Iran and Turkey smoked more than older male immigrants of these countries. Among native-born Swedish men the pattern is the opposite. Snuff-taking, however, is commoner among younger men than among older. In international terms, the proportion of daily smokers among men is low in Sweden, where men and boys smoke the least in Europe. For women, the proportion of smokers started to decline considerably later than for men. This is why lung cancer, now decreasing among men, is increasing among women and will continue to do so for 10–20 years. Smoking underlies four fifths of all lung cancer. Four hundred cases of lung cancer occur annually as a consequence of radon. Sweden Is Eating Better. Eating habits have developed positively. We are eating more fruit and vegetables, more fibre food and less fat. This applies to men and women, young people and old people. More People Taking Exercise but Still Too Few. Exercise in free time is also becoming more common. Yet only one fifth of the population may be considered
Annexes
sufficiently active in their free time to give a positive effect on health. Some Challenges Alcohol Problems May Be Going to Increase. Changes in alcohol policy towards increased availability and lower prices may be expected to lead to alcohol consumption increasing. This may partly be countered by changes in drinking habits towards increased consumption of wine and less of spirits, which may reduce the risk of alcohol-related diseases. Young People’s Habits Disquieting. Recent increases in young people trying drugs and regularly drinking alcohol, together with increased frequencies of teenage abortions and more cases of chlamydia, are causes for concern. Not the least serious is the fact that the proportion of overweight young people is increasing at the same time as more and more appear to move about less and less in their daily lives and are choosing sedentary free-time activities. Swedish children and young people in international interview surveys in European countries normally appear as the most healthy and the most contented with life. Nonetheless, psychosomatic symptoms such as stomach ache, headache and sleep disturbances have been increasing continuously among schoolchildren since the middle of the 1980s. Excess Weight More Common, Especially among Young Adults. The proportion of overweight people of all ages is increasing but particularly among fairly young adults. The increase is probably because we are moving about too little in relation to how much we eat. The proportion of overweight people has increased in all socioeconomic groups since the beginning of the 1980s. Regarding obesity the social differences have increased somewhat for both sexes, with greater differences women than among men. Obesity increases the risk of disorders and complaints of the locomotive organs and – where there is belly fat – high blood pressure, cardiovascular disease and type 2 diabetes. Greater Health Risks in Socially Vulnerable Groups. Single people’s health should be noted. Among them there are groups with considerable health risks. This often applies to people with low incomes and poor education. Single-parent children also run greater risks of becoming ill or being injured than children in families with two adults. During the 1990s the social and economic problems of single parents with children increased. Just over 40% of single mothers smoke, which is double the 203
proportion among women in general. This suggests among other things a need to review the living conditions of single people, not least those of single parents. Children of mentally-ill parents and children of drug abusers also run greater risks of illness or injury than other children do. That the risks are greater in certain groups does not mean that everybody in them has health problems. On the contrary, even in groups with a serious excess risk it may be a matter of a few individuals with greater-thanaverage problems. Children of mentally-ill parents, for example, run a greater risk than children in general of dying, or of institutional psychiatric care, drug-dependence or accidents. It is thus important to know that not more than 2% of the children with a mentally-ill parent received a psychiatric diagnosis during a studied fouryear period. Even for children of drug-abusing parents, who also had demonstrably great excess risks, only a very small proportion is taken into care. Having Simultaneous Problems Increases the Risk of Ill-Health. The risks are greatest for those who have several adverse circumstances at the same time. To be a single parent does not perhaps itself increase the risk particularly. But if one also has a poor education and a low income, opportunities for a good life are hampered. Perhaps also, unhealthy habits of life tend to accumulate in groups that are socially vulnerable in other ways. The risk of ill-health then increases for parents and children alike. The Future Burden of Disease. It seems that the disease panorama of the future will be dominated by the health problems of ageing. As the risk of serious illness or premature death from serious disease declines, more and more people are living to higher ages. The present Report shows that old people’s health is continuing to improve. Their vision and mobility are getting better, as is their dental health. There is nothing to demonstrate any lengthening of the period of illness normally entered in the final phase of life. But even if the individual risk of falling ill at a given age is decreasing for many conditions such as cardiovascular disease, there is much to indicate that the prevalence of disease will grow as a consequence of more people surviving the diseases they do get. Many of those who now survive a myocardial infarction will get other diseases later in life such as heart failure or cancer. For this reason we must anticipate that the diseases of the elderly are going to place an increased burden upon the community and upon the health and medical care services. 204
Annexes
United Kingdom Adults (19–64 years) The average energy intake of adults in the UK was relatively consistent among all age groups, in both men and women (table 230). The average proportion of protein in total energy intake increased with increasing age. In the age groups of 25 years and older the average proportion was above the normal range indicated by the WHO (2003). It has, however, to be considered that the energy intake from alcohol was not included here. The absolute protein intake numbers show that the supply of protein in men and women of the UK can be regarded as sufficient. The share of carbohydrate in total food energy intake was relatively low in the UK in men as well as in women. In all age classes it was below the normal range indicated by Eurodiet (2000). The share of sugar in total carbohydrate intake was on average higher in men than in women. The average intake of non-starch polysaccharides (NSP) was particularly low in men of the first age group and in women of all age groups. The proportion of fat in total food energy intake was very high in UK adults. With about 36% of total food energy in men and between 34 and 36% in women the upper level recommended by Eurodiet (2000) was exceeded in both male and female participants of all age classes. Also the proportion of SFA in total fat intake was in men as well as in women above the recommended upper level of Eurodiet (2000) as well. However, the average intake of essential fatty acids (n-3 and n-6 PUFA) was relatively high which has to be valuated positively. The mean intake of cholesterol was relatively low in female adults in the UK with about 190–240 mg/day. In the male participants the average intake was higher than in women and increased with increasing age. The alcohol intake was indicated in percentage of total energy intake as well as in absolute numbers. The relative share of alcohol in energy intake was slightly higher in men than it was in women. The absolute intake numbers show that the average alcohol intake was in men (20–23 g/day) about twice as high as in women (9–11 g/day). The supply of vitamin A was on average sufficient in the interviewed sample. Only in the first age group of men the average intake was slightly lower than the population reference intake indicated by the SCF
Table 230. Mean daily intake of energy and macronutrients (mean SD) in UK adults (19–64 years) Men
19–24 years (n 108)
25–34 years (n 219)
35–49 years (n 253)
50–64 years (n 253)
SCF
Energy (MJ) Energy1 (MJ) Protein* %E Protein (g) Carbohydrates* %E Sugar2,* %E Dietary fibre3 (g) Fat* %E SFA* %E MUFA* %E PUFA * %E n-3-PUFA* %E n-6-PUFA* %E Cholesterol (mg) Alcohol %E Alcohol (g)
9.4 2.2 8.6 2.1 15 3 78 19 49 6 17 7 12 4 36 6 14 3 12 2 6.2 0.9 0.3 5.3 1.5 269 134 68 20 25
9.8 2.5 8.9 2.4 16 5 91 51 48 6 14 7 15 6 36 5 13 3 12 2 6.4 1.0 0.4 5.4 1.3 298 120 77 22 24
9.9 2.6 9.1 2.3 17 3 90 23 47 6 13 7 16 6 36 6 14 3 12 2 6.4 1.0 0.4 5.4 1.5 309 130 77 23 24
9.6 2.4 8.8 2.3 17 3 89 23 47 6 12 6 16 6 36 6 13 3 12 2 6.3 1.0 0.4 5.3 1.9 319 127 68 21 26
12.8/11.3/9.2 – 10–15*** 56 55** – 203*** 30** 10** – 6–10** 0.5**** 2.5**** 300*** – 20****
Women
(n 104)
(n 210)
(n 318)
(n 259)
Energy (MJ) Energy1 (MJ) Protein* %E Protein (g) Carbohydrates* %E Sugar2,* %E Dietary fibre3 (g) Fat* %E SFA* %E MUFA* %E PUFA * %E n-3-PUFA* %E n-6-PUFA* %E Cholesterol (mg) Alcohol %E Alcohol (g)
7.0 1.9 6.6 1.9 15 4 60 16 49 8 14 8 11 4 36 8 13 4 12 3 6.6 1.0 0.4 5.6 1.7 196 112 56 11 15
6.6 1.6 6.3 1.6 16 4 59 16 49 6 12 6 12 5 35 6 13 3 12 2 6.6 1.0 0.3 5.6 1.8 188 83 45 9 11
6.7 1.8 6.6 1.8 17 3 65 17 49 7 12 7 13 5 34 6 13 3 11 3 6.3 1.0 0.4 5.3 1.6 214 92 45 9 11
6.9 1.7 6.6 1.7 17 3 67 16 48 7 11 6 14 5 35 7 13 4 11 3 6.1 1.1 0.6 5.0 1.5 239 93 45 9 12
9.0/8.6/7.7 – 10–15*** 47 55** – 203*** 30** 10** – 6–10** – – 300*** – 10****
%E % of total energy; SFA saturated fatty acids; MUFA monounsaturated fatty acids; PUFA polyunsaturated fatty acids, Total food energy (excluding alcohol), 2 Non-milk extrinsic sugars, 3 Non-starch polysaccharides. * % of total food energy (without energy of alcohol). ** Eurodiet (2000); *** WHO (2003); **** D-A-CH (2000). 1
(table 231). The mean intake of -carotene was relatively low in UK adults. Also the average vitamin D intake was relatively low, especially in women aged 19–49 years and in men of the first age group. In regard of the relative low sun irradiation this low intake of vitamin D in the population of the UK might not always cover the average requirements, especially during the winter months.
Annexes
Compared to the recommended folate intake of 400 g/day [Eurodiet, 2000] the mean intake in adults of the UK, both men and women of all age groups, has to be valuated as too low. On average, the intake was lower in women than in men. The population reference intake of the SCF for potassium (3.1 g/day) was reached by the male sample, apart from those of the first age group. In the female sample 205
Table 231. Mean daily vitamin intake (mean SD) in UK adults (19–64 years) Men
19–24 years (n 108)
25–34 years (n 219)
35–49 years (n 253)
50–64 years (n 253)
SCF
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
0.6 0.4 1.3 0.9 3.0 1.6 10.1 4.3
0.9 0.7 1.6 1.1 4.1 3.2 11.9 7.2
1.1 1.4 1.9 1.1 4.2 3.1 14.4 27.4
1.3 1.3 2.3 1.8 4.9 3.3 15.2 27.7
Vitamin B1 (mg) Vitamin B2 (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folic acid4 (g) Vitamin B12 (g) Vitamin C (mg)
1.6 0.6 1.7 0.8 40 12 6.0 2.3 2.7 1.0 31 12 305 114 4.5 1.7 67 55
2.3 2.6 2.4 2.2 49 30 7.9 7.1 3.3 2.2 45 27 376 224 6.2 4.3 84 66
2.3 2.6 2.4 1.8 47 16 8.1 5.6 3.5 5.1 47 39 355 171 7.4 7.3 108 208
2.4 3.1 2.5 3.7 46 16 8.2 4.6 3.4 4.6 46 25 373 151 7.6 6.6 125 142
0.7 – 0–10 (0.4 g PUFA) 5.9/6.2/6.2/6.4 1.1 1.6 18 3–12 1.5 15–100 200/400* 1.4 45
Women
(n 104)
(n 210)
(n 318)
(n 259)
Vitamin A1 (mg) -Carotene (mg) Vitamin D (g) Vitamin E2 (mg)
0.6 0.6 1.4 1.9 2.9 2.5 9.4 9.2
0.6 0.7 1.6 1.2 2.7 2.0 8.6 4.7
0.8 0.6 1.8 1.5 3.5 2.9 14.3 40.1
1.0 0.8 2.0 1.2 5.1 4.1 23.2 60.5
Vitamin B1 (mg) Vitamin B2 (mg) Niacin3 (mg) Pantothenic acid (mg) Vitamin B6 (mg) Biotin (g) Folic acid4 (g) Vitamin B12 (g) Vitamin C (mg)
1.6 1.0 1.5 0.8 31 10 5.2 2.4 2.1 0.9 27 23 248 109 4.1 2.1 96 134
1.6 1.3 1.5 0.6 29 9 5.1 2.0 2.3 3.2 28 22 249 113 4.0 2.2 85 85
2.0 5.7 2.1 5.5 34 12 6.4 5.8 3.4 9.8 34 26 280 123 5.5 6.4 123 299
2.3 6.6 2.5 6.6 35 12 7.9 14.6 3.3 8.3 37 41 359 917 6.1 3.7 127 161
0.6 – 0–10 (0.4 g PUFA) 4.7/4.4/4.5/4.2 0.9 1.3 14 3–12 1.1 15–100 200/400* 1.4 45
Retinol equivalent ( 1 mg retinol 6 mg all-trans--carotene 12 mg other carotenoids), RRR--Tocopherol equivalent (mg -tocopherol mg -tocopherol 0.5 mg -tocopherol 0.25 mg -tocotrienol 0.33), 3 Niacin equivalent ( 1 mg niacin 60 mg tryptophan), 4 Folate equivalent ( 1 g food folate 0.5 g folic acid (PGA) 0.6 g folic acid taken with meals). * Eurodiet (2000). 1 2
the average potassium intake was below the population reference intake of the SCF. It increased with increasing age in both men and women (table 232). The average iron intake in men seemed to be sufficient with an average of 11.5–15.2 mg/day. In women (premenopausal women), who have higher requirements than men due to their monthly period, the mean intake was not sufficient. On average the intake of iron in the female sample was only between 9.8 and 12.9 mg/day. The requirements of postmenopausal women were probably covered with these average amounts of iron intake. 206
Annexes
An increase in iron consumption would be desirable among women in the UK. Compared to the recommendations for calcium made by Eurodiet (800 mg/day), the mean intake was too low in women younger than 35 years. Vitamin and Mineral Status in Adults (19–64 years) The average serum ferritin level in UK adults was far above the lower levels in both men and women (table 233). Thus, the iron status seems to be relatively good. However, 4% of the male and 11% of the female
Table 232. Mean daily mineral intake (mean SD) in UK adults (19–64 years) Men
19–24 years (n 108)
25–34 years (n 219)
35–49 years (n 253)
50–64 years (n 253)
SCF
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g)
3.3 1.1 2.8 0.7 867 325 1,341 319 260 73 11.5 4.6 9.2 2.5 1.2 0.3 2.5 0.8 167 70
3.4 1.1 3.3 1.0 1,030 606 1,550 727 311 105 13.9 7.5 10.7 4.4 1.4 0.7 3.2 1.3 223 122
3.3 1.0 3.5 0.9 1,049 359 1,524 429 322 106 14.1 12.9 11.4 8.4 1.6 1.0 3.6 3.1 226 93
3.2 1.0 3.6 1.0 1,035 331 1,508 403 320 103 15.2 13.2 10.8 4.2 1.6 0.9 3.8 1.5 235 85
0.6–3.5 3.1 700/800* 550 150–500 9 9.5 1.1 1–10 130/150*
Women
(n 104)
(n 210)
(n 318)
(n 259)
Sodium (g) Potassium (g) Calcium (mg) Phosphorous (mg) Magnesium (mg) Iron (mg) Zinc (mg) Copper (mg) Manganese (mg) Iodine (g)
2.3 0.7 2.4 0.7 706 264 1,050 299 260 73 10.0 4.9 7.1 3.2 1.0 0.4 2.2 1.0 167 70
2.3 0.7 2.4 0.7 736 233 1,045 279 311 105 9.8 6.0 7.1 2.9 1.0 0.4 2.5 1.0 223 122
2.3 0.7 2.7 0.8 814 293 1,134 296 322 106 12.9 23.3 8.2 3.8 1.1 0.5 2.9 1.2 226 93
2.3 0.7 2.9 0.7 903 382 1,180 309 320 103 12.3 8.0 8.6 3.7 1.1 0.4 3.1 1.5 235 85
*
0.6–3.5 3.1 700/800* 550 150–500 16* 7.0 1.1 1–10 130/800*
Eurodiet (2000).
33
Percentage of total sample
35
Men
Women
30 25
22
20 14 15
15
11
10 5
4
5
3
5
5 2
4
4
4
0
Fig. 80. Prevalence of low vitamin and mineral status in UK adults (19–64 years).
Serum ferritin (20/15 g/dl)
participants had serum ferritin levels lower than 20 and 15 g/l, respectively which indicates low iron stores (fig. 80) [Henderson, 2003c]. On average the plasma vitamin C concentration was relatively good in UK adults. 5% of men and 3% of women had plasma vitamin C concentrations lower than 11 mol/l which indicates biochemical depletion [Henderson, 2003c].
Annexes
Plasma Red cell folate Serum vitamin Plasma Plasma 25Plasma vitamin C (350nmol/l) B12 homocysteine OH-vitamin D -tocopherol (11 mol/l) (118pmol/l) (12 mol/l) (25nmol/l) (11.6mol/l)
The average red cell folate concentration was in all age groups far above the lower borderline of a normal folate status [Henderson, 2003c]. Only 5% of men and women had a red cell folate concentration which was lower than 350 nmol/l which indicates and inadequate folate store. The mean serum folate concentration, an indicator of short term folate intake, was far above the lower borderline. Hardly anyone (only 1% of men and 207
Table 233. Vitamin and mineral status (mean SD) in UK adults (19–64 years) Men
19–24 years (n 108)
25–34 years (n 219)
35–49 years (n 253)
50–64 years (n 253)
Recommended level
Serum ferritin (g/l) Plasma vitamin C (mol/l) Red cell folate (nmol/l) Serum folate (nmol/l) Serum vitamin B12 (pmol/l) Plasma total homocysteine (mol/l) Plasma retinol (mol/l) Plasma 25-hydroxyvitamin D (nmol/l) Plasma -tocopherol (mol/l)
78 34 55 24 561 262 17.4 7.1 286 112 12.5 5.4
101 52 54 26 688 281 20.1 8.2 298 102 11.1 4.0
129 110 50 23 677 245 20.9 8.0 294 108 11.1 3.2
145 158 52 28 773 320 22.9 9.4 308 155 12.4 5.5
20 11 350 6.3 118 12
1.8 0.5 41 22
1.9 0.5 49 23
2.1 0.5 48 21
2.1 0.6 52 21
0.7 25
16.6 5.6
19.7 5.3
22.0 7.5
23.3 7.3
11.6
Women
(n 104)
(n 210)
(n 318)
(n 259)
Recommended level
Serum ferritin (g/l) Plasma vitamin C (mol/l) Red cell folate (nmol/l) Serum folate (nmol/l) Serum vitamin B12 (pmol/l) Plasma total homocysteine (mol/l) Plasma retinol (mol/l) Plasma 25-hydroxyvitamin D (nmol/l) Plasma -tocopherol (mol/l)
41 26 60 24 576 194 20.6 8.0 247 91 9.3 3.9
43 31 63 30 630 275 21.2 11.1 259 122 9.6 2.9
49 47 59 26 691 293 21.9 9.0 288 145 10.4 6.6
71 54 62 27 768 317 23.7 9.0 329 274 10.6 3.4
15 11 350 6.3 118 12
1.8 0.4 45 24
1.8 0.5 52 27
1.8 0.4 48 23
2.0 0.6 52 23
0.7 25
16.6 4.5
17.8 4.7
20.3 5.5
24.7 6.7
11.6
less than 1% of women) had a serum folate concentration below 6.3 nmol/l. The serum concentration of vitamin B12 is a good indicator for vitamin B12 status. For adults, the lower level of a normal serum vitamin B12 concentration is usually taken as 118 pmol/l [Henderson, 2003c]. The mean serum concentration of this vitamin was clearly above this lower level in both men and women. Only 2% of men and 4% of women had a serum vitamin B12 level lower than 118 pmol/l. The mean plasma concentration of homocysteine was relatively high in adults of the UK. Especially men had an average plasma homocysteine concentration around the upper borderline of a normal level. In women it was slightly lower with around 10 mol/l. 33% of men and 22% of women had a homocysteine concentration higher than the upper border of the normal level (12 mol/l). The vitamin D status in UK adults was insufficient in 14% of the male and 15% of the female sample with a plasma 25-hydroxyvitamin D concentration of less than 25 nmol/l. The mean plasma -tocopherol concentration 208
Annexes
increased with increasing age in both men and women. In the male sample the mean concentration increased from 16.6 to 23.3 mol/l, in the female sample from 16.6 to 24.7 mol/l. Concentrations below 11.6 mol/l, the lower borderline of a sufficient -tocopherol status, were found in 4% of the male as well as the female participants. Food Patterns from the National Diet and Nutrition Survey in Adults Detailed food patterns are available from the National diet and nutrition surveys://www.food.gov.uk/science/ 101717/ndnsdocuments/ Health Survey for England – Introduction This information has been downloaded from: http:// www.dh.gov.uk/PublicationsAndStatistics/Published Survey/HealthSurveyForEngland/fs/en on the 10th of September 2004.
The Health Survey for England is a series of annual surveys about the health of people in England. The Health Survey was first proposed in 1990 to improve information of morbidity by the (then) newly created Central Health Monitoring Unit within the Department of Health. This information is used to underpin and improve targeting of nationwide health policies. The survey was carried out in 1991–1993 by the Office for Population Censuses and Surveys which is now part of the Office for National Statistics. From 1994 onwards the survey has been carried out by the Joint Survey Unit of the National Centre of Social Research and the Department of Epidemiology and Public Health at University College London.
• • • • • • •
Aims The survey aims: to provide annual data about the nation’s health; to estimate the proportion of the population with specific health conditions; to estimate the prevalence of risk factors associated with those conditions; to assess the frequency with which combinations of risk factors occur; to examine differences between population sub-groups; to monitor targets in the health strategy; (from 1995) to measure the height of children at different ages, replacing the national study of health and growth.
Subject Content The Health Survey combines questionnaire answers and physical measurements as well as other objective measures such as analysis of blood samples, ECG readings and lung function tests. The Health Survey for England contains a ‘core’ which is repeated each year and each survey year has one or more modules on subjects of special interest. The ‘core’ includes: • questions on general health and psychosocial indicators • smoking • alcohol • demographic and socioeconomic indicators • questions about use of health services and prescribed medicines – the focus for these may vary from year to year to suit the modular content of the survey • blood pressure • measurements of height, weight and blood pressure. Annexes
The modules may be about a single topic, several topics or about population groups. The modules to date have been: 1993: cardiovascular disease 1994: cardiovascular disease 1995: asthma, accidents, disability 1996: asthma, accidents, special measures of general health (Euroquol, SF36) 1997: children and young people 1998: cardiovascular disease 1999: ethnic groups 2000: older people, social exclusion Blood and Saliva Sample Analysis Analysis of blood and saliva samples are associated with modules in the Health Survey. For 1998 where cardiovascular disease will be the main focus, the following blood analyses were undertaken: • total cholesterol • HDL cholesterol • fibrinogen (a clotting agent – raised levels can contribute to cardiovascular disease and stroke) • haemoglobin • ferritin • c-reactive protein. For years in which asthma was included, blood samples were analysed for immunoglobulin E (IgE – the antibody responsible for the immediate type of immune response – a raised level of IgE is found in people with an atopic predisposition) and house dust mite specific IgE. Cotinine (a metabolite of nicotine) levels have also been included in the survey to measure for smoking and are particularly useful in assessing passive smoking. Cotinine levels can be obtained from either a blood sample or a saliva sample. Other Objective Measures Other objective measures are included in the survey. For example, when asthma is the focus lung function measurements are carried out and ECGs may be used when cardiovascular disease is the focus. The main reports also give the full methodology of each year of the survey. From 1996 the main reports are available on the Internet as detailed below. Population Coverage The Health Survey is designed to be nationally representative of people of different age, sex, geographic area and sociodemographic circumstances. 209
The 1991 and 1992 surveys had a limited population sample of about 3,000 and 4,000 adults, respectively. For 1993–1996 adult sample was boosted to about 16,000 to enable analysis by socioeconomic characteristics and health regions. In 1995 for the first time a sample of about 4,000 children was also introduced. In the 1997 Health Survey the sample was about 7,000 children and 9,000 adults. In 1998 the sample was again about 16,000 adults and 4,000 children.
Health Survey for England 1993 Bennett N et al. ISBN 011 691614 1 £38
Published Reports A main report of about 500–600 pages of tables and commentary is published for each year of the Health Survey together with a Summary of Key Findings. The main reports published in print through the Stationery Office – further details are below. Summaries of Key Findings are available from the Department of Health, and some main reports are also available on the Internet – please see the Health Survey Results pages for further details.
Health Survey for England 1991 White A et al. ISBN 011 691532 3
Health Survey for England: The Health of Minority Ethnic Groups ’99 Edited by Bob Erens, Paola Primatesta and Gillian Prior ISBN 011 322448–6 Health Survey for England: Cardiovascular Disease 98 Edited by Bob Erens and Paola Primatesta ISBN 011 322307 2 £75 Health Survey for England: The Health of Young People 95–97 Edited by Patricia Prescott-Clarke and Paola Primatesta ISBN 011 322266 1 £70 Health Survey for England 1996 Edited by Patricia Prescott-Clarke and Paola Primatesta ISBN 011 322029 1 X £60 Health Survey for England 1995 Edited by Patricia Prescott-Clarke and Paola Primatesta ISBN 011 322021 9 £60 Health Survey for England 1994 Edited by Helen Colhoun and Patricia Prescott-Clarke ISBN 011 321895 8 £40 210
Annexes
Health Survey for England 1992 Breeze E et al. ISBN 011 691569 2 £27.50
Archived Dataset The full (anonymised) datasets for the Health Survey are available through the Data Archive at Essex University which is the largest national resource of computer readable copies of social science and humanities data in the United Kingdom. Further information can be obtained from: The Data Archive, University of Essex, Wivenhoe Park, Colchester, Essex CO4 3SQ. Telephone 01206 872001. Fax 01206 872003. E-mail: archive@ essex.ac.uk; Mailbase:
[email protected]. Essex data archive (external link) Question Bank The full set of questions for the Health Survey for England are held on the Question Bank at the Centre for Applied Social Surveys which is an ESRC resource centre run jointly by SCPR and the University of Southampton, with the University of Surrey. E-mail:
[email protected] Enquiries Queries about the Health Survey should be sent to: Patrick Tucker, Department of Health, Room 451c Skipton House, 80 London Road, London SE1 6LH. Telephone: 020 7972 5718; Fax: 020 7972 5662. E-mail:
[email protected] Summary of Trends Adults Blood Pressure. Between 1993 and 2002, systolic blood pressure among men decreased from 139 mm Hg to 135 mm Hg and among women from 136 mm Hg to 131 mm Hg. The downward trend continued between 2001 and 2002 but the difference between the two years
was not significant. The observed reduction in systolic blood pressure was larger for men and women aged 64 and over (at least 9 mm Hg) than for those under 65 (between 3 and 6 mm Hg). High blood pressure is defined as a systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg or on anti-hypertensive drugs, as described in the 1998 report. In 1998 and in 2001 the prevalence of high blood pressure among men was 40.8%, but this decreased to 37.4% in 2002. The proportion of women with high blood pressure varied between 32.9% in 1998 and 34.7% in 2001 and there were no significant changes over this period. Among men and women there was a reduction (of 6% for men of 2.5% for women) in the prevalence of those with high blood pressure who had not been prescribed antihypertensive drugs. BMI. The proportion of adults with a desirable BMI decreased between 1993 and 2002, from 37.8% in to 29.6% among men and from 44.3 to 37.4% among women. There was no significant change in the proportion of adults who were overweight, there was a marked increase in the proportion who were obese. The proportion who were categorised as obese (BMI over 30) increased from 13.2% of men in 1993 to 22.1% in 2002 and from 16.4% of women in 1993 to 22.8% in 2002. Cigarette Smoking and Alcohol. Among men there was an increase in the proportion who never regularly smoked cigarettes (from 39% in 1993 to 44% in 2002) and a decrease in the proportion of men who used to smoke cigarettes regularly but no longer smoke (from 33% in 1993 to 29% in 2002). The proportion of men who were smokers (27%) was similar to that in 1993 (28%) but had decreased since 1996 (30%). Among current smokers there was no change in smoking behaviour over this period: 7% of men were classed as light smokers (10 cigarettes a day), 10% as medium smokers (10 to 20 a day) and 10% as heavy smokers (20 or more a day). The proportion of women who had never smoked increased from 52% in 1993 to 54% in 2002, whilst the proportion who used to smoke regularly but no longer smoked decreased from 22% in 1993 to 20% in 2002. There was no change in the proportion of current smokers between 1993 and 2002 (26%) but the prevalence of heavy smoking among women (20 or more a day) decreased from 8% in 1993 to 6% in 2002. The proportion of women who were classed as light (10 cigarettes per day) or medium (10 to 20 per day) did not change over this period (8% were light smokers and 11% were medium smokers).
Annexes
Since 1993, the proportion of men with weekly alcohol consumption of over 1–10 units decreased (from 34% in 1993 to 31% in 2002) and the proportion consuming over 10–21 units increased (from 21% in 1993 to 23% in 2002). There were no changes in the proportion of men consuming less than 1 unit or more than 21 units per week. Among women a different pattern was observed. Since 1993, there was an overall decrease in the proportion of women consuming 1–7 units (from 38% in 1993 to 36% in 2002), but the proportion of women drinking over 21 units increased from 2% in 1993 to 6% in 2002. For both males and females, the greatest changes in drinking behaviour were found among those aged 16–24. Among young men of this age, the proportion consuming 1–10 units per week decreased from 32% in 1993 to 23% in 2002 while the proportion consuming more than 28 units per week increased from 22% in 1993 to 34% in 2002. Among women aged 16–24, the proportion consuming 1–7 units per week decreased from 41% to 29% while the proportion consuming over 21 units per week increased from 9% in 1993 to 23% in 2002. There was little variation with age for those aged 25 and over. Between 1998 and 2002, the proportion of adults who had consumed no alcohol in the previous week varied between 24 to 25% for men and between 38 and 40% among women. There were no significant changes between survey years. Current government guidelines advise that daily drinking should not regularly exceed 4 units for men and 3 units for women. The proportion of men and women who had not exceeded this limit on the heaviest days drinking was relatively stable over time, with 30% of men and 32% of women having consumed alcohol within these limits in 2002. Overall, between 44 and 46% of men had consumed more than 4 units on the heaviest days drinking, while 28% to 30% of women had consumed more than 3 units. There was no clear pattern although there were significant differences for some years. Among men, there was a significant decrease in the proportion who had consumed more than 4 units, but less than 8, from 21% in 2001 to 19% in 2002. Among women, there was an overall increase in the proportion who had consumed 6 or more units (twice the limit) on the heaviest days drinking from 11% in 1998 to 14% in 2002. There was some variation in alcohol consumption across the age range, with younger men and women being more likely to exceed the limits of 4 units for men and 3 units for women. Marked trends in alcohol consumption were 211
apparent for those aged 16–24. Among men aged 16–24, there was a significant increase in the proportion who had consumed more than 4 units from 52% in 1998 to 58% in 2002. A similar pattern was observed for women aged 16–24, with the proportion consuming more than 3 units increasing from 39% in 1998 to 49% in 2002. Fruit and Vegetable Consumption. Questions about fruit and vegetable consumption were first included in 2001, and are designed to assess fruit and vegetable consumption in terms of portions per day. Overall, 22% of men and 25% of women consumed 5 portions or more and there was no significant variation between 2001 and 2002. In 2002 the mean number of serves of fruit and vegetables for adults was 3.3 for men and 3.5 for women; with 12% of men and 9% of women reporting consuming less than one portion per day. Children Blood Pressure. Among boys, systolic blood pressure varied between 111.7 mm Hg and 111.0 mm Hg and but there was no significant difference between 1995 (111.7 mm Hg) and 2002 (111.3 mm Hg). Among girls systolic blood pressure varied between 110.1 and 111.8 mm Hg but there was no significant difference between 1995 (111.8 mm Hg) and 2001 (111.2 mm Hg). There was an increase in systolic blood pressure across the age range in all survey years from 102.5–105.2 mm Hg for boys and girls aged 5 to 115.3–123.2 mm Hg for those aged 15.
212
Annexes
Height and Weight. Infants aged 0–1 were first included in the survey in 2001. As the infant length and weight measurements were included from 2001, trends in overall height and weight from 1995 to 2001 and from 2001 to 2002 are examined separately. Overall, childrens’ mean height increased between 1995 and 2002. Mean height increased from 130.6 cm in 1995 to 132.2 cm in 2001 among boys aged 2–15 and from 129.7 cm in 1995 to 131.6 cm in 2001 among girls aged 2–15. Among boys aged 0–15, mean height increased from 127.6 cm in 2001 to 129.0 cm in 2002 and among girls of the same age mean height increased from 126.9 cm in 2001 to 127.6 cm in 2002. There was no clear variation in trends within different age groups. Between 1995 and 2002, mean weight of children aged 2–15 increased from 32.0 to 33.2 kg among boys and from 32.0 to 33.6 kg among girls. Obesity. Mean body mass index increased between 1995 and 2001. A similar pattern was observed for boys and girls and there was little variation in trends within different age groups. Fruit and Vegetable Consumption. There was a significant increase in the proportion of boys consuming between 2 and 3 portions of fruit and vegetables from 21% in 2001 to 24% in 2002. There were no changes in the proportion of boys who consumed 3 portions or more and there was no significant variation in fruit and vegetable consumption among girls. Mean number of serves of 5–14 year old boys was 2.5 and for girls 2.6 serves per day. 16% of boys and 13% of girls reported consuming less than 1 serve of fruit and vegetables a day.
References
Adamidis D, Konstantinou D, Koufoyianni K, Psatha A, Sali Amet Goulai, Konstantinidou X: Detection program of anemia in rural Xanthi. 35th Panhellenic Pediatric Conference, 1997, p 414. Afonso C: Saúde, actividade física e peso corporal: Contributo para o seu conhecimento numa amostra de população adulta Portuguesa. Mestrado em Saúde Pública. Faculdade de Medicina e Instituto de Ciências Biomédicas Abel Salazar, Universidade do Poerto, 1999a. Afonso C: Health, Physical Activity and Body Weight. Porto, 1999b. Afonso C, Graça P, Kearney JM, Gibney MJ, de Almeida MD: Physical activity in European seniors: Attitudes, beliefs and levels. PMID: 11753479 [PubMed – indesed for MEDLINE]. J Nutr Health Aging 2002;6(1):63–65. Afonso C, Graça P, de Almeida MDV: Obesity, body weight changes and weight loss practices in Portuguese seniors. V congreso de la sociedad Espanola de nutricion comunitaria – III congreso iberoamericano de nutrition y salud publica. Libro de resumens. P301:223. Madrid, 2002. de Almeida MDV, Thomas JE: Nutritional consequences of migration. Scand J Nutr 1996;40(2);(suppl 31):S119–S121. de Almeida MDV, Graça P, Afonso C, D’Amicis A, Lappalainen R, Damkjaer S: Physical activity levels and body weight in a nationally representative sample in the European Union. Public Health Nutr 1999a;2(1A):105–113. de Almeida MDV, Graça P, Afonso C, D’Amicis A, Lappalainen R, Damkjaer S: Physical activity levels and body with in a nationally representative sample in the European Union. PMID 10933630 [PubMed – indexed for MEDLINE]. Public Health Nutr 1999b;2:105–113. Amorim CJA, Moreiras-Varela O, Staveren WA, Trichopoulou A, Roskowski W:
Intake of vitamins and minerals. Eur J Clin Nutr 1991;45:121–138. Andersen NL, Fagt S, Groth MV, Hartkopp HB, Møller A, Ovesen L, Warming DL: Danskernes kostvaner 1995, Levnedsmiddelstyrelsen, Publikation nr. 235, Søborg. Anthony G, Kafatos, Codrington C: European diet and public health: The continuing challenge; in Eurodiet Reports and Proceedings. Public Health Nutr 2001; 2(A):275–292. Apostolopoulou-Michailidou E, Kouri N: Variation in hemoglobin, hematocrit and serum ferritin and frequency of anemia among health students in Corfu. Paediatriki 1981;44:312–325. Aranceta J, Pérez C, Eguileor I, González de Galdeano L, Mataix J, Sáenz de Buruaga J: Encuesta nutricional. Documentos técnicos de Salud Pública serie A, No 9. Vitoria, Gobierno Vasco, 1990. Aranceta J, Pérez C, Marzana I, Eguileor I, Gondra J, González de Galdeano L, Sáenz de Buruaga J: Estado nutricional vitamínico en ancianos. Rev Esp Nutr Comunitaria 1997;3(2):87–94. Aranceta J, Pérez C, Marzana I, Eguileor I, González de Galdeano L, Sáenz de Buruaga J: Encuesta de nutrición de la Comunidad Autónoma Vasca. Tendencias de consumo alimentario, indicadores bioquímicos y estado nutricional de la población adulta. Vitoria, Servicio de Publicaciones Gobierno Vasco, 1995. Aranceta J, Pérez C, Amela C, García Herrera R: Encuesta de nutrición de la Comunidad de Madrid. Madrid, Consejería de Salud de la Comunidad de Madrid, 1994. Aranceta J, Pérez RC, Eguileor I, Marzana I, Gonzalez de Galdeano L, Saenz de Buruaga J: Food consumption patterns in the adult population of the Basque Country (EINUT-I). Public Health Nutr 1998;1(3):185–192.
Aranceta J, Pérez RC, Serra ML, Ribas Barba L, Quiles Izquierdo J, Vioque J, et al.: Prevalencia de obesidad en España: Actualización con el estudio SEEDO’2000. Med Clin (Barc) 2003; 120(16):608–612. Aranceta J, Pérez RC, Serra ML, Ribas L, Quiles-Izquierdo J, Vioque J, Foz M: Influence of sociodemographic factors in the prevalence of obesity in Spain. The SEEDO’97 Study. Eur J Clin Nutr 2001;55(6):430–435. Aranceta J, Serra ML, Ortega R, Entrala A, Gil A: Libro blanco. Las Vitaminas en la alimentación de los españoles. Estudio Eve. Madrid, Ed Medica Panamericana 2000, pp 1–288. Bakoula C: Personal communication, 2004. Barth C: Verzehrsgewohnheiten von Vorschulkindern im Alter von 3–6 Jahren in Oberösterreich und Wien; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2001. Bayerische Verzehrsstudie II 2003: http://www.wzw.tum.de/wdh/Res/BVS2/ bvs2.html. Beck A, Kritz H, Müller M, Silberbauer K, Sinzinger H: Cholesterin. 2. ACCC 2002, Konsensus-Statement; in CliniCum, Sonderausgabe, Oktober 2002. Becker W, Pearson M: Riksmaten 1997–98. Befolkningens kostvanor och näringsintag. Metod- och resultatanalys. Livsmedelsverket, Uppsala, 2002. Becker W: Svenskarna äter nyttigare – allt fler väljer grönt. Vår Föda nr 1, s. 24–27, 1999. Becker W. Riksmaten 1997–98: Vi äter nyttigare – men har blivit tyngre. Vår Föda 1999a;2:3–7. Becker W: Vilka är källorna till våra näringsämnen? Vår Föda 2000;3:16–26. Pearson M, Becker W. Ålder och utbildning – viktigast för våra matvanor. Vår Föda 2001;53(3):12–17. Becker W: Befolkningens kostvanor och näringsintag i Sverige 1989. Metod- och
213
resultatanalys. Statens livsmedelsverk, Uppsala, 1994. Becker W: Dietary guidelines and patterns of food and nutrient intake in Sweden. Br J Nutr 1999b;81(suppl 2):S113–S117. Becker W, Lennernäs M, Gustafsson I-B, Haraldsdottir J, Nydahl M, Vessby B, Ytterfors A: Precoded food records compared with weighted food records measuring dietary habits in a population of Swedish adults. Scand J Nutr/ Näringsforskning 1998;42:145–149. Beer A: Gesundheitszustand und Aufnahme von Energie, Hauptnährstoffen, ausgewählten Vitaminen und Spurenelementen älterer und alter Menschen in Wiener Pensionistenheimen; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 1995. Bellù R, Giovannini M, et al. Nutr Res 1991; 11:1221–1229. Bergmann KE, Mensink GBM: Körpermaße und Übergewicht. Gesundheitswesen 1999; 61:S115–S120. Biró G, Hulshof KFAM, Ovesen L, Amorim Cruz JA: Selection of methodology to assess food intake. Eur J Clin Nutr 2002; 56(suppl 2): S25–S32. Bíró G, Lindner K (ed): Tápanyagtáblázat (Food composition tables). Budapest, Medicina, 1995, pp 39;47;65–66. Bíró G, Antal M, Zajkás G: Nutrition survey of the Hungarian population in a randomised trial between 1992–1994. Eur J Clin Nutr 1996a;50:201–208. Bíró G, Antal M, Zajkás G: A magyar lakosság egy csoportjának táplálkozási vizsgálata 1992–1994 között [Nutrition survey of a Hungarian population group between 1992–1994]. Népegészségügy (Public Health) 1996b;77(4):3–13. Bohlke K, Spiegelman D, Trichopoulou A, Katsouyanni K, Trichopoulos D: Vitamins A, C and E and the risk of breast cancer: Results from a case-control study in Greece. Br J Cancer 1999;79(1):23–29. Brussaard JH, Johansson L, Kearney J: Rationale and methods of the EFCOSUM project. Eur J Clin Nutr 2002;56(suppl 2): S4–S7. Brussaard JH, Löwik MRH, Steingrímsdóttir L, Møller A, Kearney J, De Henauw S, Becker W: A European food consumption survey method – Conclusions and recommendations. Eur J Clin Nutr 2002; 56(suppl 2):S89–S94. Carmo I, Carreira M, de Almeida MDV, Lima Reis JP, Medina JL, Galvão Teles A: Estudo da prevalência da obesidade em Portugal. Boletim da SPEO, Jan/Jun 3–5, 2000. Chiotis D, Tsiftis G, Hatzisymeon M, ManiatiChristidis M, Krikos X, Dacou-Voutetakis C: Height and weight in Children of
214
References
Hellenic origin aged 0–18 years (2000– 2001): Comparison with data collected during the period 1978–1979. Annales Clinicae Paediatricae Universitatis Atheniensis 2003; 50(2):136–155. Chiotis D, Krikos X, Tsiftis G, Hatzisymeon M, Maniati-Christidis M, Dacou-Voutetakis C: Body mass index and prevalence of obesity in subjects of Hellenic origin aged 0–18 years, living in the area of Athens. Annales Clinicae Paediatricae Universitatis Atheniensis 2004;51(2):139–154. Cole TJ: Sampling, study size, and power; in Margetts B, Nelson M (eds): Design Concepts in Nutritional Epidemiology. New York, Oxford University Press,1997. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH: Establishing a standard definition for child overweight and obesity worldwide: International survey. BMJ 2000;320:1240– 1243. Commission of the European Communities: Reports of the Scientific Committee for Food (Thirty-first series). Nutrient and Energy Intakes for the European Community. (Opinion expressed on 11 December 1992). Published by the Commission of the European Communities, Luxembourg. Internet: http:// www.europa.eu.int/comm/food/fs/sc/scf/ out89.pdf (accessed: 29 March 2004). Costacou T, Bamia C, Ferrari P, Riboli E, Trichopoulos D, Trichopoulou A: Tracing the Mediterranean diet through principal components and cluster analyses in the Greek population. Eur J Clin Nutr 2003; 57(11):1378–1385. Csillag C: Verzehrsgewohnheiten von 4–6jährigen Vorschulkindern im Raum Vorarlberg und Tirol; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. D-A-CH, DGE, ÖGE, SGE, SVE: Referenzwerte für die Nährstoffzufuhr. Frankfurt/Main, Umschau, 2000. D’Amicis A, et al.: Nutrients intake in Italy: A global analysis carried out on INN-CA Study 1994–1996 data. (submitted for publication). D’Amicis A, et al.: Studio sui Consumi Alimentari e Ripartizione dei Pasti degli Scolari dell’obbligo in Italia (SCARPS). La Rivista Italina di Scienze dell’ Alimentazione 2002a;31(3):235–248. D’Amicis A, D’Acapito P, Gargiulo L, Granicolo E, Sabbadini L: Dimensione del problema obesità in Italia e suoi rapporti con alcune patologie correlate. 4⬚ Rapporto sull’Obesità in Italia. Franco Angeli, Milano, Istituto Auxologico Italiano, 2002b. De Henauw S, Brants HAM, Becker W, KaicRak A, Ruprich J, Sekula W, Mensink
GMB, Koenig JS: Operationalization of food consumption surveys in Europe: Recommendations from the European Food Consumption Survey Methods (EFCOSUM) Project. Eur J Clin Nutr 2002;56(suppl 2):S75–S88. De Henauw S, Wilms L, Mertens J, Standaert B, De Backer G: Overall and MealSpecific Macronutrient Intake in Belgian Primary School Children. Nutrition & Metabolism, 1997, vol 41, pp 89–97. Antwerpen/Gent: Provinciaal Instituut voor Hygiëne (P.I.H.) en Vakgroep Maatschappelijke Gezondheidkunde van de Universiteit Gent (RUG). De Henauw S: Jongeren scoren slecht voor het vak gezond eten. Nutrinews 1998a, vol 4, pp 3–8. De Henauw S, et al.: Voedingsgewoonten bij jongeren van 14–18 jaar. Eindrapport. Gent: faculteit Geneeskunde, Vakgroep Maatschappelijke Gezondheidkunde van de Universiteit Gent (RUG), 1998b. Deutsche Gesellschaft für Ernährung (DGE): Ernährungsbericht 2000. Frankfurt/Main, DGE, 2000. Díaz C, López F, Henríquez P, Rodríguez E, Serra-Majem L: Serum manganese concentrations in a representative sample of the Canarian population. Biol Trace Elem Res 2001;80(1):43–51. Díaz RC, Henríquez SP, López BF, Rodríguez RE, Serra ML: Serum copper and zinc concentrations in a representative sample of the Canarian population. J Trace Elem Med Biol 2002;16(2):75–81. Díaz RC, Henríquez SP, López BF, Rodríguez RE, Serra ML: Concentraciones de Na, K, Ca y P en sueros de una muestra representativa de la población canaria. Nutr Hosp 2002;XVII(4):204– 212. Díaz RC, López BF, Henríquez SP, Rodríguez RE, Serra-ML: Serum selenium concentrations in a representative sample of the Canarian population. Sci Total Environ 2001;269(1–3):65–73. Dirren H, Decarly B, Lesourd B, Schlienger JL, Deslypere JP, Kiepurski A: Nutritional Status: haematology and albumin. Eu J Clin Nutr 1991;45:43–52. Dontas AS, Moschandreas J, Kafatos A: Physical activity and nutrition in older adults. Public Health Nutr 1999;2(3A): 429–436. DOXA: Il fumo in Italia. Osservatorio OSSFAD fumo, alcol e droga. Istituto Superiore di Sanità. Istituto ricerche farmacologiche Mario Negri e Lega Italiana Lotta contro Tumori, 2004. ECHI project: ECHI-2 list of recommended ‘First Phase Core Indicators’ (‘The Shortlist’). Version of June 22, 2004, for
discussion in the Network of Competent Authorities (NCA) and Network of Working Party Leaders (NWPL) of July 5/6, 2004. EFCOSUM: European food consumption survey method. Eur J Clin Nutr 2002;56: (suppl 2). Elmadfa I, Burger P, König J, Derndorfer E, Kiefer I, Kunze M, Leimüller G, Manafi M, Mecl HR, Papathanasiou V, Rust P, Vojir F, Wagner KH, Zarfl B: Österreichischer Ernährungsbericht. Institute of Nutritional Science, University of Vienna, Vienna, 1998. Elmadfa I, Freisling H, König J, Blachfelner J, Cvitkovich-Steiner H, Genser D, Grossgut R, Hassan-Hauser C, Kichler R, Kunze M, Majchrazak D, Manari M, Rust P, Schindler K, Vojir F, Wallner S, Zilberszac A: Österreichischer Ernährungsbericht 2003. Institute of Nutritional Science, University of Vienna, Vienna, 2003. Elmadfa I, Leitzmann C: Ernährung des Menschen, ed 4th Stuttgart, Eugen Ulmer Verlag, 2004. Elmadfa I, Wasserbacher B: Expertengutachten zur Ernährung von Vorschulkindern in Österreich. Feldstudie über die Verzehrsgewohnheiten und Lebensmittelpräferenzen von Vorschulkindern (3 bis 6 Jahre) in Österreich – Endbericht. On behalf of the Federal Ministry of Social Safety and Generations. Im Auftrag des Bundesministeriums für Soziale Sicherheit und Generationen. Wien, GZ, 2002. EPIC-Greece: EPIC Newsletter, 2002, Issue 3. Eurobarometer: Smoking and the Environment: Actions and Attitudes. Special Eurobarometer 183/Wave 58.2 – European Opinion Research Group EEIG. Brussels, European Commission, 2003. Eurodiet: Nutrition and Diet for Healthy Lifestyles in Europe. Science and Policy Implications. University of Crete, School of Medicine, 2000. European Commission: The Report of the Scientific Committee on Human Nutrition. Brussels, Official Press of the European Community, 1993. European Commission: A Pan-EU survey on consumer attitudes to physical activity, body weight and health. Luxembourg, 1999. Fagt S, et al.: Udviklingen i danskernes kost 1985–2001. Danish Institute for Food and Veterinary Research, 2004. FAO: Food Balance Sheets, FAOSTAT data 2004. Internet: http://faostat.fao.org/ faostat/form?collection⫽FBS&Domain⫽ FBS&servlet⫽1&hasbulk⫽&version⫽ext &language⫽EN (accessed August, 2003). FAO: Food Balance Sheets, A Handbook. Rome, Food and Agriculture Organization of the United Nations, 2001.
References
Ferlay J, Bray F, Pisani P, Parkin DM: GLOBOCAN 2000: Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0. IARC Cancer Base No. 5. Lyon, IARC Press, 2001. Limited version available from: URL: http://www.dep.iarc. fr/globocan/globocan.htm (accessed July 8, 2004). Freeman V, van’t Hof M, Haschke F: Patterns of milk and food intake in infants from birth to age 36 months: The Euro-growth study. J Pediatr Gastroenterol Nutr 2000; 31(suppl 1):S76–S85. Freidl W, Stronegger W-J, Neuhold C: Vienna Health and Social Survey. Magistrat der Stadt Wien, 2001. Frisiras S, Metaxotou-Mavromamati A, Pikramenou A, Lagos P, Kattamis X: Epidemiologic study of iron deficiency in early childhood. Assessment of the preventive administration of iron supplements. 37th Panhellenic Pediatric Conference, 1999, p 50. Frisiras S, Metaxotou-Mavromamati A, Pikramenou A, Lagos P, Kattamis X: Determination of normal values for Hb, Ht and red blood cell indexes for the ages of 9–10 months and 1–4 years. 38th Panhellenic Pediatric Conference, 2000, p 121. Frisiras S: Longitudinal study of iron deficiency and iron anemia epidemiology in Greece. Physiology and deficiencies of iron metabolism. Greek Peadiatric Hematology-Oncology Society, Athens, 2003. Gall IB: Nährstoffaufnahme österreichischer Schwangerer und der Stellenwert nährstoffangereicherter Lebensmittel und Supplemente; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Garrow JS, Seidell JC: SENECA: Nutrition and the elderly in Europe. Eur J Clin Nutr 1996;50(suppl 2). García CR, Serra ML, Chacón CP, Olmos CM, Ribas BL, Salleras SL: Grupo de Investigación sobre Evaluación del Estado Nutricional de la Población Catalana: Evaluación Bioquímica. Distribución de la concentración de lípidos séricos en una muestra representativa de la población adulta de Cataluña. Med Clin (Barc) 1999; 113(1):6–12. García CR, Serra ML, Pastor FC, Olmos CM, Roman B, Ribas BL, Salleras SL: Grupo de investigación sobre evaluación nutricional de la población catalana. Evaluación bioquímica. Distribución de la concentración sérica de -caroteno, retinol y ␣-tocoferol en una muestra representativa de la población adulta de Cataluña. Med Clin (Barc) 2002;118(7): 256–261.
García CR, Serra ML, Sabater SG, Olmos CM, Ribas BL, Salleras SL: Grupo de investigación sobre evaluación nutricional de la población catalana: Evaluación bioquímica. Distribución de la concentración sérica de vitamina C, ácido fólico y vitamina B12 en una muestra representativa de la población adulta de Cataluña. Med Clin (Barc) 2002;118(4): 135–141. Gascon VP, García CR, Serra ML, Pastor MC, Ribas L, Ramon JM, et al.: Determinants of the nutritional status of vitamin E in a nonsmoking Mediterranean population. Analysis of the effect of vitamin E intake, alcohol consumption and body mass index on the serum alpha-tocopherol concentration. Eur J Clin Nutr 1997;51(11):723–728. Gezondheidsenquête 2001: Internet: www.iph.fgov.be, nl. 24, 6, S83–S89. [N ⫽ 1844, 18–60 jaar]. Gezondheidsenquête 1997. Raadpleegbaar op http://www.iph.fgov.be/epidemio/epinl/ index4.htm Giammaroli S, Sanzini E, Ambruzzi AM, Chiaretti F, Fasano G: Nutrient intake of Italian women during lactation. Int J Vitam Nutr Res 2002;72(5):329–335. Goldberg GR, Black AE, Jebb SA, Cole TJ, Murgatroyd PR, Coward WA, Prentice AM: Critical evaluation of energy intake data using fundamental principles of energy physiology. I. Derivation of cut-off values to identify under-reporting. Eur J Clin Nutr 1991;45:569–581. Greek WHO Collaborating Center for Nutrition: EPIC database 2004. Graça P, Mendes de Oliveira B, Nogueira P, Branco MJ, de Almeida MDV: Autopercepção estatoponderal e estratégias de redução de peso em adultos portugueses. Revista de Alimentação Humana 2000;6(2): 121–130. Grandolfo et al.: Indagine conoscitiva sul percorso nascita. Istituto Superiore di Sanità, 2002. Gschaider G: Ernährungsphysiologische Beurteilung der Schuljausen an gesundheitsfördernden Volksschulen; Doctoral thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Haas K: Ernährungsverhalten und Ernährungswissen österreichischer Lehrlinge; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Haller J, Löwik MRH, Ferry M, Ferro-Luzzi: Nutritional Status: Blood vitamins A, E, B6, B12, folic acid and carotene. Eur J Clin Nutr 1991;45:53–61. Haraldsdottir J: Dietary guidelines and patterns of intake in Denmark. Br J Nutr 1999; 81(suppl 2):S43–S48. [National dietary survey 1995, 15–80 jaar].
215
Hassapidou M, Kafatos A, Manoukas G: Dietary vitamin E intake and plasma tocopherol levels of a group of adolescents from Spili, Crete. Int J Food Sci Nutr 1996; 47(5):365–368. Hassapidou M, Manstrantoni M: Dietary intakes of elite female athletes in Greece. J Hum Nutr Diet 2001;14(5):391–396. HBSC – Portugal, 2002. Helakorpi S, Patja K, Prättälä R, Aro AR, Uutela A: Health Behaviour and Health among Finnish Adult Population. Helsinki, Publications of the National Public Health Institute, 2003. Henderson L, Irving K, Gregory J, Bates CJ, Prentice A, Perks J, Swan G, Farron M: The National Diet & Nutrition Survey: Adults aged 19 to 64 years. Energy, protein, carbohydrate, fat and alcohol intake. Volume 2. Office for National Statistics, Medical Resource Council Human Nutrition Research, Food Standard Agency, London, 2003a. Henderson L, Irving K, Gregory J, Bates CJ, Prentice A, Perks J, Swan G, Farron M: The National Diet & Nutrition Survey: Adults aged 19 to 64 years. Vitamin and mineral intake and urinary analytes. Volume 3. Office for National Statistics, Medical Resource Council Human Nutrition Research, Food Standard Agency, London, 2003b. Henderson L, Irving K, Gregory J, Bates CJ, Prentice A, Perks J, Swan G, Farron M: The National Diet & Nutrition Survey: Adults aged 19 to 64 years. Nutritional status (anthropometry and blood analytes), blood pressure and physical activity. Volume 4. Office for National Statistics, Medical Resource Council Human Nutrition Research, Food Standard Agency, London, 2003c. Henderickx HK: Ondervoeding, overvoeding, wanvoeding: Elders maar ook bij ons. Nutrinews 1997;5(4):7–10. Henderickx HK: Voedingsaanbevelingen voor België. Impact van voeding op gezondheid: recente ontwikkelingen – 1 (1ste voedings- en gezondheidscongres). Garant, 1998, pp 9–16. Henríquez SP, Díaz RC, Rodríguez RE, López BF, Alvarez LE, Díaz CJ, Pastor FMC, Serra Majem L: Evaluación bioquímica del estado nutricional de la población canaria (1997–98). Arch Latinoam Nutr 2000;50(suppl 1): 43–54. Hermann-Kunz E, Thamm M: Dietary recommendations and prevailing food and nutrient intakes in Germany. Br J Nutr 1999;81(suppl 2):S61–S69. Hertner M: Ernährungsverhalten und Nährstoffzufuhr von Niederösterreichischen und Wiener Volksschulkindern; Diploma
216
References
thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Heseker H, et al.: Lebensmittel- und Nährstoffaufnahme Erwachsener in der Bundesrepublik Deutschland; In VERASchriftenreihe, Band III. Kübler W, et al. (ed). Niederkleen, Wissenschaftlicher Fachverlag, 1994, pp 98–99. Hinterndorfer C: Nährstoffaufnahme und Ernährungsverhalten von Hauptschülern und Gymnasiasten in Österreich; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Hitthaller A: Das Ernährungswissen und Ernährungsverhalten von österreichischen Frauen und Methoden zur Verbesserung der Ernährungsinformation; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2000. Hulshof KF, van Ero-Baart MA, Anttolainen M, Becker W, Church SM, Couet C, Hermann-Kunz W, Kesteloot H, Leth T, Martins I, Moreiras O, Moschandreas J, Pizzoferrato L, Rimestad AH, Thorgeirsdottir H, van Amelsvoort JM, Aro A, Kafatos A, Lanzmann-Petithory D, van Poppel G: Intake of fatty acids in western Europe with emphasis on trans fatty acid: The TRANSFAIR study. Eur J Clin Nutr 1999;53(2):143–157. IDEWE: De gezondheidstoestand van de Vlaamse werknemers. [onderzoeksrapport, nr. 98.4]. Leuven, 1998, pp 40–58. IDEWE: De evolutie van overgewicht bij werknemers in Vlaanderen en Brussel tussen 1993 en 2000 [onderzoeksrapport nr. 02.1]. Leuven, 2002, p 12. Ioannidis I, Kaklamanos I, Kaklamanou M, Kapantais E, Lanaras L, Mortoglou A, Bakatselos S, Tzotzas T: Panhellenic epidemiological Study on the prevalence of obesity. Scientific Newsletter of the Greek Society of Obesity 2004;3:1. INRAN: Manuale di Sorveglianza Nutrizionale. Roma, INRAN, 2003. Instituto Nacional de Estadística. Datos de mortalidad. www.ine.es. Instituto de alimentação BECEL: Estudio epidemiológico de caracterização do perfil lipídico da população portuguesa. International Diabetes Federation: Prevalence estimates and data sources by regions (e-Atlas), 2003. Internet: http:// www.idf.org/e-atlas/home/index.cfm? u n o d e ⫽3 B 9 6 A 0 F 7 - C 0 2 6 - 2 F D 3 8770383FA748A8FB (accessed July 9, 2004). Ireland J, van Erp-Baart AMJ, Charrondière UR, Møller A, Smithers G, Trichopoulou A: Selection of a food classification system and a food composition database for future food consumption surveys. Eur J Clin Nutr 2002;56(suppl 2):S33–S45.
ISTAT – Unit “Struttura e dinamica sociale”, health interview survey “Health status and use of health services – Years 1999–2000”. Johansson L, Solvoll K: Norkost 1997. Landsomfattende kostholdsundersökelser blant menn og kvinner 16–79 år. Rapport nr.2/1999. Statens råd för ernæring og fysisk aktivitet, Oslo 1999a. Johansson L, Solvoll K: Norkost 1993–94 og 1997. Landsomfattende kostholdsundersökelser blant menn og kvinner 16–79 år. Rapport nr. 3/1999. Statens råd för ernæring og fysisk aktivitet, Oslo 1999b. Joint FAO/WHO Expert Consultation: Diet, Nutrition and the Prevention of Chronic Diseases. Geneva, WHO, 2003. Junge B, Nagel M: Das Rauchverhalten in Deutschland. Gesundheitswesen 61 1999; S121–S125. Kafatos A, Diacatou A, Labadarios D, Kounali D, Apostolaki J, Vlachonikolis J, Mamalakis G, Megremis S: Nutrition status of the elderly in Anogia, Crete, Greece. J Am Coll Nutr 1993;12(6):685–692. Kafatos A, Diacatou A, Voukiklaris G, Nikolakakis N, Vlachonikolis J, Kounali D, Mamalakis G, Dontas AS: Heart-disease risk factor status and dietary changes in the Cretan population over the past 30 years: The Seven Countries Study. Am J Clin Nutr 1997;65(6):1882–1886. Kafatos A, Schlienger JL, Ferro-Luzzi A, Amorim Cruz JA: Nutritional Status: Serum lipids. Eur J Clin Nutr 1991;45: 53–61. Kapantais E, Haralambides V, Tzotzas T, Mortoglou A, Bakatselos S, Kaklamanou M, Ioannidis I, Lanaras L, Kaklamanos I: First National Epidemiological Large Survey on the Prevalence of Childhood and Adolescent Obesity in Greece. Int J Obes 2004:28(suppl 1);71. Kapantais E, Tzotzas T, Mortoglou A, Bakatselos S, Kaklamanou M, Ioannidis I, Lanaras L, Kaklamanos I: First national epidemiological large scale survey on the prevalence of obesity in Greek adults. Int J Obes 2004:28(suppl 1);72. Karanikolaou E, Lepidas G, Tsifouti G, Xatzikonstantinou N, Pantazi A: Frequency of iron deficiency and iron deficiency anemia among children in the Rodopi region. 30th Panhellenic Pediatric Conference, 1992, p 326. Karayiannis D, Yannakoulia M, Terzidou M, Sidossis LS, Kokkevi A: Prevalence of overweight and obesity in Greek schoolaged children and adolescents. Eur J Clin Nutr 2003;57(9):1189–1192. Kattamis C, Metaxotou-Mavromati A, Konidaris C, Touliatos N, Constantsas N, Matsaniotis N: Iron deficiency in Greece. J Pediatr 1974;84(5):666–671.
Keramida M, Tsantali X, Athanasiou-Metaxa M: Dietary habits of children and iron deficiency. Paediatriki 1998;61: 374– 380. Kiselka M: Untersuchung zur Nahrungsaufnahme und Lebensmittlpräferenz von Vorschulkindern im süd-östlichen Raum Österreichs; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Kjøller M and Rasmussen NK: Sundhed og sygelighed i Danmark 2000. Statens Institut for Folkesundhed, 2002. Kohlmeier M, et al.: Verbreitung von klinischchemischen Risikoindikatoren in der Bundesrepublik Deutschland; in VERASchriftenreihe, Band VII. Kübler W, et al. (ed). Niederkleen, Wissenschaftlicher Fachverlag, 1993, pp 56–57. Krassas GE, Tzotzas T, Tsametis C, Konstantinidis T: Prevalence and trends in overweight and obesity among children and adolescents in Thessaloniki, Greece. J Pediatr Endocrinol Metab 2001;14(suppl 5): 1319–1326; discussion 1365. Krokidas G, Routi E, Kousoulakou A, Stavropoulou F, Papageorgiou O, Filias N: Iron deficiency and nutrition. A problem in southwest Greece. 30th Panhellenic Pediatric Conference, 1992, p 327. Kromeyer-Hausschild K, Wabitsch M, Kunze D, Geller F, Gei HC, Hesse V, von Hippel A, Jaeger U, Johnsen D, Korte W, Menner K, Müller G, Müller JM, Niemann-Pilatus A, Remer T, Schaefer F, Wittchen H-U, Zabransky S, Zellner K, Ziegler A, Hebebrand J: Perzentile für den Bodymass-Index für das Kindes- und Jugendalter unter Heranziehung verschiedener deutscher Stichproben. Monatsschrift Kinderheilkunde, SpringerVerlag 2001;149:807–818. Kuper H, Tzonou A, Kaklamani E, Hsieh C, Lagiou P, Adami H, Trichopoulos D, Stuver SO: Tobacco smoking, alcohol consumption and their interaction in the causation of hepatocellular carcinoma. Int J Cancer 2000;85(4):498–502. Lagström H: Nutrient intake and food choice during a child-targeted coronary heart disease prevention trial; Dissertation. University of Turku, 1999. Studies in social security and health 41. Kela. The Social Insurance Institution, Finland. Lamberg-Allardt C, Ojaniemi R, Ahola M, Räsänen L: The vitamin D intake of children and adolescents in Finland. Hum Nutr Appl Nutr 1984;38A:377–382. Leclercq C, Piccinelli R, Arcella D, le Donne C: Food consumption and nutrient intake in a sample of Italian secondary school students: Results from the INRAN-RM2001 food survey. Int J Food Sci Nutr 2004; 55(4):265–277.
References
Levnedsmiddelstyrelsen: Danskernes kostvaner 1995, hovedresultater. Publikation nr. 235. Sundhetsministeriet Søborg, Danmark, 1996. Leifman H, Österberg E, Ramstedt M: Alcohol in Postwar Europe, ECAS II: A discussion of indicators on alcohol consumption and alcohol related harm. European Comparative Alcohol Study – ECAS, Final Report, Edita Ljunglöfs, Stockholm, 2002. Lopes C: Food and Ischaemic Heart Disease, Community-based case-control study. PhD dissertation. Faculty of Medicine, University of Porto, 2000. Madlmayr I: Nährstoffaufnahme von 60–90Jährigen in Wien; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Maes L, et al.: Rapport: VEKA-project. Een buurtgericht voedingsvoorlichtingsproject met focus op het bereiken van kansarmen. Brussel/Gent, Voeding en Gezondheid vzw (VOEG), en Vakgroep Maatschappelijke gezondheidkunde van de Universiteit Gent (RUG), 1998. Maes L, Vereecken C: Gegevens uit de studie Jongeren en Gezondheid. RUG, vakgroep maatschappelijke gezondheidkunde, 1998. Website: http://allserv.rug.ac.be/ ⬃cvereeck/hbsc Mamalakis G, Kafatos A: Prevelance of Obesity in Greece. Int J Obes 1996;20: 488–649. Mamalakis G, Kafatos A, Manios Y, Anagnostopoulou T, Apostolaki I: Obesity indices in a cohort of primary school children in Crete: A six year prospective study. Int J Obes Relat Metab Disord 2000;24(6): 765–771. Mammas I, Bertsias G, Linardakis M, Tzanakis N, Labadarios D, Kafatos A: Cigarette smoking, alcohol consumption, and serum lipid profile among medical students in Greece. Eur J Public Health 2003;13(3):278–282. Mammas I, Bertsias G, Linardakis M, Moschandreas J, Kafatos A: Nutrient intake and food consumption among medical students in Greece assessed during a Clinical Nutrition course. Int J Food Sci Nutr 2004;55(1):17–26. Männistö S, Ovaskainen ML, Valsta L: FINRAVINTO 2002-tutkimus. The National FINDIET 2002 Study. Helsinki, Kansanterveyslaitoksen julkaisuja B3/ 2003. Manz F, Anke M, Bohnet HG, et al.: JodMonitoring 1996. Nomos, Baden-Baden, 1998, pp 1–264. Margetts BM, Nelson M: Design Concepts in Nutritional Epidemiology. New York, Oxford University Press, 1997.
Mataix VJ, Llopis GJ, Martínez de Victoria E, Montellano DMA, López FM, Aranda RP: Valoración del estado nutricional de la Comunidad Autónoma de Andalucía. Granada, Dirección General de Salud Pública y Participación de la Junta de Andalucía, Instituto de Nutrición y Tecnología de Alimentos de la Universidad de Granada, Escuela Andaluza de Salud Pública. Matsaniotis N, Kattamis X, Kostantsas N, Haidas S, Papathanasiou D, Metaxotou A, Lagos P: Iron deficiency in Greece. Annales Clinicae Paediatricae Universitatis Atheniensis 1969;16(6): 461–467. Matsianiotis N, Lagos P, Nikolaidou P, Roma E, Papagrigoriou M, Karpathios Th: Breastfeeding 1980. Annales Clinicae Paeditricae Universitis Atheniensis 1981; 28:39–48. Matsaniotis N, Karpathos T, Nikolaidou P, Alexaki G: Breastfeeding in Greece. Annales Clinicae Paediatricae Universitatis Atheniensis 1987;34(3):155–159. Matsaniotis N, Karpathos T, Nikolaidou P, Tzoumaka-Bakoula C, Alexaki G: Breastfeeding in Greece: Evaluation of the 10 year effort of our hospital. 28th Panhellenic Pediatric Congress, 1990. Matthys C, et al.: Voedingsprofiel van de Vlaamse kleuter. Nutrinews 2003;4:3–8. Mensink GBM: Körperliche Aktivität. Gesundheitswesen 1999;61:126–131. Metaxotou-Mavrommati A: Epidemiologic study of iron deficiency and iron deficiency anemia during neonatal and early childhood. Doctoral Dissertation. Athens University, Department of Pediatrics, 1971. Ministerio Sanidad y Consumo. Encuesta Nacional de Salud de España 2001. Madrid, Ministerio de Sanidad y Consumo (in press). Ministerio de Sanidad y Consumo. Encuesta Nacional de Salud. www.msc.es. Moreira P, Daniel S, de Almeida MDV: Validity assessment of a Food Frequency Questionnaire by comparison with a 4-day diet record. Acta Méd Port 2003;16:412– 420. Moreira P, Fernandes T, Mourão I, Padez C, Rosado V: Dietary calcium and body mass in Portuguese school children. Clin Nutr 2004;23:901–920. Moreiras O, Staveren WA, Amorim Cruz JA, Nes M, Lund-Larsen K: Intake of energy and nutrients. Eur J Clin Nutr 1991;45: 105–119. Moschandreas, Kafatos A: Food and nutrient intakes of Greek (Cretan) adults. Recent data for food-based dietary guidelines in Greece. Br J Nutr 1999;81(suppl 2):71–76. National Council for Nutrition: Country paper for Belgium. International Conference on nutrition, June 1992, p 43.
217
National Public Health Institute: The 1997 dietary survey of Finnish adults. Helsinki, Finland, 1998. National recommendations: Valtion ravitsemusneuvottelukunta. Suomalaiset ravitsemussuositukset. Komiteanmietintö 1998:7. Helsinki, 1998. National Research Council of the USA: Diet and Health. Implications for Reducing Chronic Disease Risk. Washington DC, National Academy Press, 1989. Navarro RMC, Laínez SP, Ribas BL, Serra ML: Valores antropométricos y factores de riesgo cardiovascular en las Islas Canarias (1997–98). Arch Latinoam Nutr 2000; 50(suppl 1):34–42. Népegészségügy (Public Health) 2000;81:19. Nordic Nutrition Recommendation (NNR): Standing Nordic Committee on Food. Copenhagen, Nordic Council of Ministers, DK-1255. Report 1989:2. Nordic Nutrition Recommendation (NNR): Nordic Working Group on Diet and Nutrition. Scand J Nutr 1996;40:161–165. Norfoods 2000: Intake calculations of food consumption data in the Nordic countries. A comparison of food composition data, calculation factors and calculation methods In Swedish with English summary. TemaNord 2002:522, Nordic Council of Ministers, Copenhagen. Norwegian National Council on Nutrition and Physical Activity: Norkost 1997: National dietary survey among men and women 16–79 years of age [in Norw]. Oslo; Report no. 2, 1999. NSW Centre for Public Health Nutrition: Recommendations for monitoring overweight and obesity in NSW. NSW Department of Health, State Publication No (HP) 000028, Sydney, 2000a. NSW Food and Nutrition Monitoring Project: Recommendations for Food and Nutrition Monitoring in NSW. NSW Department of Health, State Publication No (HP) 000028, Sydney, 2000b. Nutrition in Finland. KTL. National Public Health Institute. Internet: http:// ktlwww.ktl.f i/nutrition/nutrition_and _health.htm (accessed: June 2004). Oikonomopoulou K, Athanasiou M, Tsantali C, Papadopoulou E, Manos T, Mavromatis G, Teflioudis P: Frequency of minor beta-thalassemia, iron deficiency and iron deficiency anemia among children in the Kilkis region. Pediatric Chronicles 1992;19: 35–40. Oitzl U: Ernährungsverhalten und Nährstoffzufuhr ostösterreichischer Volksschulkinder unter besonderer Berücksichtigung des Burgenlandes; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002.
218
References
Ortega RM, Aranceta J, Serra ML, Entrala A, Gil A, Mena MC: Nutritional risks in the Spanish population: Results of the eVe study. Eur J Clin Nutr 2003;57(suppl 1): S73–S75. Ortega RM, Mena MC, Faci M, Santana JF, Serra-Majem L: Vitamin status in different groups of the Spanish population: A metaanalysis of national studies performed between 1990 and 1999. Public Health Nutr 2001;4(6A):1325–1329. Overby NC, Lillegaard IT, Johansson L, Andersen LF: High intake of added sugar among Norwegian children and adolescents. Public Health Nutr 2004;7(2):285– 293. Overby NC, Andersen LF: Ungkost 2000: National dietary survey among children in 4th and 8th grade [in Norw]. Oslo, The Norwegian Directorate for Health and Social affairs; Report 2002. Padez C, Fernandes T, Mourão I, Moreira P, Rosado V: Prevalence of overweight and obesity in 7–9 years Portuguese children – Trends in BMI from 1970 to 2002. Am J Hum Biol (in press). Peridou E, Zavras A, Lefatzis D, Dessypris N, Laskaris G, Dokinankis G, Segas J, Douglas C, Diehl SR, Trichopoulos D: The role of diet and specific micronutrients in the etiology of oral carcinoma. Cancer 2002;94(11):2981–2988. Petersen TA-G, et al.: Danske skolebørns BMI målt i perioden 1986/1987–1996/ 1997 sammenlignet med danske målinger fra 1971–1972. Ugeskr Læger 2002;164: 5006–5010. Pirko C: Das Ernährungswissen und Ernährungsverhalten von österreichischen Männern und Methoden zur Verbesserung der Ernährungsinformation; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2000. Pollestad ML, Overby NC, Andersen LF: The diet among 4 year olds. National dietary survey. Ungkost 2000 [in Norw]. Oslo, The Norwegian Directorate for Health and Social affairs; Report 2002. Public Health Information Development Unit: Measuring Physical Activity. Discussion Paper. Working Papers Series No. 6, University of Adelaide, 2000. Reibnagl P: Ernährungsverhalten und Nährstoffaufnahme westösterreichischer Hauptschüler; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2003. Rodler I, Zajkás G: Hungarian Cancer Mortality and Food Availability Data in the Last Four Decades of the 20th Century. Ann Nutr Metab 2002;46:49–56. Rodler I, Zajkás G: Az egészséges táplálko ´´zás, és a daganatos betegségek
megelozése [Healthy nutrition and the prevention of cancer diseases]. Orv Hetil (Medical Weekly) 2003;144:413–418. Rodler I, Zajkás G: A túlsúly és elhízás, valamint a daganatos kockázat [Overweight and obesity, and the cancer risk]. Budapesti Népegészségügy (Public Health of Budapest) 2002;33:351–355. Rodler I, Zajkás G: Elso´´ élelmezés- és táplálkozásegészségügyi cselekvési terv Europa számára, 2000–2005 [The First Action Plan for Food and Nutrition Policy in Europe, 2000–2005]. Tisztiorvos (Medical Officer) 2001;4:15–19. Roma-Giannikou E, Adamidis D, Giannou M, Nikolara R, Matsaniotis N: Nutritional survey in Greek children: Nutrient intake. Eur J Clin Nutr 1997;51:273–285. Roma-Giannikou E, Adamidis D, Matsaniotis N: Dietary habits of Greek children. Peaditriki 1994;54:496–534. Roman VB, Serra ML, Ribas BL, Pérez RC, Aranceta BJ: Crecimiento y desarrollo: Actividad física. Estimación del nivel de Actividad física mediante el Test Corto Krece Plus. Resultados en la población española; in Serra Majem L, Aranceta J, Rodríguez-Santos F (eds): Crecimiento y desarrollo. Estudio enKid. Krece plus, vol 4. Barcelona, Masson, 2003, pp 57–98. RUG: Conut-project: Naar een voedingsbeleid in Vlaanderen. Verslag van de workshop van 15 maart 1994. Universiteit Gent, Fac. Geneeskunde. Vakgroep Maatschappelijke Gezondheidskunde, 1994. Sandström B, Lyhne N, Pedersen JI, Aro A, Thorsdóttir I, Becker W: Nordic Nutrition Recommendations. Scand J Nutr/Näringsforskning 1996;40:161–165. Saíz M-AI, Rubio CJ, Espiga LI, Alonso de la IB, Blanco AJ, Cortés MM, et al.: Plan Nacional de Prevención y control del tabaquismo. Rev Esp Salud Pública 2003; 77:441–473. Scafato E, Ghirini S, Russo R: I consumi alcolici in Italia. Report 2004 sui consumi e le tendenze (1998–2001). Osservatorio OSSFAD fumo, alcol e droga. Istituto superiore di Sanità, Roma, 2004. Scaglioni S, Agostoni C, et al. Int J Obesity 2004;24:777–781. Schmid IT: Der Anteil nährstoffangereicherter Lebensmittel an der Bedarfsdeckung österreichischer Erwachsener; Doctoral thesis. Institute of Nutritional Sciences, University of Vienna. Schneider R: Vom Umgang mit Zahlen und Daten. Frankfurt am Main, Umschau Zeitschriftenverlag, 1997. Schuh W: Lipidprofil und Status an fettlöslichen Vitaminen, Carotinoiden und Vitamin C älterer Menschen; Doctoral thesis.
Institute of Nutritional Sciences, University of Vienna, 2003. Schulte H, Cullen P, Assmann G: Obesity, mortality and cardiovascular disease in the Munster Heart Study (PROCAM). Atherosclerosis 1999;144:199–209. Schulze MB, Manson JAE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, Hu FB: Sugar-Sweetened beverages, weight gain, and incidence of Type 2 diabetes in young and middle-aged women. JAMA 2004;292:927–934. Scientific Committee for Food (SCF): Report of the Scientific Committee for Food. Nutrition and energy intakes for the European Community. Commission of the European Communities, Directorate General, 1993. Serra ML, Ribas L, Ramon J: Compliance with dietary guidelines in the Spanish population. Results from the Catalan Nutrition Survey. Br J Nutr 1999;81(suppl 2): S105–S112. [1992, 18–60 jaar]. Serra ML (ed): Evaluación del estado nutricional de la población canaria (1997–98). Arch Latinoamer Nutr 2000;50(suppl 1): 1–70. Serra ML, Aranceta BJ (eds): Nutrición infantil y juvenil. Estudio enKid, vol 5. Barcelona, Masson, 2004. Serra ML, Aranceta BJ (eds): Obesidad infantil y juvenil. Estudio enKid, vol 2. Barcelona, Masson, 2001, pp 1–200. Serra ML, Henríquez SP, López BF, Alvarez LEE, Díaz RC, Rodríguez RE, Pastor FMC, Díaz CJ, Soria LA, Hernández BMJ: Encuesta Nutricional de Canarias 1997–98. Evaluación bioquímica del estado nutricional, vol 4. Santa Cruz de Tenerife, Servicio Canario de Salud 2000, pp 1–130. Serra ML, Navarro MC, Ribas L, Lainez P on behalf of the ENCA Research Group: Epidemiology of cardiovascular risk factors in the Canary Islands (1997–98). A crossroads between the Mediterranean and Latin American models. CVD Prevention 2000b;3(1):64–70. Serra ML, Ribas L, García CR, Ramon JM, Salvador G, Farran A, et al.: Llibre Blanc: Avaluació de l’estat nutricional de la població catalana (1992–93). Barcelona, Departament de Sanitat i Seguretat Social, Generalitat de Catalunya, 1996, pp 1–252. Serra ML, Ribas BL, Aranceta BJ, Pérez RC, Saavedra SP, Peña QL: Obesidad infantil y juvenil en España. Resultados del estudio enKid (1998–2000). Med Clin (Barc) 2003;121(19):725–732. Serra ML, García CR, Ribas L, Pérez RC, Aranceta J: Food patterns of Spanish schoolchildren and adolescents: The enKid Study. Public Health Nutr 2001;4(6A): 1433–1438.
References
Serra ML, Ribas L, Ngo J, Aranceta J, Garaulet M, Carazo E, et al.: Risk of inadequate intakes of vitamins A, B1, B6, C, E, folate, iron and calcium in the Spanish population aged 4 to 18. Int J Vitam Nutr Res 2001;71(6):325–331. Serra ML, Ribas L, Pérez R, García CR, Peña QL, Aranceta J: Factors associated to nutrient intake among children and adolescents: Results from the enKid study. Ann Nutr Metab 2002;46(suppl 1): 31–38. Slimani N, Valsta L: Perspectives of using the EPIC-SOFT programme in the context of pan-European nutritional monitoring surveys: Methodological and practical implications. Eur J Clin Nutr 2002;56 (suppl 2):S63–S74. Slimani N, et al.: Overweight, obesity and fat distribution in 50- to 64-year-old participants in the European Prospective Investigation into Cancer and Nutrition (EPIC) Public Health Nutr 2002;5:1125– 1145. Staessen L, et al.: Fatty acid composition of the Belgian Diet: Estimates derived from the Belgian Interuniversity Research on Nutrition and Health. Ann Nutr Metab 1998;42:151–159. Statistik Austria: Lebenssituation älterer Menschen. Ergebnisse des Mikrozensus Juni 1998. Wien, Verlag Österreich, 2000. Statistik Austria. Statistisches Jahrbuch Österreichs 2003. Wien, Verlag Österreich GmbH, 2003, p 102. Steingrímsdóttir L, Ovesen L, Moreiras O, Jacob S: Selection of relevant dietary indicators for health. Eur J Clin Nutr 2002; 56(suppl 2):S8–S11. Steingrímsdóttir L, þorgeirsdóttir H, Ægisdóttir S: Könnun á mataræði Íslendinga 1990. I. Helstu niðurstöður. (Undersökning av islänningarnas kostvanor 1990. 1. Huvudresultat.) Islands Ernæringsråd, Reykjavik, 1991. Svenska Näringsrekommendationer. Vår Föda 1997;49(2):7–14. Szallai M: Der Ernährungsstand von Schwangeren, Stillenden und Säuglingen in Wien. Ergebnisse der Verzehrserhebungen und anthropometrischen Untersuchungen im Rahmen der MILUPA-Multizenterstudie; Doctoral thesis. Institute of Nutritional Sciences, University of Vienna, 1997. Thefeld W: Prävalend des Diabetes mellitus in der erwachsenen Bevölkerung Deutschlands. Gesundheitswesen 1999;61(2): S85–S89. Tojo Sierra R, Leis Trabazo R: Estudio Galinut. Santiago de Compostela: Conselleria de Sanidad-Departamento de Pediatría, 1999. Trichopoulou A, Toupadaki N, Tzonou A, Katsouyanni K, Manousos O, Kada E,
Trichopoulos D: The macronutrient composition of the Greek diet: Estimates derived from six case-control studies. Eur J Clin Nutr 1993;47(8):549–558. Trichopoulou A, Kouris-Blazos A, Wahlquvist ML, Gnardellis C, Lagiou P, Polychronopoulos E, Vassilakou T, Lipworth L, Trichopoulos D: Diet and survival in elderly persons. BMJ 1995a;511: 1457–1460. Trichopoulou A, Kouris-Blazos A, Vassilakou T, Gnardellis C, Polychronopoulos E, Venizelos M, Lagiou P, Wahlqvist ML, Trichopoulos D: Diet and survival of elderly Greeks: A link to the past. Am J Clin Nutr 1995b;61(6):S1346–S1350. Tur MJA, Obrador AA: Libro Blanco de la Alimentación y la Nutrición en las Islas Balerares. Estudio de nutrición de las Islas Baleares ENIB (1999–2000). Revista de Ciencia, num 27, 2002. Turrini A, Leclercq C, D’Amicis A: Patterns of food and nutrient intakes in Italy and their application to the development of food-based dietary guidelines. Br J Nutr 1999;81(suppl 2):S83–S89. [N ⫽ 1844, 18–60 jaar]. Tzonou A, Lagiou P, Trichopoulou A, Tsoutsos V, Trichopoulos D: Dietary Iron and Coronary Heart Disease Risk: A study from Greece. Am J Epidemiol 1998; 147(2): 161–167. Universiteit Gent: Voedingsgewoonten bij jongeren van 14–18 jaar. [eindrapport], 1998, p 62. Universiteit Gent & NICE: Onderzoek naar het voedingspatroon van kleuters. Onderzoek bij 1819 Vlaamse kleuters via 50 scholen, 2003. Resultaten raadpleegbaar op de website http://www.123aantafel.be. Universiteit Gent: Onderzoek naar voedingspatroon bij Vlaamse kleuters, 2003. Resultaten te raadplegen op www.123aantafel.be & www.nice-info.be (Nutrinews, 4, 2003). Unterdorfer S: COPD: Schleichende Lungenerkrankung durch Rauchen. Science.Orf.at 2002, Sylvia Unterdorfer, Modern Times. Internet: http://science. orf.at/science/news/62026 (accessed: 4 July 2003). Uusitalo U, Pietinen P, Leino U: Food and nutrient intake among adults in east and southwest Finland – A dietary survey of the Finmonica project in 1982. Helsinki, Kansanterveyslaitoksen julkaisuja B1/ 1987, 1987. Valsta and the National FINDIET 2002 Study Group: Summary; in Männistö S, Ovaskainen ML, Valsta L (eds). FINRAVINTO 2002-tutkimus. The National FINDIET 2002 Study. Helsinki, Kansanterveyslaitoksen julkaisuja B3/2003, 2003.
219
Valsta L: Food-based dietary guidelines for Finland – A staged approach. Br J Nutr 1999;81(suppl 2):S49–S55. [N ⫽ 1861, 25–64 jaar]. Varela G: Tablas de ingestas recomendadas en energía y nutrientes para la población española. Departamento Bromatología. Universidad Complutense de Madrid, 1994. Verger P, Ireland J, Møller A, Abravicius JA, De Henauw S, Nasaka A: Improvement of comparability of dietary intake assessment using currently available individual food consumption surveys. Eur J Clin Nutr 2002;56(suppl 2):S18–S24. Viana V: Food Behavior, Nutritional Status and some Psychological and Social Factors related, in an adolescent group; PhD dissertation. Faculty of Nutrition and Food Sciences, University of Porto, 2000. Virtanen SM, Ylönen K, Kupiainen E, Räsänen L, Mäenpää J, Åkerblom HK: A two-year prospective follow-up of the diet of newly diagnosed diabetic children aged ⬍6 years at diagnosis (abstract). Diabetes in the Young 1992;28:18. Volatier JL, Turrini A, Welten D: Some statistical aspects of food intake assessment. Eur J Clin Nutr 2002;56(suppl 2):S46– S52. Volatier JL, Verger P: Recent national French food and nutrient intake data. British Journal of Nutrition 1999;81 (suppl 2): S57–S59. [resultaten van de 1ste nationale voedselconsumptiepeiling ASPCC 1993–1994, leeftijdsgroep 19–64 jaar]. Weichselbaum E: Stellung der Ernährung und Ernährungsberatung im Breitensport;
220
References
Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. Woess E: Gesundheitszustand und Verzehrsgewohnheiten von Wiener SeniorInnen im Pensionistenwohnheim und Privathaushalt; Diploma thesis. Institute of Nutritional Sciences, University of Vienna, 2002. World Health Organization (WHO): International guide for monitoring alcohol consumption and related harm. Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health Cluster, World Health Organization, 2002. World Health Organization (WHO): Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO Expert Consultation. Geneva, World Health Organization, 2003. World Health Organization (WHO): The World Health Report 2003 – Shaping the Future. Geneva, World Health Organization, 2003a. World Health Organization (WHO): WHO Mortality Database 2003b. Internet: http://www3.who.int/whosis/menu.cfm? path⫽whosis,inds,mort&language⫽english (accessed July 7, 2004). World Health Organization (WHO): Global Strategy for Infant and Young Child Feeding. Geneva, World Health Organization, 2003c. World Health Organization (WHO): Cancer, 2004. Internet: http://www.who.int/ health_topics/cancer/en (accessed July 8, 2004). World Health Organization Europe: Atlas of Health in Europe. Copenhagen, 2002a.
World Health Organization Europe: The European Health Report 2002. Copenhagen, 2002b. Xatzigeorgiou D, Aivazis B, Augoustidou SP, Tsantaki X, Ntantamis X, Bekioti KE, Athanasiou MM: Anthropometric variables, blood pressure, blood lipids, and serum ferritin in 1030 children aged 14–16 years in the Karditsa region. 34th Panhellenic Pediatric Conference, 1996, p 209. Xatzis X, Kafatos A, Kiriakou D, Repaninou Z, Xilouri E, Castenmiller J, West C: Iron deficiency anemia among adolescent girls in Crete. Paediatriki 1998;61:573–584. Yannakoulia M, Karayiannis D, Terzidou M, Kokkevi A, Sidossis LS: Nutrition-related habits of Greek adolescents. Eur J Clin Nutr 2004;58(4):580–586. Ylönen K, Virtanen SM, Ala-Venna E, Räsänen L: Composition of diet in relation to fat intake of children aged 1–7 years. J Hum Nutr Diet 1996;9:207–218. Zajkás G: Iskolás gyermekek táplálkozása Magyarországon [Nutrition of school children in Hungary]; in Aszmann A (ed): Iskola-Egészségügy (School Health). Budapest, Anonymous, 1998, pp 373–381. Zajkás G, Greiner E, Balázs A, Vántsa J, Sági K, Bíró L, Domokos A, Mozsáry E: Budapesti VIII. osztályos általános iskolai tanulók táplálkozása [Nutrition of pupils of 8th form in primary schools of Budapest]; not published. Zarfl B, Elmadfa I: Body Mass Index (BMI) als Indikator für das Übergewicht bei Kindern und Jugendlichen – Ergebnisse der ASNS. Akt Ernähr Med 1995;20: 201–206.
Subject Index
Adolescents Austria nutrient intake data 82–84 Belgium nutrient intake data 97, 98 Denmark nutrient intake data 102–104, 110 energy and macronutrient intake 25, 28, 29 Germany nutrient intake data 126, 127 Greece nutrient intake data 134–137 Italy nutrient intake data 163, 164 mineral intake 30–32 Norway nutrient intake data 171 Portugal nutrient intake data 173 Spain nutrient intake data 181–185, 189 vitamin intake 28, 30–32 Adults Austria nutrient intake data 85, 86 Belgium nutrient intake data 98, 99 Denmark nutrient intake data 104–107 energy and macronutrient intake 32–36 Finland nutrient intake data 112, 114–118 France health status 121–124 nutrient intake 119–121 vitamin and mineral status 121 Germany nutrient intake data 127–129 Greece nutrient intake data 137–140 Hungary nutrient intake data 154–157 Italy nutrient intake data 164 mineral intake 36, 39–41 Norway nutrient intake data 171, 172 obesity prevalence 47–50 Portugal nutrient intake data 173, 174, 176 Spain nutrient intake data 185, 186, 189 United Kingdom nutrient intake data 204–207 vitamin intake 36–38
Alcohol Health Survey for England trends 211, 212 household availability 18 supply beer 9, 75 calculated total 10 wine 9, 10, 75 Swedish trends in use and abuse 201, 203 Allergy, Swedish trends 202 Animal fat household availability 18 supply 6, 70 Austria nutrient intake data adolescents 82–84 adults 85, 86 children 80–82, 84 data sources 80 elderly 87–89 fruits and vegetables 96 lactation 91, 92 physical activity effects 92, 94–96 pregnancy 89–91 vitamins 84, 88, 89, 91, 93 Beer, see Alcohol Belgium nutrient intake data adolescents 97, 98 adults 98, 99 children 96, 97 data sources 96 elderly 99 Beverages alcoholic, see Alcohol non-alcoholic beverage household availability 18 Blood lipids Greece 145–147 Spain 191 status by country 49–51
Body mass index, see Obesity Breastfeeding, see Infants; Lactation Cancer incidence by country 54–56 mortality rates 53 Swedish trends 201 Cardiovascular disease (CVD) mortality rates 52 Swedish trends 201 Cereals household availability 13 supply 3, 4, 68 Cerebrovascular disease, mortality rates 53 Children Austria nutrient intake data 80–82, 84 Belgium nutrient intake data 96, 97 Denmark nutrient intake data 100–102 Finland nutrient intake data 112 Germany nutrient intake data 124–126 Greece nutrient intake data 134–136 Hungary nutrient intake data 150–154 Italy nutrient intake data 163 Norway nutrient intake data 168–171 obesity prevalence 47 Portugal nutrient intake data 173 Spain nutrient intake data 176–181, 189 Cholesterol, see Blood lipids Cirrhosis, mortality rates 53 Caronary heart disease (CHD), mortality rates 52, 53 Data Food Networking (DAFNE) initiative average daily food availability calculation 78 DafneSoft application tool 78 data bank 79 data collection 77 harmonization of data 78 participants by country 76, 77 socioeconomic indicators 78, 79
221
Denmark nutrient intake data adolescents 102–104, 110 adults 104–107 children 100–102 data sources 99, 100 elderly 107–109 obesity prevalence 110 Diabetes mellitus Greece 148 mortality rates 53 prevalence 56 Swedish trends 202 Dyslipidemia, see Blood lipids Education level, effects on household food availability 78, 79 Eggs, supply 9, 74 Elderly Austria nutrient intake data 87–89 Belgium nutrient intake data 99 Denmark nutrient intake data 107–109 energy and macronutrient intake 41–43 Germany nutrient intake data 129–131 Greece nutrient intake data 137–140 Hungary nutrient intake data 157, 158 Italy nutrient intake data 164 mineral intake 43, 45, 46 Norway nutrient intake data 172, 173 Portugal nutrient intake data 176 Spain nutrient intake data 186, 187, 189 vitamin intake 43, 44 Energy adolescent intake 25, 28, 29 adult intake 32–36 elderly intake 41–43 intake by country 19–22 macronutrient proportions in total energy supply 10, 11 Exercise, see Physical activity Finland nutrient intake data adults 112, 114–118 children 112 diseases of overnutrition 111 infants 111, 112 vitamin D supplementation 118, 119 Fish, see Meat Food balance sheets (FBS) comparative data 62, 63 data sources 1 France nutrient intake data adults health status 121–124 nutrient intake 119–121 vitamin and mineral status 121 data sources 119
222
Subject Index
Fruits Austria nutrient intake data 96 Health Survey for England trends in consumption 212 household availability 16, 17, 63 supply 1, 63, 66 Germany nutrient intake data adolescents 126, 127 adults 127–129 children 124–126 data sources 124 elderly 129–131 recommendations 132, 133 Greece nutrient intake data adolescents 134–137 adults 137–140 athletes 140 case-control studies 141, 142 children 134–136 elderly 137–140 health status adults and elderly 143–149 blood lipids 145, 147 children 142, 143 obesity 142–145 physical activity 149 smoking 149 infants, breastfed 133, 134 recommendations 149, 150 Health Survey for England aims 209 archived dataset 210 body fluid analysis 209 population coverage 209, 210 published reports 210 queries 210 question bank 210 subject content 209 trends 210, 211 Household budget surveys (HBS) comparative data 62, 63 data sources 12, 77 harmonization of data 78 Hungary nutrient intake data adults 154–157 children 150–154 elderly 157, 158 health status nutritional status assessment 158–160 obesity 160 smoking 160, 161 Hypertension Greece 148 Health Survey for England trends 210–212
Infants Finland nutrient intake data 111, 112 Greece nutrient intake data 133, 134 Italy nutrient intake data 162, 163 Italy nutrient intake data adolescents 163, 164 adults 164 children 163 elderly 164 infants 162, 163 lactation 164 nutritional status assessment 165, 166 recommendations 166, 167 Juices, household availability 17 Lactation Austria nutrient intake data 91, 92 Italy nutrient intake data 164 Legumes, see Pulses Life expectancy, Swedish trends 200, 201 Macronutrients adolescent intake 25, 28, 29 adult intake 32–26 elderly intake 41–43 intake by country 19–22 proportions in total energy supply 10, 11 Meat household availability fish and seafood 15 red meat 14, 15 supply beef 6, 7, 69, 71 fish and seafood 8, 73 mutton and goat meat 7, 8, 72 pork 7, 72 poultry 8, 73 Milk household availability 13, 14 supply 9, 74 Minerals adolescent intake 30–32 adult intake 36, 39–41 elderly intake 43, 45, 46 intake by country 25–27 Spain nutrient intake data 187–189 United Kingdom nutrient intake data 206–208 Mortality rates, diseases by country 51–53 Norway nutrient intake data adolescents 171 adults 171, 172 children 168–171 data sources 167, 168 elderly 172, 173
Obesity comparative data 64 Health Survey for England trends 211, 212 prevalence adults 47–50 children 47 Denmark 110 Greece 142–145 Hungary 160 Portugal 176 Spain 189–191 Spain 189–191 Swedish trends 203 Oilcrops, supply 4, 5, 69 Olive oil, supply 5 Physical activity Austria nutrient intake data of effects 92, 94–96 comparative data 64 definition 56, 57 exercise definition 57 habits by country 58–60 Greece 149 Spain 196, 197 Swedish trends 203 Portugal nutrient intake data adolescents 173 adults 173, 174, 176 children 173 data sources 173 elderly 176 Potatoes household availability 13 supply 3, 67 Pregnancy Austria nutrient intake data 89–91 Spain nutrient intake data 187–189
Subject Index
Pulses household availability 13 supply 4, 69 Smoking comparative data 64, 65 Greece 149 Health Survey for England trends 211 Hungary 160 incidence by country 60, 61 Spain 191–195 Sweden 203 Spain nutrient intake data adolescents 181–185, 189 adults 185, 186, 189 children 176–181, 189 elderly 186, 187, 189 health status blood lipids 191 obesity 189–191 physical activity 196, 197 smoking 191–195 pregnancy 187–189 recommendations 197 vitamins and minerals 187–189 Sugar and sweeteners household availability 18 supply 4, 68 Suicide, Swedish trends 201 Sweden nutrient intake data data sources 197–199 health status alcohol-related mortality 201, 203 allergy 202 burden of disease 204 cancer 201 cardiovascular disease 201 diabetes 202 infectious disease 202 life expectancy 200, 201
locomotive pain 202 obesity 203 physical activity 203 smoking 203 stress 202, 203 suicide 201 Nordic country comparisons 200 sociodemographic differences 200 Total energy supply, macronutrient proportions 10, 11 United Kingdom nutrient intake data, see also Health Survey for England adults 204–207 data sources 208 vitamin and mineral status 206–208 Vegetable oils household availability 18 supply 5, 70 Vegetables Austria nutrient intake data 96 Health Survey for England trends in consumption 212 household availability 15, 16, 63 supply 1–3, 63, 67 Vitamins adolescent intake 28, 30–32 adult intake 36–38 Austria nutrient intake data 84, 88, 89, 91, 93 elderly intake 43, 44 intake by country 22–25 Spain nutrient intake data 187–189 United Kingdom nutrient intake data 206–208 vitamin D supplementation in Finland 118, 119 Wine, see Alcohol
223
