Food frequency questionnaires.

Food Frequency Questionnaires are dietary assessment tools widely used in epidemiological studies investigating the relationship between dietary intake and disease or risk factors since the early '90s. The three main components of these questionnaires are the list of foods, frequency of consumption and the portion size consumed. The food list should reflect the food habits of the study population at the time the data is collected. The frequency of consumption may be asked by open ended questions or by presenting frequency categories. Qualitative Food Frequency Questionnaires do not ask about the consumed portions; semi-quantitative include standard portions and quantitative questionnaires ask respondents to estimate the portion size consumed either in household measures or grams. The latter implies a greater participant burden. Some versions include only close-ended questions in a standardized format, while others add an open section with questions about some specific food habits and practices and admit additions to the food list for foods and beverages consumed which are not included. The method can be self-administered, on paper or web-based, or interview administered either face-to-face or by telephone. Due to the standard format, especially closed-ended versions, and method of administration, FFQs are highly cost-effective thus encouraging its widespread use in large scale epidemiological cohort studies and also in other study designs. Coding and processing data collected is also less costly and requires less nutrition expertise compared to other dietary intake assessment methods. However, the main limitations are systematic errors and biases in estimates. Important efforts are being developed to improve the quality of the information. It has been recommended the use of FFQs with other methods thus enabling the adjustments required.

Los cuestionarios de frecuencia de consumo son herramientas ampliamente utilizadas en los estudios epidemiológicos que investigan la relación entre ingesta dietética y enfermedad o factores de riesgo desde comienzos de la década de los 90. Los tres componentes principales de estos cuestionarios son la lista de alimentos, la frecuencia de consumo y el tamaño de la ración consumida. La lista de alimentos debe reflejar los hábitos de consumo de la población de estudio en el momento en que se recogen los datos. La frecuencia de consumo puede preguntarse de forma abierta u ofreciendo categorías de frecuencia de consumo. Los cuestionarios cualitativos no preguntan por la ración consumida; los semi-cuantitativos presentan raciones estándar y los cuestionarios cuantitativos solicitan al encuestado que estime el tamaño de la ración consumida en medidas caseras o en gramos. Esta última opción supone un esfuerzo importante para el participante. Existen versiones exclusivamente cerradas en un formato estandarizado y otras que incorporan preguntas abiertas sobre algunos hábitos y prácticas alimentarias específicas y permiten añadir alimentos y bebidas consumidos que no están incluidos en la lista. Pueden ser auto-administrados, en papel o en soporte web, o bien mediante entrevista personal o telefónica. Por su formato estandarizado, especialmente los cerrados, y por la forma de administración, son un método con un alto rendimiento en términos de coste-efectividad que ha favorecido su extendido uso en grandes estudios epidemiológicos de cohortes y también con otros diseños. También el coste de codificación y proceso de la información recogida resulta menos costoso y requiere menos experiencia en temas nutricionales que otros métodos de evaluación de la ingesta. Sin embargo, presenta el inconveniente de incorporar errores sistemáticos y sesgos importantes, por lo que en la actualidad se buscan procedimientos para mejorar la calidad de la información y se recomienda utilizarlos junto a otros métodos que permitan realizar los ajustes necesarios.

Dietary intake and anthropometric reference values in population studies.

In nutritional epidemiology it is essential to have reference values for nutrition and anthropometry in order to compare individual and population data. With respect to reference nutritional intake, the new concept of Dietary Reference Intakes is generated based more on the prevention of chronic diseases than on covering nutritional deficiencies, as would occur in the early Recommendations. As such, the more relevant international organizations incorporated new concepts in their tables, such as the Adequate Intake levels or the Tolerable Upper Intake levels. Currently, the EURRECA recommendations (EURopean micronutrient RECommendations Aligned) are generating reference values for Europe in a transparent, systematic and scientific manner. Using the DRI, health-care authorities formulated nutritional objectives for countries or territories and Dietary Guides to disseminate the dietary advice to the population. Anthropometric assessment continues to be one of the most-used methods for evaluating and monitoring health status, nutritional state and growth in children, not only individuals but also communities. Different organizations have established anthropometric reference patterns of body mass index (BMI) with cut-off points to define overweight and obesity. In children, growth curves have been revised and adapted to the characteristics of healthy children in order to obtain anthropometric reference standards that better reflect optimum growth in children. The Growth Standards for children below 5 years of age of the WHO are a response to these principles, and are widely accepted and used worldwide.

En epidemiologia nutricional son fundamentales las referencias nutricionales y antropométricas para comparar los datos de individuos o colectivos. En relación a las ingestas nutricionales de referencia, el nuevo concepto de Ingestas Dietéticas de Referencia se realizó basándose más en la prevención de las enfermedades crónicas actuales, que en cubrir deficiencias nutricionales, como ocurría con las primeras Recomendaciones. Así, las Organizaciones Internacionales más relevantes han incorporado nuevos conceptos en sus tablas, como el de Ingestas Adecuadas o el Límite Superior de Ingesta Tolerable. Actualmente, la (EURopean micronutrien REComendations Aligned) (EURRECA) está creando valores de referencia para Europa, de manera transparente, sistemática y científicaA partir de las IDR, las autoridades de salud formulan los objetivos nutricionales para un país o territorio y las Guías Alimentarias, que transmiten el consejo alimentario para la población La valoración antropométrica sigue siendo uno de los métodos más utilizados para evaluar y vigilar el estado de salud, el estado nutricional y el crecimiento de los niños, tanto en los individuos, como en las comunidades. Diferentes organismos establecen los patrones de referencia antropométrica del IMC y definen los puntos de corte para definir sobrepeso y obesidad. En los niños, se han revisado las curvas de crecimiento adaptándolas a las características de niños sanos desarrollados en ambientes saludables para obtener estándares antropométricos de referencia que reflejen mejor el crecimiento óptimo de los niños. A estos principios responden los Estandares de Crecimiento para niños menores de cinco años de edad de la OMS, los cuales han sido ampliamente aceptados y utilizados a nivel mundial.

Caloric beverage drinking patterns are differentially associated with diet quality and adiposity among Spanish girls and boys.

UNLABELLED: The present study assesses the impact of beverage consumption pattern on diet quality and anthropometric proxy measures for abdominal adiposity in Spanish adolescents. Data were obtained from a representative national sample of 1,149 Spanish adolescents aged 10-18 years. Height, weight, and waist circumferences were measured. Dietary assessment was performed with a 24-h recall. Beverage patterns were identified by cluster analysis. Adherence to the Mediterranean diet was measured by the KIDMED index. Three beverage clusters were identified for boys--"whole milk" (62.5 %), "low-fat milk" (17.5 %) and "soft drinks" (20.1 %)-and for girls--"whole milk" (57.8 %), "low-fat milk" (20.8 %) and juice (21.4 %), accounting for 8.3, 9.6, 13.9, 8.6, 11.5 and 12.9 % of total energy intake, respectively. Each unit of increase in the KIDMED index was associated with a 14.0 % higher (p = 0.004) and 11.0 % lower (p = 0.048) probability of membership in the "low-fat milk" and "soft drinks" cluster in girls and boys, respectively, compared with the "whole milk" cluster. Boys in the "soft drinks" cluster had a higher risk of 1-unit increase in BMI z score (29.0 %, p = 0.040), 1-cm increase in waist circumference regressed on height and age (3.0 %, p = 0.027) and 0.1-unit increase in waist/height ratio (21.4 %, p = 0.031) compared with the "whole milk" cluster. CONCLUSION: A caloric beverage pattern dominated by intake of "soft drinks" is related to general and abdominal adiposity and diet quality in Spanish male adolescents.

Energy density, diet quality, and central body fat in a nationwide survey of young Spaniards.

OBJECTIVES: To determine the impact of energy density on diet quality and anthropometric proxy measures for central body fat in young Spaniards. METHODS: Data were obtained from a representative national sample of 2513 young Spaniards aged 10 to 24 y. Dietary assessment was performed with a 24-h recall. Adherence to the Mediterranean diet was measured by the KIDMED index. Reduced rank regression analysis was used to identify energy-density dietary patterns. Waist circumferences and height were measured. RESULTS: Pastries and sausages showed the strongest loading for the dietary energy density factor score (DED-FS), with fruits and vegetables at the opposite end of the scale. Multiple linear regression analysis showed a positive association (P < 0.01) of dietary energy density (DED) and the DED-FS with waist circumferences regressed on height and age (WCheight+age) and waist-to-height ratio (WHtR). The adjusted odds ratio for elevated WCheight+age and WHtR increased across quartile distribution of DED (P < 0.001) and DED-FS (P < 0.05). Diet quality characterized by the KIDMED index was negatively associated (P < 0.001) with DED and the DED-FS. CONCLUSIONS: Higher DED is a risk for increased central fat distribution and is associated with low adherence to the Mediterranean diet.

Recommended dietary reference intakes, nutritional goals and dietary guidelines for fat and fatty acids: a systematic review.

Dietary fat and its effects on health and disease has attracted interest for research and Public Health. Since the 1980s many bodies and organizations have published recommendations regarding fat intake. In this paper different sets of recommendations are analyzed following a systematic review process to examine dietary reference intakes, nutritional goals and dietary guidelines for fat and fatty acids. A literature search was conducted in relevant literature databases along a search for suitable grey literature reports. Documents were included if they reported information on either recommended intake levels or dietary reference values or nutritional objectives or dietary guidelines regarding fat and/or fatty acids and/or cholesterol intake or if reported background information on the process followed to produce the recommendations. There is no standard approach for deriving nutrient recommendations. Recommendations vary between countries regarding the levels of intake advised, the process followed to set the recommendations. Recommendations on fat intake share similar figures regarding total fat intake, saturated fats and trans fats. Many sets do not include a recommendation about cholesterol intake. Most recent documents provide advice regarding specific n-3 fatty acids. Despite efforts to develop evidence based nutrient recommendations and dietary guidelines that may contribute to enhance health, there are still many gaps in research. It would be desirable that all bodies concerned remain transparent about the development of dietary recommendations. In order to achieve this, the type of evidence selected to base the recommendations should be specified and ranked. Regular updates of such recommendations should be planned.

Physiological and public health basis for assessing micronutrient requirements in children and adolescents. The EURRECA network.

This paper provides an overview of the current knowledge relating to the nutritional requirements and corresponding recommended nutrient intake values of children and adolescents for micronutrients and specificities related to these requirements in the course of childhood and adolescence in Europe. Aspects that can influence micronutrient requirements, such as physiological requirements and bioavailability of the nutrients in the organism, are discussed. The methodology used to obtain the data and also the main knowledge gaps regarding these concepts are emphasized. Methodological critical points in achieving the data and physiological aspects of children and adolescents are important in order to standardize the reference values for micronutrients among Europe for these stages of life.

Community nutrition in Spain: advances and drawbacks.

Scientific evidence has placed community nutrition among the front-line strategies in health promotion. Community nutrition in different regions of Spain has developed at an unequal pace. Early initiatives in the mid 1980s provided good-quality population data and established a basis for nutrition surveillance including individual body measurements, dietary intake data, information on physical activity, and biomarkers. The Nutrition and Physical Activity for Obesity Prevention Strategy (NAOS) reinforces community nutrition action in Spain. Presented here is an overview of developments in community nutrition in Spain in recent years as well as potential trends under the scope of the NAOS.

Prevention of overweight and obesity from a public health perspective.

International organizations have raised awareness of the increasing prevalence of overweight and obesity worldwide and the impact on morbidity, mortality, quality of life, and cost of healthcare. The development and implementation of obesity prevention strategies requires the identification and understanding of determinant factors that can be influenced by effective large-scale action plans over time. Strategies aimed at the primary prevention of obesity in a population should be multifaceted and designed to actively involve stakeholders and other major parties concerned; in addition, multiple settings for implementation should be considered. In this paper, an overview is presented of the strategies currently in place for obesity prevention, particularly in Spain.

Methodological limitations in measuring childhood and adolescent obesity and overweight in epidemiological studies: does overweight fare better than obesity?

OBJECTIVES: International definitions of childhood obesity based on body mass index (BMI) are intended to be used for international comparisons of obesity prevalence. In general, they are not appropriate to be used in clinical practice. The objective of this study is to compare international-ecological vs. national-clinical reference data of obesity in Spain, as well as to describe trends. DESIGN: Cross-sectional study from a representative national random sample of Spanish children and youth conducted between 1998 and 2000. Prevalence estimates of obesity in a national random sample of Spanish children and youth are presented in this paper, defined by age- and sex-specific BMI national reference standards for the 85th percentile (overweight) and 95th percentile (obesity), as well as by Cole et al. criteria. The study protocol included personal data, data on education and socio-economic status for the family and anthropometric measurements. SETTING: Population-based study set in Spain. SUBJECTS: A random sample of 3,534 individuals, aged 2-24 years. RESULTS: Prevalence of obesity using national reference data was higher (15.3%) than using international data (5.8%), but overweight rates were similar. Agreement observed for both definitions was low for obesity but higher for overweight. Obesity trends among children and adolescents in Spain show increasing patterns in boys but not in girls. CONCLUSIONS: Results indicate the need to standardise the definitions of obesity and overweight in childhood and recommend the use of overweight due to the greater degree of agreement observed among the different methods used. The IOTF reference method underestimates obesity rates in Spanish schoolchildren.

Inflammation, obesity and comorbidities: the role of diet.

The adipocyte metabolism has been shown to change during the fat enlargement process associated to obesity. Several procoagulant proteins such as plasminogen activator inhibitor type 1, tissue factor or factor VII and also inducible nitric oxide synthase show higher expression in adipose tissue of obese people in comparison to lean. This overexpression could explain at least a part of the atherogenic and cardiovascular risk associated with obesity. In addition to cytokine secretion, many other features have been observed to be common to adipocyte and monocyte/macrophage lines: for example, phagocytic and microbicidal activities, and possibly a cellular plasticity of adipose precursors. Overweight and obesity are associated with an increased risk of such metabolic abnormalities as dyslipidemia, hypertension or type 2 diabetes mellitus and cardiovascular diseases, common features of the metabolic syndrome. Initially, insulin resistance or hyperinsulinemia was suggested as the origin of these abnormalities. More recent studies indicate that adipokynes have an important role in obesity-associated metabolic complications, and suggest that chronically elevated local or systemic concentrations of adipokynes contribute to the development of complications associated with obesity and metabolic syndrome. Considering all the evidence relating to diet and inflammation, the best diet for protecting against the metabolic derangements associated with obesity and metabolic syndrome would be high in fibre-rich cereals, fruit, vegetables, fish, virgin olive oil and nuts; moderate in wine; and low in meat, processed meat foods and trans-fatty acids.

Prevention of overweight and obesity: a Spanish approach.

BACKGROUND: Obesity is considered a major public health issue in most developed countries nowadays. This paper provides an overview of current population data available in Spain and the approach to develop preventive strategies in the country. METHODS: Review of population data available is based on individually measured weight and height as well as determinants. On this basis, the approach used in the country to develop preventive strategies is discussed. RESULTS: According to the DORICA study, the prevalence of obesity (BMI >or=30 kg m-2) is 15.5% in Spanish adults aged 25-60 years (13.2% in men and 17.5% in women). Obesity rates are higher among women aged 45 years and older, low social class, living in semi-urban places. Population estimates for the prevalence of obesity in Spanish children and young people based on the enKid study are 13.9% for the whole group. In this study, overweight and obesity is related to absence of breastfeeding, low consumption of fruit and vegetables, high consumption of cakes, buns, softdrinks and butchery products, low physical activity levels and a positive association with time spent watching TV. In 2005, the Spanish Ministry of Health jointly with the Spanish Agency for Food Safety and Nutrition launched the multifaceted NAOS strategy for nutrition, physical activity and the prevention of obesity. The important role of the family and the school setting as well as the responsibility of the Health Administration and Pediatric Care in the prevention of obesity is highlighted in the document. The need for environmental actions is recognised. The PERSEO programme, a multicomponent school-based intervention project is part of the strategy currently in place. CONCLUSION: Obesity is a public health issue in Spain. A national multifaceted strategy was launched to counteract the problem. Environmental and policy actions are a priority. Young children and their families are among the main target groups.

Trends in food availability determined by the Food and Agriculture Organization's food balance sheets in Mediterranean Europe in comparison with other European areas.

OBJECTIVE: The aims of this study were to assess the changes that have occurred in food patterns in Europe over the last 40 years based on food availability data and to compare the stability of the traditional Mediterranean diet in the south of Europe in this period. DESIGN: An ecological study carried out on the basis of Food and Agriculture Organization food balance sheets for three geographical areas of Europe (Mediterranean, north and east) over two time periods: 1961-1963 and 1998-2000. The average availability of total energy, energy provided from macronutrients and food groups was calculated for each area and each period studied. RESULTS: Over the last 40 years total energy availability and energy availability from lipids have increased considerably in the three European areas, while the percentage of energy from carbohydrates has fallen. The greatest changes have occurred in Mediterranean Europe, with an increase of 20.1% in total energy availability, an increase of 48.1% in energy availability from lipids and a fall of 20.5% from carbohydrates. Moreover, Mediterranean Europe showed a significant fall in the energy supplied by cereals (29.9%) and wine (55.2%), while the contribution of milk (77.8%) and dairy products (23.6%) increased. CONCLUSIONS: The results of this study suggest that European Mediterranean countries should take nutrition policy action to maintain their traditional healthy food pattern, with a cultural added value. This implies actions at all levels, including raising awareness of consumers, collaboration with the food sector and a call to set the agenda of the concerned politicians and stakeholders.

Nut consumption in Spain and other countries.

In countries of the Mediterranean region, nuts have been consumed in moderate quantities since ancient times. Epidemiological studies show lower risk of cardiovascular diseases in populations with frequent nut consumption, independent from other dietary components. This article assesses nut consumption in Spain and other countries using different sources of data collected at the country, household or individual levels. The per capita consumption of nuts in Spain in 2001 was 7.9 g/person/d. The varieties most widely consumed are walnuts, almonds, hazelnuts and peanuts. Results of the eVe study estimate an average nut consumption in the Spanish population aged 25-60 years of 3.3 g/person/d. No significant statistical differences were observed between men and women. Consumption is higher in men aged between 35 and 44 years (4.5 g/d) and in women aged between 45 and 54 years (3.5 g/d). In the population of 2-24 years, according to the enKid study, nut consumption is estimated at 4.9 +/- 18.5 g/person per d. The age group with the highest consumption is teenagers between 14 and 17 years. The northeastern, northern and eastern regions of Spain show the highest consumption. According to FAO balance sheets, in 2001, Lebanon (16.5 kg/person per year) and Greece (11.9 kg/person per year) were the countries in the Mediterranean region with the highest consumption of nuts, followed by Spain (7.3 kg/person per year), Israel and Italy.

The contribution of ready-to-eat cereals to daily nutrient intake and breakfast quality in a Mediterranean setting.

OBJECTIVES: To examine if and how ready-to-eat cereals (RTEC) contribute to the quality of the diet of children, adolescents and young adults in a Mediterranean setting. METHODS: A random sample of 3534 subjects aged 2 to 24 years in Spain was studied. Food and nutrient intakes were determined by a 24 hour recall. RTEC consumption was assessed by a quantitative food frequency questionnaire. Additional questions on socioeconomic level and nutritional knowledge were administered. Cereal consumption was classified into non-consumers and daily intakes between 1 and 20g, 21 and 40g, and more than 40g. After excluding the underreporters the final sample consisted of 2852 individuals. RESULTS: About half of the population (49.8%) reported eating RTEC. Macronutrient profile improved with increasing cereal consumption. Intakes of thiamine, riboflavin and vitamin B6 increased significantly with increasing consumption of RTEC in all age-sex groups, whereas niacin and folate intake improved in almost all groups and calcium, iron and vitamin D in at least half of the groups. Except for magnesium, vitamin B12 and vitamin E in males, consumption of RTEC was significantly associated with increased coverage of the daily nutrient requirements for all micronutrients studied. Higher levels of RTEC consumption was associated with a greater consumption of dairy products, and related to better breakfast quality. CONCLUSIONS: Level of RTEC consumption is associated with a better nutritional profile in the diets of Spanish children, adolescents and young adults and a lower risk for inadequate micronutrient intakes. RTEC consumers have better quality breakfasts, in terms of both food choices as well as energy and nutrient content.

Obesidad y riesgo cardiovascular

Documento de consenso estructurado en los siguientes siete puntos: 1.Prevalencia de la obesidad en España, 2.Obesidad, factores de riesgo y arterioesclerosis, 3.Alteraciones metabólicas en el obeso, 4.Evaluación del paciente obeso, 5.Criterios de intervención y objetivos terapeúticos, 6.Estrategias terapeúticas en el obeso y 7. Prevención de la obesidad. Contiene además, una detallada bibliografía.

The pro children intervention: applying the intervention mapping protocol to develop a school-based fruit and vegetable promotion programme.

BACKGROUND/AIMS: The importance of careful theory-based intervention planning is recognized for fruit and vegetable promotion. This paper describes the application of the Intervention Mapping (IM) protocol to develop the Pro Children intervention to promote consumption of fruit and vegetable among 10- to 13-year-old schoolchildren. METHODS: Based on a needs assessment, promotion of intake of fruit and vegetable was split into performance objectives and related personal, social and environmental determinants. Crossing the performance objectives with related important and changeable determinants resulted in a matrix of learning and change objectives for which appropriate educational strategies were identified. Theoretically similar but culturally relevant interventions were designed, implemented and evaluated in Norway, the Netherlands and Spain during 2 school years. RESULTS: Programme activities included provision of fruits and vegetables in the schools, guided classroom activities, computer-tailored feedback and advice for children, and activities to be completed at home with the family. Additionally, optional intervention components for community reinforcement included incorporation of mass media, school health services or grocery stores. School project committees were supported. CONCLUSION: The Pro Children intervention was carefully developed based on the IM protocol that resulted in a comprehensive school-based fruit and vegetable promotion programme, but culturally sensible and locally relevant.

[Community Nutrition]. / Nutrición Comunitaria.

In the last 20 years, Public Health Nutrition focused mainly on the qualitative aspects which may influence the onset of chronic diseases, quality of life, physical and mental performance and life expectancy. This applied knowledge organised as part of preventive and health promotion programs led to the development of Community Nutrition. The aim of Community Nutrition actions is to adequate lifestyles related to food consumption patterns in order to improve the quality of life and contribute to health promotion of the population in the community where programs and services are delivered. Key functions to develop in a Community Nutrition Unit consist in the identification and assessment of nutrition problems in the community as well as the design, implementation and evaluation of intervention programs by means of appropriate strategies. These should aim at different populations groups and settings, such as work places, schools, high risk groups or the general public. Nowadays, Community Nutrition work efforts should focus on three main aspects: nutrition education in schools and in the community; food safety and food security and the development and reinforcement of food preparation skills across all age groups. Social catering services, either in schools, the work place or at the community level, need to ensure adequate nutritional supply, provide foods contributing to healthy eating practices as well as to enhance culinary traditions and social learning. Food safety and food security have become a top priority in Public Health. The concepts referes to the availability of food safe and adequate as well as in sufficient amount in order to satisfy nutrition requirements of all individuals in the community. Social changes along new scientific developments will introduce new demands in Community Nutrition work and individual dietary counselling will become a key strategy. In order to face new challenges, community nutrition pactitioners require a high quality profesional training.