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

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

A national FFQ for the Netherlands (the FFQ-NL 1.0): validation of a comprehensive FFQ for adults.

A standardised, national, 160-item FFQ, the FFQ-NL 1.0, was recently developed for Dutch epidemiological studies. The objective was to validate the FFQ-NL 1.0 against multiple 24-h recalls (24hR) and recovery and concentration biomarkers. The FFQ-NL 1.0 was filled out by 383 participants (25-69 years) from the Nutrition Questionnaires plus study. For each participant, one to two urinary and blood samples and one to five (mean 2·7) telephone-based 24hR were available. Group-level bias, correlation coefficients, attenuation factors, de-attenuated correlation coefficients and ranking agreement were assessed. Compared with the 24hR, the FFQ-NL 1.0 estimated the intake of energy and macronutrients well. However, it underestimated intakes of SFA and trans-fatty acids and alcohol and overestimated intakes of most vitamins by >5 %. The median correlation coefficient was 0·39 for energy and macronutrients, 0·30 for micronutrients and 0·30 for food groups. The FFQ underestimated protein intake by an average of 16 % and K by 5 %, relative to their urinary recovery biomarkers. Attenuation factors were 0·44 and 0·46 for protein and K, respectively. Correlation coefficients were 0·43-0·47 between (fatty) fish intake and plasma EPA and DHA and 0·24-0·43 between fruit and vegetable intakes and plasma carotenoids. In conclusion, the overall validity of the newly developed FFQ-NL 1.0 was acceptable to good. The FFQ-NL 1.0 is well suited for future use within Dutch cohort studies among adults.

Socio-economic status and ethnicity are independently associated with dietary patterns: the HELIUS-Dietary Patterns study.

BACKGROUND: Differences in dietary patterns between ethnic groups have often been observed. These differences may partially be a reflection of differences in socio-economic status (SES) or may be the result of differences in the direction and strength of the association between SES and diet. OBJECTIVE: We aimed to examine ethnic differences in dietary patterns and the role of socio-economic indicators on dietary patterns within a multi-ethnic population. DESIGN: Cross-sectional multi-ethnic population-based study. SETTING: Amsterdam, the Netherlands. SUBJECTS: Principal component analysis was used to identify dietary patterns among Dutch (n=1,254), South Asian Surinamese (n=425), and African Surinamese (n=784) participants. Levels of education and occupation were used to indicate SES. Linear regression analysis was used to examine the association between ethnicity and dietary pattern scores first and then between socio-economic indicators and dietary patterns within and between ethnic groups. RESULTS: 'Noodle/rice dishes and white meat', 'red meat, snacks, and sweets' and 'vegetables, fruit and nuts' patterns were identified. Compared to the Dutch origin participants, Surinamese more closely adhered to the 'noodle/rice dishes and white meat' pattern which was characterized by foods consumed in a 'traditional Surinamese diet'. Closer adherence to the other two patterns was observed among Dutch compared to Surinamese origin participants. Ethnic differences in dietary patterns persisted within strata of education and occupation. Surinamese showed greater adherence to a 'traditional' pattern independent of SES. Among Dutch participants, a clear socio-economic gradient in all dietary patterns was observed. Such a gradient was only present among Surinamese dietary oatterns to the 'vegetables, fruit and nuts' pattern. CONCLUSIONS: We found a selective change in the adherence to dietary patterns among Surinamese origin participants, presumably a move towards more vegetables and fruits with higher SES but continued fidelity to the traditional diet.

A prospective cohort study of dietary patterns of non-western migrants in the Netherlands in relation to risk factors for cardiovascular diseases: HELIUS-Dietary Patterns.

BACKGROUND: In Western countries the prevalence of cardiovascular disease (CVD) is often higher in non-Western migrants as compared to the host population. Diet is an important modifiable determinant of CVD. Increasingly, dietary patterns rather than single nutrients are the focus of research in an attempt to account for the complexity of nutrient interactions in foods. Research on dietary patterns in non-Western migrants is limited and may be hampered by a lack of validated instruments that can be used to assess the habitual diet of non-western migrants in large scale epidemiological studies. The ultimate aims of this study are to (1) understand whether differences in dietary patterns explain differences in CVD risk between ethnic groups, by developing and validating ethnic-specific Food Frequency Questionnaires (FFQs), and (2) to investigate the determinants of these dietary patterns. This paper outlines the design and methods used in the HELIUS-Dietary Patterns study and describes a systematic approach to overcome difficulties in the assessment and analysis of dietary intake data in ethnically diverse populations. METHODS/DESIGN: The HELIUS-Dietary Patterns study is embedded in the HELIUS study, a Dutch multi-ethnic cohort study. After developing ethnic-specific FFQs, we will gather data on the habitual intake of 5000 participants (18-70 years old) of ethnic Dutch, Surinamese of African and of South Asian origin, Turkish or Moroccan origin. Dietary patterns will be derived using factor analysis, but we will also evaluate diet quality using hypothesis-driven approaches. The relation between dietary patterns and CVD risk factors will be analysed using multiple linear regression analysis. Potential underlying determinants of dietary patterns like migration history, acculturation, socio-economic factors and lifestyle, will be considered. DISCUSSION: This study will allow us to investigate the contribution of the dietary patterns on CVD risk factors in a multi-ethnic population. Inclusion of five ethnic groups residing in one setting makes this study highly innovative as confounding by local environment characteristics is limited. Heterogeneity in the study population will provide variance in dietary patterns which is a great advantage when studying the link between diet and disease.

Validation of an FFQ and options for data processing using the doubly labelled water method in children.

OBJECTIVE: To validate an FFQ designed to estimate energy intake in children against doubly labelled water (DLW). To investigate how quality control and standard beverage portion sizes affect the validity of the FFQ. DESIGN: Thirty healthy children, aged 4-6 years, participated. Total energy expenditure (EE) was measured by the DLW method during an observation period of 15 d. At the end of this period parents filled out an FFQ designed to assess the child's habitual energy intake (EI) of the preceding four weeks. SETTING: Validation study in The Netherlands. SUBJECTS: Thirty healthy children (fifteen boys and fifteen girls), aged 4-6 years. RESULTS: Mean EI (6117 (sd 1025) kJ/d) did not differ significantly from mean EE (6286 (sd 971) kJ/d; P = 0·15); the mean EI:EE ratio was 0·98. The Pearson correlation coefficient between EI and EE was 0·62. The Bland-Altman plot showed no systematic bias and a constant bias close to zero. Less intensive quality control of the FFQ maintained the mean EI:EE ratio and decreased the correlation slightly. Using standard instead of individually measured beverage portion sizes decreased the mean EI:EE ratio, but maintained the correlation. CONCLUSIONS: It can be concluded that the developed FFQ is a valid instrument to estimate mean energy intake in a group of 4- to 6-year-old children and performs reasonably well to rank the subjects with respect to energy intake. It is therefore a useful instrument to estimate energy intake in children in surveys and epidemiological studies in The Netherlands.

Higher dietary flavone, flavonol, and catechin intakes are associated with less of an increase in BMI over time in women: a longitudinal analysis from the Netherlands Cohort Study.

BACKGROUND: Dietary flavonoids are suggested to have antiobesity effects. Prospective evidence of an association between flavonoids and body mass index (BMI) is lacking in general populations. OBJECTIVE: We assessed this association between 3 flavonoid subgroups and BMI over a 14-y period in 4280 men and women aged 55-69 y at baseline from the Netherlands Cohort Study. DESIGN: Dietary intake was estimated at baseline (1986) by a validated food-frequency questionnaire. BMI was ascertained through self-reported height (in 1986) and weight (in 1986, 1992, and 2000). Analyses were based on sex-specific quintiles for the total intake of 6 catechins and of 3 flavonols/flavones. Linear mixed effect modeling was used to assess longitudinal associations in 3 adjusted models: age only, lifestyle (age, energy intake, physical activity, smoking status, alcohol intake, type 2 diabetes, and coffee consumption), and lifestyle and diet (vegetables, fruit, fiber, grains, sugar, dessert, and dieting habits). RESULTS: After adjustment for age and confounders, the BMI (kg/m(2)) of women with the lowest intake of total flavonols/flavones and total catechins increased by 0.95 and 0.77, respectively, after 14 y. Women with the highest intake of total flavonols/flavones and total catechins experienced a significantly lower increase in BMI of 0.40 and 0.31, respectively (between group difference: P < 0.05). This difference remained after additional adjustment for dietary determinants and after stratification of median baseline BMI. In men, no significant differences in BMI change were observed over the quintiles of flavonoid intake after 14 y. CONCLUSION: Our results suggest that flavonoid intake may contribute to maintaining body weight in the general female population.

Dietary glycemic load, glycemic index and colorectal cancer risk: results from the Netherlands Cohort Study.

Since hyperinsulinemia is implicated in the development of colorectal cancer, determinants of serum insulin levels, like the glycemic load and the glycemic index of the diet, could influence cancer risk. Our objective was to evaluate whether a diet with a high glycemic load or glycemic index is associated with increased colorectal cancer risk. In the Netherlands Cohort Study, 120,852 subjects completed a food frequency questionnaire in 1986. After 11.3 years of follow-up, 1,225 colon and 418 rectal cancer cases were available for analysis. A case-cohort approach was used to estimate multivariate adjusted rate ratios and 95% confidence intervals for quintiles of energy-adjusted glycemic load and glycemic index. The RR for colorectal cancer comparing the highest versus the lowest quintile levels of glycemic load and glycemic index were 0.83 (95% CI: 0.64-1.08) and 0.81 (95% CI: 0.61-1.08) for men and 1.00 (95% CI: 0.73-1.36) and 1.20 (95% CI: 0.85-1.67) for women. In general, no clear associations with cancer subsites were observed. Glycemic load and glycemic index were borderline significantly associated with an increased risk of proximal colon cancer in women (p-trend = 0.06 and 0.08, respectively), however, these associations were attenuated after exclusion of the first 2 years of follow-up (p-trend = 0.165 and 0.254, respectively). In men, glycemic index was associated with a reduced risk of distal colon cancer (p-trend = 0.03). Overall, our findings do not support the hypothesis that a diet with a high glycemic load or index is associated with a higher risk of colorectal cancer.

Validation of a food frequency questionnaire to assess folate intake of Dutch elderly people.

Folate is required for 1-carbon metabolism and deficiency in folate leads to megaloblastic anemia. Low levels of folate have been associated with increased risk of vascular disease. To investigate whether RDA of folate are met, habitual folate intake needs to be assessed reliably. We developed a FFQ to specifically measure folate intake over the previous 3 months in elderly people in the Netherlands. Major sources of folate intake, i.e. foods contributing to at least 80% of the average folate intake, were identified through an analysis of the second Dutch Food Consumption Survey for the sub-population of men and women aged 50-70. In 2000 and 2001, folate intake was estimated with this questionnaire in 1286 individuals aged 50-75 years. Concentrations of serum and erythrocyte folate served as biomarkers with which relative validity of the questionnaire was assessed. The same FFQ was repeated after 3 years in 803 subjects in order to assess long-term reproducibility. Mean folate intake was estimated to be 196 (SD 69) microg/d. Spearman correlation coefficients between folate intake and serum and erythrocyte concentrations were 0.14 (P < 0.01) and 0.05 (P = 0.06) respectively. Spearman correlations between folate intakes measured at baseline and after 3 years were 0.58 (P < 0.01). 47% of the participants were classified in the same quartiles on the two occasions. Our FFQ showed a weak correlation between folate intake and blood folate concentrations and reproducibility was acceptable. This FFQ is able to rank subjects according to their folate intake.

Common and country-specific dietary patterns in four European cohort studies.

The association between diet and cancer, predominantly investigated univariately, has often been inconsistent, possibly because of the large number of candidate risk factors and their high intercorrelations. Analysis of dietary patterns is expected to give more insight than analysis of single nutrients or foods. This study aimed to develop and apply a common methodological approach to determine dietary patterns in four cohort studies originating in Finland, the Netherlands, Sweden and Italy. Food items on each of the food frequency questionnaires were aggregated into 51 food groups, defined on the basis of their position in the diet pattern and possible relevance to cancer etiology. Exploratory factor analysis was used to analyze dietary patterns. Using a standardized approach, 3-5 stable dietary patterns were identified, explaining 20-29% of total variance in consumption of the food groups. Two dietary patterns, which explained most of the variance, were consistent across the studies. The first pattern was characterized by high consumption of (salad) vegetables, the second by high consumption of pork, processed meat and potatoes. In addition, a few specifically national food patterns were identified. Sensitivity analyses showed that the identified patterns were robust for number of factors extracted, distribution of input variables and energy adjustment. Our findings suggest that some important eating patterns are shared by the four populations under study, whereas other eating patterns are population specific.

Isoflavone intake in four different European countries: the VENUS approach.

The aim of this study was to identify the level of isoflavone intake (total isoflavones, daidzein and genistein) in four European countries: Ireland, Italy, The Netherlands and the UK. For this purpose national food composition databases of isoflavone content were created in a comparable way, using the Vegetal Estrogens in Nutrition and the Skeleton (VENUS) analytical database as a common basis, and appropriate food consumption data were selected. The isoflavone intake in Ireland, Italy, The Netherlands and the UK is on average less than 1 mg/d. Small groups of consumers of soya foods could be identified in Ireland, The Netherlands and the UK. The estimated intake levels are low compared with those found in typical Asian diets (approximately 20-100 mg/d) and also low compared with levels where physiological effects are expected (60-100 mg/d). The results (including a subgroup analysis of soya product consumers) showed that such levels are difficult to achieve with the European diets studied here.

Intake of dietary folate vitamers and risk of colorectal carcinoma: results from The Netherlands Cohort Study.

BACKGROUND: Several studies have reported inverse associations between folate intake and colorectal carcinoma risk. Few were prospective studies and none evaluated the association between the intake of individual folate vitamers and colorectal carcinoma risk. METHODS: The aim of the current study was to investigate the relationship between dietary folate intake and the risk of colorectal carcinoma in a large prospective cohort study in The Netherlands comprising 120,852 men and women aged 55-69 years. After 7.3 years of follow-up, 760 colon and 411 rectal carcinoma cases were available for analysis. Data processing and analysis used the case-cohort approach. A new Dutch database was used to estimate intakes of total and individual folate vitamers. RESULTS: Analyses adjusted for age, energy intake, family history of colorectal carcinoma, alcohol, vitamin C, iron, and dietary fiber intake yielded an inverse association between colon carcinoma risk and total dietary folate intake (rate ratio [RR]highest vs. lowest quintile, men: 0.73; 95% confidence interval [CI], 0.46-1.17, P trend = 0.03; women: 0.68; 95% CI, 0.39-1.20, P trend = 0.18). An inverse association between rectal carcinoma and total dietary folate intake was found only among men (RR highest vs. lowest quintile, men: 0.66; 95% CI, 0.35-1.21, P trend = 0.03). Analyses showed no clear difference in colorectal carcinoma risk associated with intake of different folate vitamers. CONCLUSIONS: Dietary folate intake was related inversely to colon and male rectal carcinoma risk.

Intake of conjugated linoleic acid, fat, and other fatty acids in relation to postmenopausal breast cancer: the Netherlands Cohort Study on Diet and Cancer.

BACKGROUND: Conjugated linoleic acid (CLA), which is present in milk products and meat from ruminants, appears to have anticarcinogenic activity against breast cancer in animal and in vitro experiments. To date, few epidemiologic data are available in humans. OBJECTIVE: This study evaluated the relation between intakes of CLA and other fatty acids and breast cancer incidence in the Netherlands Cohort Study. DESIGN: Intake data derived from a validated 150-item food-frequency questionnaire were linked to an existing database with analytic data on specific fatty acids in European foods (the TRANSFAIR study). With 6.3 y of follow-up and 941 incident cases of breast cancer, multivariate rate ratios and 95% CIs were calculated for energy-adjusted intakes of fatty acids and CLA-containing food groups (eg, butter, cheese, milk, other milk products, and meat). RESULTS: CLA intake showed a weak, positive relation with breast cancer incidence (rate ratio for highest compared with lowest quintile: 1.24, 95% CI: 0.91, 1.69; P for trend = 0.02). Statistically significant positive associations were found with total trans fatty acids and (borderline) with saturated fatty acids. Significant inverse associations were found with monounsaturated and cis unsaturated fatty acids, whereas total fat and energy intake of CLA-containing food groups were not related to breast cancer incidence. CONCLUSION: The suggested anticarcinogenic property of CLA in animal and tissue culture models could not be confirmed in this epidemiologic study in humans.

A prospective cohort study on intake of retinol, vitamins C and E, and carotenoids and prostate cancer risk (Netherlands).

OBJECTIVES: The roles of retinol, vitamins C and E, and carotenoids as risk factors for prostate carcinoma are still questionable. We evaluated these in the Netherlands Cohort Study. METHODS: The cohort study consisted of 58,279 men ages 55-69 years at baseline in 1986. After 6.3 years of follow-up, 642 incident prostate carcinoma cases were available for analysis. Intakes of retinol, vitamins C and E, and several carotenoids were measured by means of a 150-item semi-quantitative food-frequency questionnaire. RESULTS: In multivariate analyses a positive association with prostate cancer risk was observed for intake of beta-cryptoxanthin. Rate ratios (RRs) in increasing quintiles were 1.00 (ref), 0.94, 1.01, 1.16, 1.41; p-trend < 0.01. For intake of retinol, vitamins C and E and other carotenoids (alpha-carotene, beta-carotene, lycopene, and lutein/zeaxanthin) no effect on overall prostate cancer risk was found. RRs for vitamin supplement use were decreased, but not significantly. Among nondrinkers, nonsignificant inverse associations were observed for intake of retinol, alpha-carotene, and beta-carotene (RRs, highest vs lowest quintile, were 0.23, 0.60, and 0.76, respectively). Among drinkers, beta-cryptoxanthin was positively associated (RR highest vs lowest quintile = 1.40). CONCLUSIONS: These data show a positive association between beta-cryptoxanthin and prostate cancer risk. Our study also shows inverse associations for retinol, alpha-carotene, and beta-carotene among nondrinkers; this suggests an interaction between vitamins and alcohol consumption, which needs confirmation. Lycopene was not associated with prostate cancer.