Supplementation with Folic Acid or 5-Methyltetrahydrofolate and Prevention of Neural Tube Defects: An Evidence-Based Narrative Review.

Background: Folic acid (FA), which in its chemical form is pteroylglutamic acid, is the fully oxidised, water-soluble, monoglutamic form of vitamin B9. This compound is part of the folate group but with higher bioavailability, and it is found in vitamin supplements and fortified foods and drugs. Folate metabolism is complex and associated with various metabolic pathways, all of which confer protection on the cell and allow its survival. Methods: We conducted a non-systematic search of articles published in English and Spanish including controlled trials, cohort studies, systematic re-views, and meta-analyses were included, as well as key studies in animal models related to pharmacokinetic studies. Search terms encompassed: "folic acid", "folates", "5-metyltetrahydrofolate", "5-MTHF", "neural tube defects", "supplementation", "fortification", AND "homocysteine" Results: A crucial role demonstrated for FA is to help prevent neural tube defects (NTDs). However, more studies are definitely still needed to establish 5-MTHF as a safe and effective therapeutic approach comparable with FA. Moreover, there is a lack of clinical studies that evaluate the efficacy of 5-MTHF supplementation in the prevention of NTDs. The present evidence-based narrative review discusses differences between FA and 5-MTHF in terms of structure, metabolism, bioavailability, clinical efficacy, and safety. Conclusions: Despite the potential value of 5-MTHF as an alternative to FA, clinical studies would be urgently needed to support the efficacy, dosage, timing, and/or safety of its use as a supplement.

Drug Consumption and Hydration Status: Analysis of the Associations in an Elder Population.

Hydration status plays a key role in healthy ageing, and it is potentially affected by several factors, including drug consumption. However, research on this issue to date is scarce, especially in highly vulnerable groups, such as the elderly. We aimed to study the relationship linking hydration status, analysed by means of a validated questionnaire, 24 h urine analysis, body composition assessment, and drug consumption in a sample of old adults. A total of 144 elders were included in the study. Cardiovascular drug consumption was significantly associated with a lower water intake in men (ß = -0.282, p = 0.029). Moreover, urinary analysis revealed that total drug intake as well as the consumption of diuretics and cardiovascular drugs were associated with poorer hydration status, whereas genito-urinary drugs were associated with an opposite effect, and these results were confirmed in terms of body composition. Hence, total drug consumption (ß = -0.205), diuretic (ß = -0.408), cardiovascular (ß = -0.297), and genito-urinary drugs (ß = 0.298) were significantly associated (p < 0.05) with total body water. The obtained results confirmed the impact of chronic treatment with certain drugs on hydration status. Nutritional interventions may be of great interest in certain population groups in order to prevent complications due to altered hydration status.

Dietary intake, nutritional adequacy and food sources of vitamins involved in the methionine-methylation cycle from Spanish children aged one to <10 years: results from the EsNuPI study.

Background: Methionine-methylation cycle and the derived critical functions during infancy are key regulated by folates, vitamins B12, and B6. At present in Spain, there is an absence of studies that assess the intakes and dietary sources of total folates and B12 by children consuming all types of milks and those regularly consuming adapted milk formulas. Thus, our aim was to evaluate folates intakes alongside with vitamins B6 and B12 while describing their major dietary contributors in Spanish children aged one to <10 years. Methods: A total of 1,448 children aged between 1 and 10 years (49.7% girls and 50.3% boys) from the EsNuPI, a prospective cross-sectional study, were allocated into two cohorts: one Spanish Reference Cohort (SRS) of the general population (n = 707), and another including children consuming adapted milks called Adapted Milk Consumers Cohort (AMS) (n = 741) completed two 24 h dietary recalls used to estimate their nutrient intakes and to compare them to the European Food Safety Authority (EFSA) Population Reference Intakes. Results: The median intake of vitamin B6 was 1.35 (1.06-1.70) mg/day in the SRS and 1.45 (1.17-1.79) mg/day in the AMS, being significantly higher in the AMS for all age-groups. Prevalence of adequacy for vitamin B6 in the SRS and AMS was 97.7 and 98.7%, respectively. Total folates intakes in the AMS were significantly higher (p ≤ 0.001) in all age groups than in the SRS, independently of age. In addition, the prevalence of adequacy for folates intakes in all groups was more than 60%. Vitamin B12 intake increased with age independently of the type of milk consumed. The prevalence of adequacy for vitamin B12 was highly compliant by all population groups. The major contributors to vitamin B6 were milk and dairy products being significantly higher in AMS than SRS (p ≤ 0.001). The highest contributors to folates intakes were milk and dairy products, cereals, vegetables, and fruits in both groups whereas for vitamin B12 in the SRS sample were milk and dairy products followed by meat and meats products and for adapted milks, were milk and dairy products, followed by eggs, then meat and meats products. Conclusion: A satisfactory prevalence of adequacy for vitamins B6, and B12 amongst the Spanish children population was observed, which was not the case for folates, regardless of the dietary group evaluated. Nevertheless, a possible strategy to increase folate intake among the youngest children is to increase the consumption of milk and dairy products within a healthier dietary pattern, as these may contribute significantly to the vitamin needs of the infant population.

Omega-3 and Omega-6 Polyunsaturated Fatty Acid Intakes, Determinants and Dietary Sources in the Spanish Population: Findings from the ANIBES Study.

The multiple roles of polyunsaturated fatty acids (PUFA) in growth and general health are well documented. However, available intake data for the Spanish population are limited and lack gender and age considerations. Therefore, our goal was to assess dietary intake adequacy of omega-3 and omega-6 PUFA, their determinants and their major food sources among the Spanish population. Due to their influence on various beneficial functions attributed to omega-3 PUFA, combined intake adequacy with folic acid (FA), vitamin B12 and choline was also assessed. Intake data were obtained from the ANIBES cross-sectional study on a representative sample of the Spanish population (9-75 years; n = 2009), where dietary intake was analysed with a three-day dietary record. Median intake of total omega-3 PUFA stood at 0.81 g/day (0.56-1.19 g/day), with α-linolenic acid (ALA) at 0.61 g/day (0.45-0.85 g/day), eicosapentaenoic acid (EPA) at 0.03 g/day (0.01-0.12 g/day) and docosahexaenoic acid (DHA) at 0.06 g/day (0.0-0.20 g/day). Accordingly, 65% of the Spanish population showed insufficient intakes for total omega-3 PUFA; 87% for ALA, and 83% for combined EPA and DHA. Inadequate intakes were significantly higher in children, adolescents, and younger women of childbearing age (18-30 years). In contrast, inadequacy due to excessive intakes was almost negligible. Regarding omega-6 PUFA, total intake was 10.1 g/day (7.0-14.0 g/day), 10.0 g/day (6.9-13.9 g/day) for linoleic acid (LA) and 0.08 g/day (0.05-0.13 g/day) for arachidonic acid (AA). Non-compliance due to either insufficient or excessive intakes of LA stood at around 5% of the sample, with the elderly showing significantly higher degrees of inadequacy due to insufficient intakes (10%; p ≤ 0.05). Median omega-6 to omega-3 ratio was 12:1, and significantly higher in men compared to women (p ≤ 0.05); in children, adolescents and adults compared to the elderly (p ≤ 0.05); and in younger women of childbearing age compared to the older group (31-45 years) (p ≤ 0.001). Oils and fats and meat and meat products were the main dietary sources for the essential fatty acids LA and ALA, respectively. Meat and meat products were as well the main providers of AA, while fish and shellfish were almost exclusively the only sources of EPA and DHA. However, main food sources identified showed important differences across age groups. Finally, the total combined degree of inadequacy observed for omega-3 PUFA, FA, vitamin B12 and choline reached 21.3% of the ANIBES population. The observed degree of inadequacy of omega-3 PUFA intakes among the Spanish population makes it urgent to increase its consumption and to consider the need for supplementation. This should also be the main strategy for the optimization of the omega-6/omega-3 ratio, as the adequacy observed for omega-6 intakes is relatively acceptable. Additional improvement of the dietary intake of FA, vitamin B12 and choline could contribute to the beneficial effects of omega-3 PUFA.

Dietary Intake, Nutritional Adequacy, and Food Sources of Selected Antioxidant Minerals and Vitamins; and Their Relationship with Personal and Family Factors in Spanish Children Aged 1 to <10 Years: Results from the EsNuPI Study

Minerals and vitamins involved in the antioxidant defense system are essential for healthy growth and proper development during infancy. Milk and dairy products are of particular importance for improving the supply of these nutrients to children. Indeed, the present study aimed to evaluate the nutrient intake and food sources of zinc (Zn), selenium (Se), retinol and carotenoids (sources of vitamin A), and vitamins C and E, and to analyze their relationships with personal and familiar factors in Spanish children from the EsNuPI study. One subpopulation representative of the Spanish population from 1 to <10 years old (n = 707) (reference group, REF) who reported consuming all types of milk over the last year, and another subpopulation of the same age who reported consuming fortified milk formulas (FMFs) (including follow-on formula, young child formula, growing up milk, toddler's milk, and enriched and fortified milk) (n = 741) (fortified milk consumers, FMCs) completed two 24 h dietary recalls used to estimate their nutrient intakes and to compare them to the European Food Safety Authority (EFSA) Dietary Reference Values (DRVs). The REF reported higher median intakes than FMCs for Se (61 µg/kg vs. 51 µg/kg) and carotenoids (1079 µg/day vs. 998 µg/day). Oppositely, FMCs reported higher intakes than REF for Zn (7.9 mg/day vs. 6.9 mg/day), vitamin A (636 µg/day vs. 481 µg/day), vitamin E (8.9 mg/day vs. 4.5 mg/day), vitamin C (113 mg/day vs. 71 mg/day), and retinol (376 µg/day vs. 233 µg/day). In the REF group, more than 50% of the children met the EFSA recommendations for Zn (79.6%), Se (87.1%), vitamin A (71.3%), and vitamin C (96.7%), respectively. On the other hand, 92.2% were below the EFSA recommendations for vitamin E. In the FMC group, more than 50% of the children met the EFSA recommendations for Zn (55.2%), Se (90.8%), vitamin A (75.7%), vitamin E (66.7%), and vitamin C (100%). We found statistically significant differences between subpopulations for all cases except for Se. In both subpopulations, the main sources of all antioxidant nutrients were milk and dairy products. For carotenoids, the main sources were vegetables and fruits followed by milk and dairy products. A high percentage of children had vitamins A and E intakes below the recommendations, information of great importance to stakeholders. More studies using intakes and biomarkers are needed, however, to determine an association with diverse factors of oxidative damage.

Perception and knowledge of low- and no-calorie sweeteners in multidisciplinary stakeholders from Spain.

Low- and no-calorie sweeteners (LNCS) as a category are one of the most thoroughly evaluated additives, and thus their safety has been largely recognised. However, their potential risks and benefits generate great controversy and discussion within countries' food policies and public debate. The goal of this study was to evaluate the degree of knowledge and the perception of key Spanish stakeholders about the role of LNCS in diet, their safety, regulatory issues and their impact on health and wellness, as well as to complete a SWOT analysis of the Strengths, Weaknesses, Opportunities and Threats regarding this topic from their perspective. Participants (n = 45 stakeholders) completed an anonymous survey about their knowledge and perception of LNCS, their role in the diet, safety and legislation, as well as health issues and completed a SWOT analysis. Most of them agreed with aspects related to safety guarantees and authorisation procedure of LNCS; however, certain disparity in their opinion in relation to several of the topics was observed, especially regarding the possible role of LNCS in diet quality and health. Effective communication strategies to inform professionals and the general population, as well as new research that deepens our knowledge of the role of LNCS in weight management and other health outcomes seem to be urgently needed.

Characteristics of Dietary Supplements with Folic Acid Available on the Polish Market.

One way of increasing folate status, especially in a state of increased demand (e.g., women of childbearing age), is dietary supplementation with folic acid (FA). The dietary supplements market in Poland shows a controversial situation and, for many reasons (the ease of placing them on the market, the lack of control of chemical composition), the possibility of inaccurate information provided on the supplement's label arises. We questioned whether FA supplements available in Poland are indeed complying with regulations and if they could actually improve folate status amongst the target population groups consuming them. Almost 500 products containing FA were identified and available for sale in pharmacies, all of them including specific information provided by manufacturers on the packaging, such as the amount of FA, their intended use and daily dosage. HPLC analysis of FA content in 30 randomly purchased supplements exposed that in four of the tested products, FA content was less than 4% of the declared value (DV). Another 11 samples exposed that the difference with declared FA content varied from 25% up to 80% of the DV. The obtained results are in agreement with the ones from inspections previously conducted on the Polish dietary supplements market and indicate the urgent need to implement improvements in the notification system as well as the monitorization of these product's authenticity.

A Descriptive Analysis of Macronutrient, Fatty Acid Profile, and Some Immunomodulatory Nutrients in Standard and Disease-Specific Enteral Formulae in Europe.

Foods for special medical purposes (FSMPs) are commercially available formulations used as a source of nutrition when administered orally or by tube feeding. This study examines, for the first time, the nutritional composition of enteral formulae (EFs) according to European nutritional guidelines. We developed a descriptive study on 118 EFs from 2020 to 2021. Formulae were classified as standard (SFs) and disease-specific (DSF). According to the protein-energy content, SFs were classified into G1, normoprotein-normocaloric; G2, normoprotein-hypercaloric; G3, hyperproteic-normocaloric; and G4, hyperproteic-hypercaloric. Disease-related formulae for metabolic stress, renal, cancer, pulmonary, diabetes, malabsorption, and surgery were studied. Macronutrient distribution, fatty acid profile (monounsaturated [MUFA], polyunsaturated [PUFA], saturated [SFA]), derived fat quality indexes, and immuno-modulatory nutrients (omega-3, eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], arginine and nucleotides) per 1,500 kcal infused were calculated. In total, 53% were SFs, mainly normoproteic (G1, G2) with higher carbohydrate contents in normocaloric vs. hypercaloric SFs. The most balanced fatty acid profiles (MUFA: 17.7%; PUFA: 6.8%; SFA: 9.5%) belonged to G1. The PUFA/MUFA ratio: ≥0.5 was in 85.7% with a higher proportion of EPA+DHA (46%) vs. omega-3 (15.8%) in SFs. In DSFs (46.9%), higher carbohydrate content (>50%) was in malabsorption and surgery, whereas high-fat content (>50%) was in pulmonary and renal formulae. DSFs had higher SFA vs. MUFA content, except for diabetes. EPA and DHA were added in 45.5% (cancer, malabsorption, and surgery). Only 12.7% of DSFs had arginine and nucleotides. A higher proportion of SFs was found, in line with current European guidelines. Results highlighted a wide intra-group variability of nutrients among the formula selected. These findings are useful to evaluate the nutritional composition of EFs from a preventive and/or therapeutic perspective in clinical settings.

Iron Supplementation at the Crossroads of Nutrition and Gut Microbiota: The State of the Art.

Gut microbiota has received significant attention owing to its decisive role in human health and disease. Diet exerts a significant influence on the variety and number of bacteria residing in the intestinal epithelium. On the other hand, as iron is a key micronutrient for blood formation and oxygen supply, its deficiency is highly prevalent worldwide. In fact, it is the most common cause of anemia and thus, iron supplementation is widespread. However, there is concern due to some potential risks linked to iron supplementation. Therefore, we have reviewed the available evidence of the effects that iron supplementation exerts on the gut microbiota as well as its potential benefits and risks. The compiled information suggests that iron supplementation is potentially harmful for gut microbiota. Therefore, it should be performed with caution, and by principle, recommended only to individuals with proven iron deficiency or iron-deficiency anemia to avoid potential adverse effects. In any case, large and long-term population studies are urgently needed to confirm or refute these results, mainly focused on vulnerable populations.

Dietary Intake of Individual (Intrinsic and Added) Sugars and Food Sources from Spanish Children Aged One to <10 Years­Results from the EsNuPI Study

Currently, in Spain there are no studies assessing the intakes and sources of intrinsic and added sugars by both children consuming standard milks and children regularly consuming adapted milk formulas. Our goal was to evaluate current sugar intake levels (intrinsic and added) and their major dietary sources within the EsNuPI study participants by applying two 24-h dietary recalls that were completed by 1448 children (1 to <10 years) divided into two subsamples: One "Spanish Reference Sample" (SRS) of the general population (n = 707) and another sample which included children consuming adapted milks including follow-on milk, toddler's or growing up milk and fortified and enriched milks, here called "Adapted Milk Consumers Sample" (AMS) (n = 741). Estimates of intrinsic and added sugar intakes from the Spanish EsNuPI population as well as the adherence to recommendations varied notably according to age segment, but no major differences between subsamples were found. Younger children (1 to <3 years) showed the highest added sugar contribution to total energy intake (TEI) (SRS: 12.5% for boys and 11.7% for girls; AMS: 12.2% for boys and 11.3% for girls) and the lowest adherence to recommendations set at <10% TEI (SRS: 27.4% for boys and 37.2% for girls; AMS: 31.3% for boys and 34.7% for girls). Adherence increased with age but remains inadequate, with approximately one in two children from the older age segment (6 to <10 years) exceeding the recommendations. Main food sources of intrinsic sugars for both subsamples were milk and dairy products, fruits, vegetables and cereals, while for added sugars, these were milk and dairy products (mainly yogurts), sugars and sweets (mainly sugary cocoa and nougat), bakery products (mainly cookies) and cereals (mainly bread and wheat flour). However, for the AMS, the groups milk and dairy products and cereals showed a significantly lower contribution to intrinsic sugar intake but a significantly higher contribution to that of added sugars. These results demonstrate that sugar intake and the adherence to recommendations in the studied population varied notably according to age but not to the type of milk consumed. In addition, our results highlight the need to monitor the consumption of added sugars by the infant population, as well as the need to make efforts to facilitate this task, such as harmonizing the recommendations regarding free/added sugars and the inclusion of information on their content on the nutritional labeling of products in order to incorporate them into food composition databases.

Low- and No-Calorie Sweetener (LNCS) Presence and Consumption among the Portuguese Adult Population.

The use of low and no-calorie sweeteners (LNCS) in food and beverages has become increasingly common in the development and reformulation of products to reduce energy derived from added sugars. Our aim was to identify the presence and consumption of LNCS through food and beverages according to consumption patterns in a representative sample (n = 256) of the Portuguese adult population. The study had a descriptive cross-sectional observational design and was based on the application of a Food Frequency Questionnaire. Overall, it was found that 4.1% of the foods and 16.7% of the beverages consumed by the Portuguese adult population contained LNCS. Food groups mostly contributing to LNCS consumption were non-alcoholic beverages such as soft drinks and juices (34.2%); milk and dairy products (16.5%); appetizers such as chips (8.6%); sugars and sweets such as chocolates, candies, or chewing gums (6.1%); meat and derivative products (2.2%); cereals and derivatives (1.2%) and canned fruits (1.2%). Main LNCS consumed were acesulfame-K, sucralose, and aspartame, single or combined, although their prevalence of use differs greatly among foods, beverages, or tabletop sweeteners. In conclusion, LNCS were found across a wide variety of products available in the Portuguese market and their prevalence of inclusion in the diet of the population evidences the need to develop more studies on the evolution of LNCS intake and its impact on the full dietary model and health. Consequently, these food additives should be included in food composition databases and, periodically, updated to reflect the recurrent reformulation strategies adopted by the food industry in its efforts to reduce the energy contribution of added sugars.

[Quantification, dietary intake adequacy, and food sources of nutrients involved in the methionine-methylation cycle (choline, betaine, folate, vitamin B6 and vitamin B12) in pregnant women in Spain]. / Cuantificación, adecuación de la ingesta y fuentes alimentarias de nutrientes relacionados con el ciclo metionina-metilación (colina, betaína, folatos, vitamina B6 y vitamina B12) en mujeres embarazadas en España.

INTRODUCTION: Objective: a quantification of dietary intakes of the micronutrients involved in the methylation-methionine cycle (choline, betaine, folate, vitamins B6 and B12) in a representative sample of pregnant women in Spain; assessment of intake adequacy to available official recommendations; and analysis of their main food sources. Material and methods: the median intake of each micronutrient was established using food consumption data reported in the National Dietary Survey of adults, the elderly, and pregnant women (ENALIA-2) (n = 133). For folate, vitamin B6 and vitamin B12 intake, nutritional composition data from the Spanish Food Composition Tables were used, whereas for choline and betaine, which are not included in European food composition databases, the National Nutrient Database for Standard Reference of the United States Department of Agriculture (USDA) was considered. Intake adequacy was estimated in accordance with the recommendations of the main Spanish, European, and US guidelines. Results: mean daily intakes observed were 271.1 mg/day of choline; 142.5 mg/day of betaine; 182.8 µg/day of folate; 1.4 mg/day of vitamin B6; and 4.5 µg/day of vitamin B12. Intake adequacy levels were insufficient for choline (< 60.2 %) and folate (< 30.5 %); close to adequacy for vitamin B6 (> 71.6 %); and fully adequate only in the case of vitamin B12 (> 101.1 %). It is not possible to draw any conclusions regarding betaine intake in the absence of established recommendations. Main food sources included foods of animal origin for choline and vitamin B12 (71.8 % and 97.4 %, respectively); cereals and derivatives for betaine (85.3 %); vegetables (27.5 %) together with cereals and derivatives (18.6 %) for folate; and meats and derivatives (26.6 %) followed by vegetables (17.9 %) for vitamin B6. Conclusions: these findings are clearly indicative of the need to improve the intake and nutritional status of these components, which are of great nutritional interest for the health of pregnant women and, consequently, of their offspring. Consequent to the degree of adequacy observed, it seems necessary and urgent to employ not only dietary improvement strategies and the use of fortified foods, but also nutritional supplements with an individualized approach.

INTRODUCCIÓN: Objetivo: cuantificar las ingestas dietéticas de los micronutrientes implicados en el ciclo metilación-metionina (colina, betaína, folatos, vitaminas B6 y B12) en una muestra representativa de mujeres gestantes residentes en España; determinar la adecuación a las recomendaciones, y analizar sus principales fuentes alimentarias. Material y métodos: la determinación de la ingesta media se realizó a partir de los datos de consumo de los alimentos recogidos en la "Encuesta Nacional de Alimentación en población adulta, mayores y embarazadas" (ENALIA-2) (n = 133). Para el cálculo del aporte de folatos y de vitaminas B6 y B12 se emplearon los datos de composición nutricional recogidos en las "Tablas de Composición de Alimentos en España", mientras que para la colina y la betaína, nutrientes no incluidos en las bases de datos de composición de alimentos en Europa, se empleó la "Base de Datos Nacional de Nutrientes para Referencia Estándar del Departamento de Agricultura de los Estados Unidos" (USDA). La adecuación de la ingesta se estimó de acuerdo con las recomendaciones de las principales guías españolas, europeas y estadounidenses. Resultados: las ingestas medias diarias observadas fueron de 271,1 mg/día de colina; 142,5 mg/día de betaína; 182,8 µg/día de folatos; 1,4 mg/día de vitamina B6; y 4,5 µg/día de vitamina B12. Los niveles de adecuación a las recomendaciones resultaron insuficientes para la colina (< 60,2 %) y los folatos (< 30,5 %); cercanos a la adecuación para la vitamina B6 (> 71,6 %); y plenamente adecuados únicamente en el caso de la vitamina B12 (> 101,1 %). No resulta posible extraer ninguna conclusión con respecto al aporte de betaína al no existir recomendaciones establecidas. Las principales fuentes alimentarias fueron: alimentos de origen animal para la colina y la vitamina B12 (71,8 % y 97,4 %, respectivamente); cereales y derivados para la betaína (85,3 %); verduras y hortalizas (27,5 %) junto a cereales y derivados (18,6 %) para los folatos; y carnes y derivados (26,6 %), seguidos de verduras y hortalizas (17,9 %) para la vitamina B6. Conclusiones: los resultados obtenidos son indicativos de la necesidad de mejorar la ingesta y el estado nutricional de estos componentes de gran interés para la salud de la mujer embarazada. Como consecuencia del grado de adecuación observado, parece necesario y urgente el empleo no solo de estrategias para mejorar la dieta y el uso de alimentos fortificados, sino también de suplementos nutricionales de manera personalizada.

Low and no calorie sweeteners, diet and health: an updated overview.

INTRODUCTION: Introduction: currently, there is a great deal of controversy surrounding the potential health benefits and risks associated with the use of low and/or no calorie sweeteners (LNCS). Objective: in the present work, the objective was to briefly address the current role of LNCS consumption in the diet and its effects on health. Methods: a brief narrative review of the most recent tudies and policies available was carried out. Results: a limited number of representative studies on the consumption of LNCS and their effect on health are presently available. However, these mostly indicate that the consumption of LNCS can be a useful tool along with other nutritional strategies in the treatment of overweight, obesity, diabetes and the prevention of caries when used appropriately in the context of a balanced diet and physical activity. Still, it is necessary to be cautious with the consumption of certain sweeteners since the effects of LNCS on the intestinal microbiota or its effect on premature deliveries, among others, have not been fully elucidated. Conclusions: it is essential to carry out further studies in order to clarify/establish the safety and value of sweeteners as food ingredients/additives in the medium/long term, in a model of increasing consumption as a consequence of the reformulation of many foods.

INTRODUCCIÓN: Introducción: en la actualidad, existe una gran controversia en torno a los beneficios y riesgos potenciales asociados al uso de los edulcorantes bajos en/o sin calorías (LNCS) en el modelo alimentario y su repercusión en la salud. Objetivo: en el presente trabajo, el objetivo fue abordar brevemente el papel actual del consumo de LNCS y sus efectos en la dieta y salud. Métodos: se llevó a cabo una revisión narrativa de los estudios más recientes disponibles. Resultados: se observa un número limitado de estudios representativos sobre el consumo de LNCS y su efecto en la dieta y la salud. No obstante, los estudios disponibles indican que su consumo puede constituir una herramienta útil junto con otras estrategias nutricionales en el tratamiento del sobrepeso, la obesidad, la diabetes y la prevención de las caries cuando se utilizan adecuadamente en el contexto de una dieta equilibrada y ejercicio. Sin embargo, hay que aplicar el principio de precaución con el consumo de ciertos edulcorantes, ya que los efectos de los LNCS en la microbiota intestinal o su efecto en los partos prematuros, entre otros, no han sido completamente dilucidados. Conclusiones: resulta imprescindible realizar más estudios para poder aclarar/establecer la seguridad de los edulcorantes como ingredientes/aditivos alimentarios a medio/largo plazo, en un modelo de potencial consumo creciente como consecuencia de la emergente reformulación de muchos alimentos.

Carbohydrates, Starch, Total Sugar, Fiber Intakes and Food Sources in Spanish Children Aged One to <10 Years-Results from the EsNuPI Study.

Diet quality is a modifiable factor that may contribute to the onset of diet-related chronic diseases. Currently, in Spain there are no studies that examine the intakes and sources for total carbohydrates, starch, total sugar, and fiber by both children consuming all kind of milks and children regularly consuming adapted milk formulas. Our goal was to evaluate the contribution of different food groups to total carbohydrates, starch, total sugar, and fiber consumption within the EsNuPI study participants by assessing their usual intakes by applying two 24 h dietary recalls that were completed by 1448 children (1 to <10 years) divided into two cohorts: one Spanish Reference Cohort (SRS) of the general population (n = 707) and another cohort which included children consuming adapted milks including follow-on milk, toddler's or growing up milk, fortified and enriched milks, here called Adapted Milk Consumers Cohort" (AMS) (n = 741). Estimation of the usual intake showed that nutrient intake increased with age for all nutrients except for fiber. The percentage of children by age and gender who met the reference intake (RI) range for total carbohydrates, was in all groups more than 50% of individuals, except for girls aged 6 to <10 years from the reference cohort in which only 46.9% complied the RI. Median fiber intake, both in the SRS and the AMS, was well below the adequate intake (AI) for children between 3 and 10 years. Main total carbohydrates sources were cereals, followed by milk and dairy products, fruits, bakery and pastry, vegetables and sugars and sweets. The highest contributors to starch intakes were cereals, bakery and pastry, vegetables, and fruits. Major sources of total sugar intakes were milk and dairy products, fruits, bakery and pastry, sugars and sweets, vegetables, and cereals. Nonetheless, milk and dairy products, and fruits, mainly provided lactose and fructose, respectively, which are not considered free sugars. Higher contribution to fiber intakes was provided by fruits, cereals, vegetables and bakery and pastry. There were no significant differences in relation with the total sugar intake according to the body mass index (BMI) between SRS and AMS. The present study suggests a high proportion of children had total carbohydrates intakes in line with recommendations by public health authorities, but still a significant number presented insufficient total carbohydrate and fiber intakes, while total sugar consumption was high, with no major differences between SRS and AMS cohorts.

Updated Food Composition Database for Cereal-Based Gluten Free Products in Spain: Is Reformulation Moving on?

We developed a comprehensive composition database of 629 cereal-based gluten free (GF) products available in Spain. Information on ingredients and nutritional composition was retrieved from food package labels. GF products were primarily composed of rice and/or corn flour, and 90% of them included added rice starch. The most common added fat was sunflower oil (present in one third of the products), followed by palm fat, olive oil, and cocoa. Only 24.5% of the products had the nutrition claim "no added sugar". Fifty-six percent of the GF products had sucrose in their formulation. Xanthan gum was the most frequently employed fiber, appearing in 34.2% of the GF products, followed by other commonly used such as hydroxypropyl methylcellulose (23.1%), guar gum (19.7%), and vegetable gums (19.6%). Macronutrient analysis revealed that 25.4% of the products could be labeled as a source of fiber. Many of the considered GF food products showed very high contents of energy (33.5%), fats (28.5%), saturated fatty acids (30.0%), sugars (21.6%), and salt (28.3%). There is a timid reformulation in fat composition and salt reduction, but a lesser usage of alternative flours and pseudocereals.

Current Food Consumption amongst the Spanish ANIBES Study Population.

Dietary habits amongst the Spanish population are currently a relevant cause for concern, as macronutrient profiles and micronutrient intakes seem to be inadequate and globally moving away from the traditional Mediterranean dietary pattern. However, recent food consumption patterns have not been fully assessed. In the present study, our aim was therefore to describe the current food consumption from the "anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles in Spain" (ANIBES) study population by assessing data defined by age and gender. The ANIBES study is a cross-sectional study of a nationally representative sample of the Spanish population. A three-day dietary record was used to obtain information about food and beverage consumption. The sample comprised 2009 individuals aged 9-75 years, plus a boost sample for the youngest age groups (9-12, 13-17, and 18-24 years, n = 200 per age group). The most consumed food group across all age segments were non-alcoholic beverages followed by milk and dairy products and vegetables. Consumption of cereals and derivatives, milk and dairy products, sugars and sweets, and ready-to-eat meals by children was significantly higher than those by the adult and older adult populations (p ≤ 0.05). Conversely, intakes of vegetables, fruits, and fish and shellfish were significantly higher in adults and older adults (p ≤ 0.05). In order to comply with recommendations, adherence to the Mediterranean dietary patterns should be strengthened, especially amongst younger population groups. Therefore, substantial nutritional interventions may be targeted to improve the Spanish population's dietary patterns nowadays.

Presence and consumption of sugars and low and no-calorie sweeteners in the Spanish diet: an updated overview.

INTRODUCTION: Introduction: the term "sugars" describes a specific group of carbohydrates and one of the most controversial components of our diet, as public health authorities worldwide acknowledge that there is an excessive intake. Reformulation practices with low and no-calorie sweeteners (LNCS) are being carried out worldwide. However, a lack of information about the present market status and evolution is highly recognized. Materials and methods: review of the most recent studies. Results: there is a lack of comprehensive Food Composition Tables (FCT) and Databases (DB) including sugar contents and many countries have developed their own for the estimation of sugar intakes or with the aim of monitoring changes in processed food composition. Moreover, surveys assessing carbohydrate and sugar consumption and their dietary sources are scarce and sometimes not comparable due to the different methodologies, FCT and DB used, and non-harmonised use of terms and nomenclature, especially for the estimation of added sugars. Results from studies show that total and added sugar intakes around the world are quite comparable in terms of percentage of total energy from diet and major dietary sources. WHO's recommendations are being exceeded, especially amongst the younger population groups. Conclusions: future research on sweeteners, both caloric and low or non-caloric, should comprise the development of comprehensible, harmonized and updated databases of added sugar and LNCS, the evaluation of the frequent consumption of LNCS from foods and beverages and its potential association with an improved food model/pattern and lifestyles. Finally, intervention studies with LNCS are urgently needed.

INTRODUCCIÓN: de la dieta, ya que su consumo excesivo se asocia con varios aspectos de la salud, de manera específica, los azúcares añadidos. Ello ha llevado a recomendaciones que limitan su consumo y a políticas de reformulación con edulcorantes bajos o sin calorías (LNCS). Sin embargo, se constata una falta de información actualizada sobre la presencia de azúcares y LNCS en la dieta, así como su evolución en el mercado alimentario. Material y métodos: revisión de los estudios más recientes disponibles. Resultados: se observa un número limitado de estudios representativos sobre la presencia de azúcares y LNCS en la dieta. Igualmente, hay carencia de tablas de composición de alimentos (TCA) y bases de datos (BD) actualizadas y, además, en muchos casos poco comparables por la diferente metodología utilizada o la distinta nomenclatura. En los estudios disponibles ­entre los que se incluyen españoles­, hay un consumo excesivo de azúcares totales, y añadidos en particular, en relación a las recomendaciones, y fundamentalmente entre los más jóvenes. Conclusiones: resulta imprescindible disponer de TCA y BD actualizadas y homologables internacionalmente, igual que de estudios epidemiológicos que analicen la relación entre la presencia de LNCS en la dieta habitual y diferentes indicadores de calidad de la dieta y estilos de vida. Finalmente, se requieren de manera urgente estudios de intervención validados.

Validated questionnaire to assess the hydration status in a healthy adult Spanish population: a cross sectional study.

INTRODUCTION: Introduction: adequate hydration status is crucial in most physiological functions; conversely, its assessment is hindered by the limited availability of research tools. Objective: to develop and validate a novel questionnaire that evaluates the hydration status of a healthy adult Spanish population. Method: a novel questionnaire was designed and validated relying on biochemical parameters related to blood, urine, and body water content. The study involved 39 healthy subjects aged between 18 and 39 years. Food and beverage consumption were assessed by the novel questionnaire and through a three-day dietary record. Physical activity was assessed using both: accelerometers and the Short International Physical Activity Questionnaire (IPAQ). Validity was determined by correlation of the aforementioned parameters with the water balance and water intake obtained by the novel questionnaire. The questionnaire was administered twice over the course of 28 days to evaluate its reliability. Results: water balance and total water intake were correlated with specific gravity, and urine color. Water intake obtained by the novel questionnaire was correlated with water intake results from the three-day dietary record. Intraclass correlation coefficient indicated moderate concordance between both recordings, and the Cronbach's alpha revealed high consistency. Finally, the Bland and Altman method indicated that the limits of agreement were acceptable to reveal the reliability of the estimated measures. Conclusions: the questionnaire designed is a new valid and reliable screening tool to estimate hydration status of adult populations in dietary and nutritional assessment.

INTRODUCCIÓN: Introducción: un estado hídrico adecuado es crucial para la mayoría de funciones fisiológicas; sin embargo, su evaluación se encuentra obstaculizada por la escasez de herramientas de diagnóstico e investigación. Objetivos: desarrollar y validar un cuestionario que permita evaluar el estado hídrico de población española adulta sana. Métodos: un nuevo cuestionario ha sido diseñado y validado a través de parámetros bioquímicos en orina y sangre y contenido en agua corporal. El estudio incluyó finalmente a 39 sujetos sanos con edades comprendidas entre 18 y 39 años. El consumo de alimentos y bebidas se evaluó empleando el nuevo cuestionario y un diario dietéticos de tres días. La actividad física fue estimada a través de acelerometría y con el Cuestionario Internacional de Actividad Física (IPAQ). La validez se determinó analizando la correlación de los parámetros citados, con el balance y con la ingesta hídrica. El cuestionario fue administrado por duplicado, con un transcurso de 28 días entre ambas cumplimentaciones para evaluar su reproducibilidad. Resultados: el balance y la ingesta hídrica se correlacionaron con la gravedad específica y con el color de la orina. La ingesta hídrica se correlacionó con los resultados procedentes del diario dietético. Según el coeficiente de correlación intraclase, la concordancia entre ambas cumplimentaciones fue moderada y el alfa de Cronbach indicó consistencia elevada. El método Bland-Altman mostró que los límites de confianza eran aceptables para revelar la reproducibilidad de las medidas estimadas. Conclusiones: el cuestionario diseñado constituye una herramienta de cribado válida y fiable para estimar el estado hídrico de población adulta sana.

Adaptation and Validation of the Hydration Status Questionnaire in a Spanish Adolescent-Young Population: A Cross Sectional Study.

The achievement of adequate hydration status is essential for mental and physical performance and for health in general, especially in children and adolescents. Nevertheless, little is known about hydration status of this population, mainly due to the limited availability of research tools; thus, the objective of the current study was to adapt and validate our hydration status questionnaire in a Spanish adolescent-young population. The questionnaire was validated against important hydration markers: urine colour, urine specific gravity, haemoglobin, haematocrit and total body water and involved 128 subjects aged between 12⁻17 years. Water intake was also estimated through a three-day dietary record and physical activity was assessed through accelerometers. Participants completed the questionnaire twice. Water balance and water intake were correlated with urine specific gravity and with total body water content. Water intake obtained by the questionnaire was correlated with results from the three-day dietary record. The intraclass correlation coefficient indicated moderate concordance between both recordings and the Cronbach's alpha revealed high consistency. The Bland and Altman method indicated that the limits of agreement were acceptable to reveal the reliability of the estimated measures. In conclusion, this is the first time that a questionnaire is valid and reliable to estimate hydration status of adolescent-young populations.

Added Sugars and Low- and No-Calorie Sweeteners in a Representative Sample of Food Products Consumed by the Spanish ANIBES Study Population.

Low- and no-calorie sweeteners (LNCS), intensely sweet compounds that virtually contain no calories, are used to replace added sugars in food and drinks. Knowledge about different LNCS data in Spanish foods and added sugar sources in Spain is limited, therefore our aim was to identify and compare their presence across main food groups consumed. Food and beverage products (n = 434) were obtained from the ANIBES Study (anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles), a cross-sectional study of a representative sample of the Spanish population (9⁻75 years old; n = 2009) carried out in 2013. Food records were obtained from a three-day dietary record using a tablet device. Label data from 1,164 products of different brands were collected and reviewed for content of added sugars and LNCS. LNCS were present in diet soft drinks (100%), "other sweets" (89%), soya drinks (45%), and yogurt and fermented milks (18%). Added sugars were present mainly in sugar soft drinks (100%), energy drinks (96%), sports drinks (96%), bakery and pastry (100%), chocolates (100%), ice cream (100%), breakfast cereals/bars (96%) and jams (89%). Main LNCS were acesulfame K, aspartame, cyclamate and sucralose. Sucrose, dextrose, glucose-fructose syrup, caramel and honey were the main added sugars. Our results show the diversity of foods groups including these ingredients. These data are not compiled in food composition databases, which should be periodically updated to include LNCS and added sugars to facilitate their assessment and monitoring in nutritional surveys.