Transitioning towards more plant-based diets: sharing expert knowledge through a system lens.

Transitioning towards more plant-based protein diets is essential for public and planetary health. Current research about consumption practices of protein sources provides limited insight in the multidisciplinary nature and interconnectivity of the food environment. This study aimed to collect mental models of review authors by synthesizing both their implicit and explicit system views into an overarching system view. Published reviews were used to select participants and identify variables that explain the protein transition in relation to the food environment. To overcome differences in disciplines and scale levels (e.g. individual, interpersonal, environmental), variables were organized according to the Determinants of Nutrition and Eating Framework. Eight review authors shared their mental models in an interview. Participants were asked to construct a causal loop diagram (CLD), a tool proven valuable in making one's ontology explicit to others. Implicit system views in narrative were converted into CLDs using a coding framework. The overarching system view suggests that a multitude of feedback loops sustain current consumption patterns of protein sources, for example by reinforcement through habit, availability and peer support. Several aspects require further research, such as variable relationships that were subject to disagreement and the lack of reciprocity between the physical and social elements of the food environment. In addition, knowledge gaps were exposed, including long-term behaviour and interaction of multiple variables. As a boundary object, the overarching system view can facilitate the direction of future research. The findings underscore the interconnected nature of many disparate elements within the food environment, stressing the need for holistic methods like systems thinking. These are essential in developing a systemic understanding and facilitating the transition towards more plant-based diets.

A comparison of complementary measures of vitamin B6 status, function, and metabolism in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

BACKGROUND: Vitamin B6 insufficiency has been linked to increased risk of cancer and other chronic diseases. The circulating concentration of pyridoxal 5'-phosphate (PLP) is a commonly used measure of vitamin B6 status. Ratios of substrates indicating PLP coenzymatic function and metabolism may be useful complementary measures to further explore the role of vitamin B6 in health. OBJECTIVES: We explored the sensitivity of 5 outcomes, namely PLP concentration, homocysteine:cysteine (Hcy:Cys), cystathionine:cysteine (Cysta:Cys), the 3´-hydroxykynurenine ratio (HKr), and the 4-pyridoxic acid ratio (PAr) to vitamin B6 intake as well as personal and lifestyle characteristics. MEDTHODS: Dietary intake and biomarker data were collected from participants from 3 nested case-control studies within the European Prospective Investigation into Cancer and Nutrition (EPIC). Bayesian regression models assessed the associations of the 5 biomarker outcomes with vitamin B6 intake and personal and lifestyle covariates. Analogous models examined the relations of Hcy:Cys, Cysta:Cys, and HKr with PLP. RESULTS: In total, 4608 participants were included in the analyses. Vitamin B6 intake was most strongly associated with PLP, moderately associated with Hcy:Cys, Cysta:Cys, and HKr, and not associated with PAr (fold change in marker given a doubling of vitamin B6 intake: PLP 1.60 [95% credible interval (CrI): 1.50, 1.71]; Hcy:Cys 0.87 [95% CrI: 0.84, 0.90]; Cysta:Cys 0.89 [95% CrI: 0.84, 0.94]; HKr 0.88 [95% CrI: 0.85, 0.91]; PAr 1.00 [95% CrI: 0.95, 1.05]). PAr was most sensitive to age, and HKr was least sensitive to BMI and alcohol intake. Sex and menopause status were strongly associated with all 5 markers. CONCLUSIONS: We found that 5 different markers, capturing different aspects of vitamin B6-related biological processes, varied in their associations with vitamin B6 intake and personal and lifestyle predictors.

Predictors of stunting with particular focus on complementary feeding practices: A cross-sectional study in the northern province of Rwanda.

OBJECTIVES: The aim of this study was to review the factors associated with stunting in the northern province of Rwanda by assessing anthropometric status, dietary intake, and overall complementary feeding practices. METHODS: This was a cross-sectional study with 138 children 5 to 30 mo of age. A structured questionnaire was used to collect information on sociodemographic characteristics of each mother and child and breastfeeding and complementary feeding practices. Anthropometric status was assessed using height-for-age z-scores for children and body mass index for caregivers. Dietary intakes were estimated using a 24-h recall. Multiple linear and logistic regression models were performed to study the predictors of height-for-age z scores and stunting. RESULTS: There was a 42% stunting prevalence. Prevalence of continued breastfeeding and exclusive breastfeeding were 92% and 50%, respectively. Most children (62%) fell into the low dietary diversity score group. The nutrient intake from complementary foods was below recommendations. The odds of stunting were higher in children >12 mo of age (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.08-1.29). Exclusive breastfeeding (OR, 0.22; 95% CI, 0.10-0.48) and deworming tablet use in the previous 6 mo (OR, 0.25; 95% CI, 0.07-0.80) decreased significantly the odds of stunting in children. Also, the body mass index of the caretaker (ß = 0.08 kg/m2; 95% CI, 0.00-0.17) and dietary zinc intake (ß = 1.89 mg/d; 95% CI, 0.29-3.49) were positively associated with the height-for-age z scores. CONCLUSION: Interventions focusing on optimal nutrition during the complementary feeding stage, exclusive breastfeeding, and the use of deworming tablets have the potential to substantially reduce stunting in children in the northern province of Rwanda.

Data on child complementary feeding practices, nutrient intake and stunting in Musanze District, Rwanda.

Stunting prevalence in Rwanda is still a major public health issue, and data on stunting is needed to plan relevant interventions. This data, collected in 2015, presents complementary feeding practices, nutrient intake and its association with stunting in infants and young children in Musanze District in Rwanda. A household questionnaire and a 24-h recall questionnaire were used to collect the data. In total 145 children aged 5-30 months participated in the study together with their caregivers. The anthropometric status of children was calculated using WHO Anthro software [1] according to the WHO growth standards [2]. The complementary feeding practices together with households' characteristics are reported per child stunting status. The nutrient intake and food group consumption are presented per age group of children. Also, the percentage contribution of each food groups to energy and nutrient intake in children is reported. The data also shows the association between zinc intake and age groups of children. Using multiple linear regression, a sensitivity analysis was done with height-for-age z-score as the dependent variable and exclusive breastfeeding, deworming table use, BMI of caregiver, dietary zinc intake as independent variables. The original linear regression model and a detailed methodology and analyses conducted are presented in Uwiringiyimana et al. [3].

Vitamin D concentrations in fortified foods and dietary supplements intended for infants: Implications for vitamin D intake.

Due to potential overages to cover losses during shelf life, the actual vitamin D concentration of fortified foods and dietary supplements may deviate from the label. In this pilot study the vitamin D concentrations of fortified foods (n=29; follow-on formula, baby porridge, curd cheese dessert) and dietary supplements (n=15), both specifically intended for infants, were analytically determined. Compared to the declared values, the vitamin D content ranged from 50% to 153% for fortified foods and from 8% to 177% for supplements. In general, both instant follow-on formula and oil-based supplements had a measured vitamin D content similar to or higher than the labelled value. Ready-to-eat baby porridge was the only category in which all measured vitamin D concentrations were below the declared value (74-81%). The use of label information for fortified foods and dietary supplements may result in invalid estimations of vitamin D intake distributions of infants; both under- and overestimation may occur.

Vitamin D intake of Dutch infants from the combination of (fortified) foods, infant formula, and dietary supplements.

PURPOSE: Due to changes in the Dutch fortification policy for vitamin D and the vitamin D supplementation advice for infants (10-µg/d for 0-4 year olds), a partially virtual scenario study was conducted to evaluate the risk of excessive vitamin D intake assigning all infants to a 100 % adherence to the supplementation advice and considering the current fortification practice. METHODS: Food consumption data from the Nutrition Intake Study (2002; N = 941, 7-19 months) were combined with Dutch food composition data from 2011 to estimate vitamin D intake from (fortified) foods. For infants 0-6 months of age, the consumption volume infant formula was estimated from energy requirement and body weight. All subjects were assigned to take a daily 10 µg vitamin D supplement, according the Dutch supplementation advice for infants. Habitual vitamin D intake was estimated using the Statistical Program to Assess Dietary Exposure and compared with the tolerable upper intake levels (ULs) set by the European Food Safety Authority. RESULTS: The median habitual total vitamin D intake was 16-22 µg/day for infants aged 0-6 months (increasing with age) and 13-21 µg/day for infants aged 7-19 months (decreasing with age). About 4-12 % of infants aged 7-11 months exceeded the UL. At the 99th percentile, the intake was 2-4 µg above the UL, depending on age. Infants aged 0-6 and 12-19 months did not exceed the UL. CONCLUSIONS: In case of combined intake from infant formula, (fortified) foods, and supplements, vitamin D intakes above the UL are possible among some infants during a limited time period.

SPADE, a new statistical program to estimate habitual dietary intake from multiple food sources and dietary supplements.

BACKGROUND: For the evaluation of both the adequacy of intakes and the risk of excessive intakes of micronutrients, all potential sources should be included. In addition to micronutrients naturally present in foods, micronutrients can also be derived from fortified foods and dietary supplements. In the estimation of the habitual intake, this may cause specific challenges such as multimodal distributions and heterogeneous variances between the sources. OBJECTIVE: We present the Statistical Program to Assess Dietary Exposure (SPADE) that was developed to cope with these challenges in one single program. METHOD: Similar to other methods, SPADE can model habitual intake of daily and episodically consumed dietary components. In addition, SPADE has the option to model habitual intake from dietary supplements. Moreover, SPADE offers models to estimate habitual intake distributions from different sources (e.g., foods and dietary supplements) separately and adds these habitual intakes to get the overall habitual intake distribution. The habitual intake distribution is modeled as a function of age, and this distribution can directly be compared with cutoff values to estimate the proportion above or below. Uncertainty in the habitual intake distribution and in the proportion below or above a cutoff value is quantified with ready-for-use bootstrap and provides 95% CIs. RESULTS: SPADE is implemented in R and is freely available as an R package called SPADE.RIVM. The various features of SPADE are illustrated by the estimation of the habitual intake distribution of folate and folic acid for women by using data from the Dutch National Food Consumption Survey 2007-2010. The results correspond well with the results of existing programs. CONCLUSION: SPADE offers new features to existing programs to estimate the habitual intake distribution because it can handle many different types of modeling with the first-shrink-then-add approach.

Dietary acrylamide intake of adults in the European Prospective Investigation into Cancer and Nutrition differs greatly according to geographical region.

PURPOSE: Methodological differences in assessing dietary acrylamide (AA) often hamper comparisons of intake across populations. Our aim was to describe the mean dietary AA intake in 27 centers of 10 European countries according to selected lifestyle characteristics and its contributing food sources in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. METHODS: In this cross-sectional analysis, 36 994 men and women, aged 35-74 years completed a single, standardized 24-hour dietary recall using EPIC-Soft. Food consumption data were matched to a harmonized AA database. Intake was computed by gender and center, and across categories of habitual alcohol consumption, smoking status, physical activity, education, and body mass index (BMI). Adjustment was made for participants' age, height, weight, and energy intake using linear regression models. RESULTS: Adjusted mean AA intake across centers ranged from 13 to 47 µg/day in men and from 12 to 39 µg/day in women; intakes were higher in northern European centers. In most centers, intake in women was significantly higher among alcohol drinkers compared with abstainers. There were no associations between AA intake and physical activity, BMI, or education. At least 50 % of AA intake across centers came from two food groups "bread, crisp bread, rusks" and "coffee." The third main contributing food group was "potatoes". CONCLUSIONS: Dietary AA intake differs greatly among European adults residing in different geographical regions. This observed heterogeneity in AA intake deserves consideration in the design and interpretation of population-based studies of dietary AA intake and health outcomes.

Evaluation of the Dutch general exemption level for voluntary fortification with folic acid.

INTRODUCTION: Fortification with folic acid was prohibited in the Netherlands. Since 2007, a general exemption is given to fortify with folic acid up until a maximum level of 100 µg/100 kcal. This maximum level was based on a calculation model and data of adults only. The model requires parameters on intake (diet, supplements, energy) and on the proportion of energy that may be fortified. This study aimed to evaluate the model parameters considering the changing fortification market. In addition, the risk of young children exceeding the UL for folic acid was studied. METHODS: Folic acid fortified foods present on the Dutch market were identified in product databases and by a supermarket inventory. Together with data of the Dutch National Consumption Survey-Young Children (2005/2006) these inventory results were used to re-estimate the model parameters. Habitual folic acid intake of young children was estimated and compared to the UL for several realistic fortification scenarios. RESULTS: Folic acid fortified foods were identified in seven different food groups. In up to 10% of the population, the proportion of energy intake of folic acid fortified foods exceeded 10% - the original model parameter. The folic acid intake from food supplements was about 100 µg/day, which is lower than the intake assumed as the original model parameter (300 µg). In the scenarios representing the current market situation, a small proportion (<5%) of the children exceeded the UL. CONCLUSION: The maximum fortification level of 100 µg/100 kcal is sufficiently protective for children in the current market situation. In the precautionary model to estimate the maximum fortification levels, subjects with high intakes of folic acid from food and supplements, and high energy intakes are protected from too high folic acid intakes. Combinations of high intakes are low in this population. The maximum levels should be monitored and revised with increasing fortification and supplementation practices.

A three-part, mixed-effects model to estimate the habitual total vitamin D intake distribution from food and dietary supplements in Dutch young children.

Statistical modeling of habitual micronutrient intake from food and dietary supplements using short-term measurements is hampered by heterogeneous variances and multimodality. Summing short-term intakes from food and dietary supplements prior to simple correction for within-person variation (first add then shrink) may produce estimates of habitual total micronutrient intake so badly biased as to be smaller than estimates of habitual intake from food sources only. A 3-part model using a first shrink then add approach is proposed to estimate the habitual micronutrient intake from food among nonsupplement users, food among supplement users, and supplements. The population distribution of habitual total micronutrient intake is estimated by combining these 3 habitual intake distributions, accounting for possible interdependence between Eq. 2 and 3. The new model is an extension of a model developed by the USA National Cancer Institute. Habitual total vitamin D intake among young children was estimated using the proposed model and data from the Dutch food consumption survey (n = 1279). The model always produced habitual total intakes similar to or higher than habitual intakes from food sources only and also preserved the multimodal shape of the observed total vitamin D intake distribution. This proposed method incorporates several sources of covariate information that should provide more precise estimates of the habitual total intake distribution and the proportion of the population with intakes below/above cutpoint values. The proposed methodology could be useful for other complex situations, e.g. where high concentrations of micronutrients appear in episodically consumed foods.

Reduction of salt: will iodine intake remain adequate in The Netherlands?

Salt is the main vehicle for iodine fortification in The Netherlands. A reduction in salt intake may reduce the supply of iodine. Our aim was to quantify the effect of salt reduction on the habitual iodine intake of the Dutch population and the risk of inadequate iodine intake. We used data of the Dutch National Food Consumption Survey (1997-8) and an update of the food composition database to estimate habitual salt and iodine intake. To take into account uncertainty about the use of iodised salt (industrial and discretionary) and food supplements, a simulation model was used. Habitual iodine and salt intakes were simulated for scenarios of salt reduction and compared with no salt reduction. With 12, 25 and 50 % salt reduction in industrially processed foods, the iodine intake remained adequate for a large part of the Dutch population. For the extreme scenario of a 50 % reduction in both industrially and discretionary added salt, iodine intake might become inadequate for part of the Dutch population (up to 10 %). An increment of the proportion of industrially processed foods using iodised salt or a small increase in iodine salt content will solve this. Nevertheless, 8-35 % of 1- to 3-year-old children might have iodine intakes below the corresponding estimated average requirement (EAR), depending on the salt intake scenario. This points out the need to review the EAR value for this age group or to suggest the addition of iodine to industrially manufactured complementary foods.

Region-specific nutrient intake patterns exhibit a geographical gradient within and between European countries.

Until recently, the study of nutrient patterns was hampered at an international level by a lack of standardization of both dietary methods and nutrient databases. We aimed to describe the diversity of nutrient patterns in the European Prospective Investigation into Cancer and Nutrition (EPIC) study at population level as a starting point for future nutrient pattern analyses and their associations with chronic diseases in multi-center studies. In this cross-sectional study, 36,034 persons aged 35-74 y were administered a single, standardized 24-h dietary recall. Intake of 25 nutrients (excluding intake from dietary supplements) was estimated using a standardized nutrient database. We used a graphic presentation of mean nutrient intakes by region and sex relative to the overall EPIC means to contrast patterns within and between 10 European countries. In Mediterranean regions, including Greece, Italy, and the southern centers of Spain, the nutrient pattern was dominated by relatively high intakes of vitamin E and monounsaturated fatty acids (MUFA), whereas intakes of retinol and vitamin D were relatively low. In contrast, in Nordic countries, including Norway, Sweden, and Denmark, reported intake of these same nutrients resulted in almost the opposite pattern. Population groups in Germany, The Netherlands, and the UK shared a fatty acid pattern of relatively high intakes of PUFA and SFA and relatively low intakes of MUFA, in combination with a relatively high intake of sugar. We confirmed large variability in nutrient intakes across the EPIC study populations and identified 3 main region-specific patterns with a geographical gradient within and between European countries.

Intake of selected nutrients from foods, from fortification and from supplements in various European countries.

BACKGROUND: Recent European Union regulation requires setting of maximum amount of micronutrients in dietary supplements or foods taking into account the tolerable upper intake level (ULs) established by scientific risk assessment and population reference intakes. OBJECTIVE: To collect and evaluate recently available data on intakes of selected vitamins and minerals from conventional foods, food supplements and fortified foods in adults and children. Intake of calcium, copper, iodine, iron, magnesium, phosphorus, selenium, zinc, folic acid, niacin and total vitamin A/retinol, B(6), D and E was derived from nationally representative surveys in Denmark, Germany, Finland, Ireland, Italy, the Netherlands, Poland, Spain and the United Kingdom. Intake of high consumers, defined as the 95th percentile of each nutrient, was compared to the UL. RESULTS: For most nutrients, adults and children generally consume considerably less than the UL with exceptions being retinol, zinc, iodine, copper and magnesium. The major contributor to intakes for all nutrients and in all countries is from foods in the base diet. The patterns of food supplements and voluntary fortification vary widely among countries with food supplements being responsible for the largest differences in total intakes. In the present study, for those countries with data on fortified foods, fortified foods do not significantly contribute to higher intakes for any nutrient. Total nutrient intake expressed as percentage of the UL is generally higher in children than in adults. CONCLUSION: The risk of excessive intakes is relatively low for the majority of nutrients with a few exceptions. Children are the most vulnerable group as they are more likely to exhibit high intakes relative to the UL. There is a need to develop improved methods for estimating intakes of micronutrients from fortified foods and food supplements in future dietary surveys.

Plasma phospholipid fatty acid profiles and their association with food intakes: results from a cross-sectional study within the European Prospective Investigation into Cancer and Nutrition.

BACKGROUND: Plasma phospholipid fatty acids have been correlated with food intakes in populations with homogeneous dietary patterns. However, few data are available on populations with heterogeneous dietary patterns. OBJECTIVE: The objective was to investigate whether plasma phospholipid fatty acids are suitable biomarkers of dietary intakes across populations involved in a large European multicenter study. DESIGN: A cross-sectional study design nested to the European Prospective Investigation into Cancer and Nutrition (EPIC) was conducted to determine plasma fatty acid profiles in >3,000 subjects from 16 centers, who had also completed 24-h dietary recalls and dietary questionnaires. Plasma fatty acids were assessed by capillary gas chromatography. Ecological and individual correlations were calculated between fatty acids and select food groups. RESULTS: The most important determinant of plasma fatty acids was region, which suggests that the variations across regions are largely due to different food intakes. Strong ecological correlations were observed between fish intake and long-chain n-3 polyunsaturated fatty acids (r = 0.78, P < 0.01), olive oil and oleic acid (r = 0.73, P < 0.01), and margarine and elaidic acid (r = 0.76, P < 0.01). Individual correlations varied across the regions, particularly between olive oil and oleic acid and between alcohol and the saturation index, as an indicator of stearoyl CoA desaturase activity. CONCLUSIONS: These findings indicate that specific plasma phospholipid fatty acids are suitable biomarkers of some food intakes in the EPIC Study. Moreover, these findings suggest complex interactions between alcohol intake and fatty acid metabolism, which warrants further attention in epidemiologic studies relating dietary fatty acids to alcohol-related cancers and other chronic diseases.

Framework for intake simulation of functional ingredients.

OBJECTIVE: To create a general framework for the simulation of intakes from mandatory or voluntary fortification, which will make outcomes of simulation studies more comparable and give insight on uncertainties. DESIGN: A general framework was developed based on methods used in already published case studies of mandatory fortification. The framework was extended to be suitable for the simulation of voluntary fortification. Case studies of folic acid fortification were used to illustrate the general framework. RESULTS: The developed framework consists of six steps. First, the definition of the fortification strategy (step 1), followed by the identification of potential carrier products (step 2), and the definition of fortification levels or ranges (step 3). Thereafter, virtual food/supplement composition data are created (step 4) and food/supplement consumption data are required (step 5). Finally, the intake of the functional ingredient from functional foods, other foods and dietary supplements is calculated during the simulation resulting in total habitual intake distributions (step 6). CONCLUSIONS: Simulation of both mandatory and voluntary folic acid fortification in The Netherlands showed that the general framework is applicable. Also with incomplete data or data from different sources, the (habitual) intake distributions can be estimated using assumptions, statistical procedures or probabilistic modelling approaches. It is important that the simulation procedure is described well, so that an insight on uncertainties and knowledge gaps to be filled is given.

Coffee intake and incidence of hypertension.

BACKGROUND: The long-term longitudinal evidence for a relation between coffee intake and hypertension is relatively scarce. OBJECTIVE: The objective was to assess whether coffee intake is associated with the incidence of hypertension. DESIGN: This study was conducted on a cohort of 2985 men and 3383 women who had a baseline visit and follow-up visits after 6 and 11 y. Baseline coffee intake was ascertained with questionnaires and categorized into 0, >0-3, >3-6, and >6 cups/d. Hypertension was defined as a mean systolic blood pressure (SBP) >or=140 mm Hg over both follow-up measurements, a mean diastolic blood pressure (DBP) >or=90 mm Hg over both follow-up measurements, or the use of antihypertensive medication at any follow-up measurement. RESULTS: Coffee abstainers at baseline had a lower risk of hypertension than did those with a coffee intake of >0-3 cups/d [odds ratio (OR): 0.54; 95% CI: 0.31, 0.92]. Women who drank >6 cups/d had a lower risk than did women who drank >0-3 cups/d (OR: 0.67; 95% CI: 0.46, 0.98). Subjects aged >or=39 y at baseline had 0.35 mm Hg (95% CI: -0.59, -0.11 mm Hg) lower SBP per cup intake/d and 0.11 mm Hg lower DBP (95% CI: -0.26, 0.03 mm Hg) than did those aged <39 y at baseline, although the difference in DBP was not statistically significant. CONCLUSIONS: Coffee abstinence is associated with a lower hypertension risk than is low coffee consumption. An inverse U-shaped relation between coffee intake and risk of hypertension was observed in the women.

Dietary patterns and survival in older Dutch women.

BACKGROUND: The need to gain insight into prevailing eating patterns and their health effects is evident. OBJECTIVE: This study aimed to identify dietary patterns and their relation to total mortality in older Dutch women. DESIGN: A principal component analysis of 22 food groups was used to identify dietary patterns in 5427 women aged 60-69 y who were included in the Dutch European Prospective Investigation into Cancer and Nutrition-Elderly cohort (follow-up: approximately 8.2 y). Mortality ratios for 3 major principal components were assessed by using Cox proportional hazard analysis. RESULTS: The most relevant principal components were a Mediterranean-like dietary pattern (high intakes of vegetable oils, pasta and rice, sauces, fish, and wine), a Traditional Dutch dinner dietary pattern (high intakes of meat, potatoes, vegetables, and alcoholic beverages), and a Healthy Traditional Dutch dietary pattern (healthy variant of the Traditional Dutch dinner dietary pattern; high intakes of vegetables, fruit, nonalcoholic drinks, dairy products, and potatoes). Differences in mean intakes between the highest and lowest tertiles of the 3 patterns were greatest for fruit, dairy products, potatoes, and alcoholic beverages. Consumption of Mediterranean foods, such as fish and oils, was relatively low overall. Two hundred seventy-seven deaths occurred in 44,667 person-years. Independent of age, education, and other lifestyle factors, only the Healthy Traditional dietary pattern score was associated with a lower mortality rate. Women in the highest tertile of this pattern experienced a 30% reduction in mortality risk. CONCLUSION: A Healthy Traditional Dutch diet, rather than a Mediterranean diet, appears beneficial for longevity and feasible for health promotion in older Dutch women. This diet is comparable with other reported healthy or prudent diets that have been shown to be protective against morbidity or mortality.

Fish consumption and breast cancer risk. The European Prospective Investigation into Cancer and Nutrition (EPIC).

There is current interest in fish consumption and marine omega-3 (n-3) fatty acids and breast cancer risk. Some in vitro and animal studies have suggested an inhibitory effect of marine n-3 fatty acids on breast cancer growth, but the results from epidemiological studies that have examined the association between fish consumption and breast cancer risk in humans are inconsistent. We examined fish consumption and breast cancer risk in 310,671 women aged between 25 and 70 yr at recruitment into the European Prospective Investigation Into Cancer and Nutrition (EPIC). The participants completed a dietary questionnaire between 1992-98 and were followed up for incidence of breast cancer for a median of 6.4 yr. Hazard ratio for breast cancer by intake of total and lean and fatty fish were estimated, stratified by study centre and adjusted for established breast cancer risk factors. During follow-up, 4,776 invasive incident breast cancers were reported. No significant associations between intake of total fish and breast cancer risk were observed, hazard ratio (HR) 1.01 (95% confidence interval [CI] 0.99-1.02; p = 0.28 per 10 g fish/day). When examining lean and fatty fish separately, we found a positive significant association only in the highest quintile for fatty fish (HR 1.13, 95% CI 1.01-1.26), but test for trend was not significant (p = 0.10). No associations with breast cancer risk were observed when the study participants were subdivided by menopausal status. Although the period of follow-up is relatively short, the results provide no evidence for an association between fish intake and breast cancer risk.

Maternal nutritional status and the risk for orofacial cleft offspring in humans.

Periconceptional folate and folic acid intake prevents orofacial clefts (OFC) in the offspring. It has been suggested that other nutrients also play a role. We investigated the preconceptional intake of macronutrients (protein, fat, carbohydrate, fiber, and cholesterol), vitamins (vitamin A, retinol, beta-carotene, ascorbic acid, and alpha-tocopherol), minerals (calcium, phosphorus, iron, magnesium, and zinc) and food groups in mothers of OFC children and controls. At approximately 14 mo after the index pregnancy, 206 mothers of a child with a nonsyndromic OFC and 203 control mothers completed a FFQ on current food intake and a general questionnaire. After exclusion of pregnant and lactating mothers, mothers who reported a change in diet compared with the preconceptional period, and those for whom periconceptional folic acid supplement use was unclear, 182 OFC mothers and 173 control mothers were evaluated. Macronutrient, vitamin, mineral, and food group intakes were compared. After adjustment for energy, quintiles of dietary nutrient intake and odds ratios with 95% CI were calculated. The preconceptional intake of all macronutrients, vitamins, minerals, and food groups with the exception of milk (products), potatoes, pies/cookies were lower in OFC mothers than in controls. The energy-adjusted intakes of vegetable protein, fiber, beta-carotene, ascorbic acid, alpha-tocopherol, iron, and magnesium were significantly lower in cases compared with controls. Increasing intakes of vegetable protein, fiber, ascorbic acid, iron, and magnesium decreased OFC risk. In conclusion, a higher preconceptional intake of nutrients predominantly present in fruits and vegetables reduces the risk of offspring affected by OFC.

Periconceptional folate intake by supplement and food reduces the risk of nonsyndromic cleft lip with or without cleft palate.

BACKGROUND: Inadequate maternal vitamin intake during pregnancy has been suggested as a risk factor for cleft lip with or without cleft palate (CLP). The independent role of folate has not been clarified. METHODS: To investigate the association between maternal folate intake by supplement and food and the risk of CLP offspring, a case-control study was conducted in the Netherlands (1998-2000) among 174 mothers of a child with nonsyndromic CLP and 203 mothers of a child without congenital malformations. RESULTS: Daily use of a folic acid supplement by mothers starting from 4 weeks before until 8 weeks after conception gave a 47% CLP risk reduction compared to mothers who did not use these supplements [odds ratio (OR): 0.53, 95% confidence interval (CI): 0.33, 0.85]. Ninety-three percent of the users took a supplement containing folic acid only. Dietary folate intake reduced CLP risk independently in a dose-response manner. The largest risk reductions were found on those mothers who had a diet of more than 200 microg folate per day in combination with a folic acid supplement (OR: 0.26, 95% CI: 0.09, 0.72). CONCLUSIONS: We demonstrated that periconceptional maternal folic acid supplement use was beneficial to reduce the risk for CLP. An additional effect of food folate was shown.