Operationalization of food consumption surveys in Europe: recommendations from the European Food Consumption Survey Methods (EFCOSUM) Project.

BACKGROUND: The EFCOSUM (European Food Consumption Survey Methods) Project aims at harmonizing food consumption surveys in European countries within the perspective of an overall Public Health Monitoring Programme. Harmonization implies the need for a common framework of procedures and tools, that are applicable and feasible in all potentially interested countries. A major element in such a framework is the protocol for the operationalization of a food consumption survey, referring to all practical, logistical and material conditions that need to be fulfilled in order to guarantee a successful implementation of such a survey. OBJECTIVE: The objective of this paper was to review a number of aspects of operationalization of food consumption surveys in detail. On the basis of the currently available knowledge and experience in Europe, consensus recommendations have been elaborated for an operationalization protocol that would be feasible for all European countries. METHODS: The EFCOSUM recommendations with respect to operationalization of food consumption surveys in Europe are mainly based on three sources of information, which have been discussed at several ad hoc expert meetings: experience from previous collaborative epidemiological studies, literature searches and results of two questionnaires, distributed among representatives from 23 European countries-all experts affiliated with experienced organizations in the fields of nutrition research and related fields. RESULTS: Consensus recommendations have been set up for the following topics: sampling, recruitment, fieldwork, biomarkers, interviewer qualifications and training and quality control. These recommendations have to be considered the best achievable common denominator within Europe at this time. In a number of cases, recommendations are presented in a hierarchical way, with a gradation from first choice options towards acceptable alternatives. CONCLUSIONS: It can be concluded that a high degree of standardization of fieldwork can be achieved within Europe. A number of specific problems and constraints will have to be solved in connection with the conduction of a real survey. These problems include, amongst others, country-specific decisions on, for example, target population, detailed sampling and recruiting procedures, interview setting and support. However, on the whole, these problems can be overcome and the main recommendations presented in this paper are considered feasible for every country in Europe. Application of the EFCOSUM operationalization protocol in European countries will contribute significantly to the quality and comparability of food consumption data across Europe. It is anticipated that the policy supporting and orienting potential of this type of databases-both at the national and at the EU supranational level-will be increased accordingly.

Endemic goitre and plasmatic levels of vitamins A and E in the school-children on the island of Krk, Croatia.

A total of 1975 school-children on the island of Krk aged 7-19 years of life were included in this study. The purpose was to establish the goitre status and plasmatic level of vitamins A and E in the examined children with the enlarged thyroid gland. The goitre prevalence was 29.8%. The average plasmatic values of vitamins A and E in the children with enlarged thyroids were statistically significantly lower from the reference values. Mentioned goitre prevalence at the level of moderate and heavier endemic goitre speaks on behalf of alimentary iodine deficiency. But the goiter examinations suggested the idoine deficiency not to be the only etiological factor of goitre on the island of Krk. Lower average plasmatic values of vitamins A and E in the examined with the enlarged thyroids referred to this fact to a certain degree.

[Endemic goiter in Croatia]. / Endemska gusavost u Hrvatskoj.

In the early nineties, 40 years after the introduction of iodine prophylaxis in Croatia (10 mg KI/kg salt), a nationwide study was initiated with the aim to determine the real prevalence of goiter in the country. A total of 2436 schoolchildren of both sexes, aged 7-15 years, were included in the study. Investigations were designed in a way to cover most of geographical regions in Croatia and subjects were randomly selected. The prevalence of goiter in schoolchildren was assessed by palpation and in part by ultrasonography of the neck. At the same time urinary iodine excretion was measured and potassium iodide content in salt samples was determined. The results revealed the persistence of mild endemic goiter in the inland parts of Croatia with the prevalence of 6-29% in the age group 7-11 years and 10-43% among the age group 12-15 years. The overall goiter prevalence in schoolchildren in Croatia fluctuates from 8% to 35%. The urinary iodine excretion in Zagreb varied from 1.6 to 24.4 micrograms/dL with a median of 9.0, while in 14% it was below 5 micrograms/dL. The urinary iodine excretion in Samobor varied between 0.5 and 19 micrograms/dL with a median of 7.4 micrograms/dL, while in 30% it was below 5 micrograms/dL. Examination of salt from all three salt plants in Croatia showed iodine contents between 0.0 and 12.73 mg/kg with the average value of 5.39 mg/kg. Such prevalence, most probably due to less than optimum iodine intake, is unlikely to change until potassium iodide content of salt is increased from its present level of 10 mg of KI per kg of salt, with concomitant stricter observance of legal regulations.

Recommendations for a trans-European dietary assessment method in children between 4 and 14 years.

BACKGROUND/OBJECTIVES: The main objective of European Food Consumption Validation (EFCOVAL)-child Project is to define and evaluate a trans-European methodology for undertaking national representative dietary surveys among children in the age group of 4-14 years. In the process of identifying the best dietary assessment methodologies, experts were brought together at a workshop. The paper presents the discussion of the best available method and the final recommendations for a trans-European dietary assessment method among 4- to 14-year-old children. SUBJECTS/METHODS: The starting point was to investigate whether the method (two non-consecutive 24-h dietary recalls (24-HDRs)) suggested for the adults in European Food Consumption Survey Method (EFCOSUM) would be usable for children in the age group between 4 and 14 years. However, all available dietary assessment methods were included in the discussion to ensure that the final recommendation would be based on the best evidence. Six criteria were defined and used as additional guidance in the process. RESULTS: The literature does not give a clear recommendation on the dietary assessment methods that are most suitable for children in the age group of 4-14 years. Nevertheless, on the basis of the literature, the recommendations were separated for preschoolers (4-6 years) and schoolchildren (7-14 years). CONCLUSION: For preschoolers, two non-consecutive days of a structured food record are recommended, using a (for children adapted) picture booklet and household measures for portion-size estimation. For schoolchildren, repeated 24-HDRs are recommended, using a picture booklet and household measures for portion-size estimation. In addition, the child should bring a booklet to register what is eaten out of home. One parent should assist the schoolchild at the 24-HDR interview, and therefore face-to-face interviews are required.

Feasibility of 2 × 24-h dietary recalls combined with a food-recording booklet, using EPIC-Soft, among schoolchildren.

BACKGROUND/OBJECTIVES: The aim of this study was to evaluate the feasibility of the suggested trans-European methodology for undertaking representative dietary surveys among schoolchildren: 2 × 24-h dietary recalls (24-HDRs) combined with a food-recording booklet, using EPIC-Soft (the software developed to conduct 24-HDRs in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) pc-program. SUBJECTS/METHODS: A total of 75 children aged 7-8 years and 70 children aged 12-13 years old were recruited through the Civil Registration System in Denmark, and 57 children aged 7-8 years and 47 children aged 12-13 years were recruited through schools in Spain. Each child with one parent completed two face-to-face 24-HDRs, combined with optional use of a food-recording booklet (FRB) to be filled in by the child, a parent or other proxy persons for preparing the recalls. Feasibility was evaluated by questionnaires completed by parents, children and interviewers, and by selected data from the 24-HDRs. RESULTS: The face-to-face interviews with the child and a parent together are confirmed as feasible. The children participated actively in the interviews, the oldest children being most active. The children, parents and interviewers agreed that children needed help from the parents, and that parents were of help to the child. In both countries, other proxy persons, such as teachers or the school cafeteria staff, were involved before the interview, and the majority of the parents and children reported that the FRB had been a help for the child during the interview. Further results point at specific needed improvements of the tools. CONCLUSIONS: The evaluated method is shown feasible in two culturally diverse European populations. However, the feasibility study also points to specific improvements of tools and data collection protocol that are strongly recommended before implementation of the method in each country of a pan-European dietary survey.

Evaluation of 2 × 24-h dietary recalls combined with a food-recording booklet, against a 7-day food-record method among schoolchildren.

BACKGROUND/OBJECTIVES: The aim of this study was to evaluate the estimated energy, nutrient and food intake from the suggested trans-European methodology for undertaking representative dietary surveys among schoolchildren: 2 × 24-h dietary recalls (24-HDRs) combined with a food-recording booklet (FRB), using EPIC-Soft pc-program (the software developed to conduct 24-HDRs in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study), against a 7-day food-record (7-dFR) method among Danish schoolchildren. SUBJECTS/METHODS: A total of 74 children aged 7-8 years and 70 children aged 12-13 years were recruited through the Civil Registration System in Denmark. Each child and one of their parents completed two face-to-face 24-HDRs, combined with optional use of a FRB, followed by a 7-day-estimated FR. RESULTS: Energy intake was significantly higher with the 24-HDR method than with the 7-dFR method for both age groups. Mean energy intake was 6% higher for the youngest (P = 0.02) and 11% for the oldest children (P = 0.01); underreporting of energy occurs among the oldest children, being less present with the 24-HDR method. The intakes of carbohydrate and dietary fiber (absolute and related to energy) were significantly higher with the 24-HDR than with the 7-dFR for both age groups (P < 0.001). No significant differences between the two methods were observed for absolute intake of fat and added sugar between both age groups, and for intake of protein among the 7- to 8-year olds. The percentage of energy intake from fat from the 24-HDR, however, was significantly lower for both age groups and for energy intake from added sugar for the 12- to 13-year olds. CONCLUSIONS: The 2 × 24-HDR method compared with the 7-dFR yields relatively good values on the group level for many macronutrients and foods. However, some differences in estimated intakes of macronutrients suggest the need to carefully adapt the tools to be age and country specific. There is a tendency for parents and schoolchildren to report a healthier diet with the 24-HDR than with the FRs; this results in some concern about the method and has to be studied further.

Feasibility of repeated 24-h dietary recalls combined with a food-recording booklet, using EPIC-Soft, among preschoolers.

BACKGROUND/OBJECTIVES: This study evaluates the feasibility among preschoolers of the 2 × 24-h dietary recalls (24-HDRs) method combined with a food-recording booklet (FRB), using EPIC-Soft pc-program for the 24-HDR (the software developed to conduct 24-HDRs in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study). SUBJECTS/METHODS: A total of 20 and 25 (4- to 5-year-old) children were recruited, as a convenience sample, through worksites or day or healthcare in Denmark and Spain, respectively. One parent (or both parents together) completed two face-to-face 24-HDR, combined with an optional use of a FRB. Feasibility was evaluated by evaluation questionnaires completed by parents and interviewers. RESULTS: The face-to-face interviews were primarily conducted with the mothers. The FRB was used by 90% of the participants, and proxy persons, other than the parent, were also involved; involvement of proxy persons seems necessary in a majority of the recalls in both the countries. CONCLUSIONS: The results suggest that 2 × 24-HDR with one parent combined with a FRB is feasible for registering preschoolers' diet. An FRB and/or information from proxy persons, other than the parent, is needed for a majority of the parents. In future studies, it may be beneficial to develop the FRB more like a structured food record (FR), which might, in principle, change the method to a one-day FR method from more than a 24-HDR method. It is recommended then to further investigate the use of EPIC-Soft as a data-entry tool.

Rationale and methods of the European Food Consumption Validation (EFCOVAL) Project.

BACKGROUND/OBJECTIVES: The overall objective of the European Food Consumption Validation (EFCOVAL) Project was to further develop and validate a trans-European food consumption method to be used for the evaluation of the intake of foods, nutrients and potentially hazardous chemicals within the European population. SUBJECTS/METHODS: The EFCOVAL Project was carried out by 13 institutes from 11 European countries. The main activities were centered on the three main objectives of the project organized in different sub-projects. RESULTS: In EFCOVAL, EPIC-Soft (the software developed to conduct 24-h dietary recalls (24-HDRs) in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) was reprogrammed and adapted according to prioritized specifications, resulting in a software program working under the Windows operating system. In parallel of the EPIC-Soft development, the repeated 24-HDR method using EPIC-Soft and a food propensity questionnaire was evaluated against biomarkers in 24-h urine collections and in blood samples among adults from Belgium, the Czech Republic, (the South of) France, the Netherlands and Norway. As a result from an expert workshop on a proposed dietary assessment method for children (4-12 years), the suggested method was tested in a feasibility study in Denmark and Spain among children of 4-5, 7-8 and 12-13 years. To ensure that collected data had sufficient detail in food description for the assessment of additives and contaminants to foods the EPIC-Soft databases were adapted. Finally, the EFCOVAL Consortium developed a statistical tool (Multiple Source Method) for estimating the usual intake and distribution, which has been tested using real food consumption data and compared with three other statistical methods through a simulation study. In addition, a methodology was developed to quantify uncertainty due to portion-size estimation in usual intake distributions. CONCLUSION: The findings of EFCOVAL provide sufficient evidence to conclude that the repeated 24-HDR using EPIC-Soft for standardization in combination with a food propensity questionnaire and modeling of usual intake is a suitable method for pan-European surveillance of nutritional adequacy and food safety among healthy adults and maybe in children aged 7 years and older.

The European Food Consumption Validation Project: conclusions and recommendations.

BACKGROUND/OBJECTIVES: To outline and discuss the main results and conclusions of the European Food Consumption Validation (EFCOVAL) Project. SUBJECTS/METHODS: The EFCOVAL Project was carried out within the EU Sixth Framework Program by researchers in 11 EU countries. The activities focused on (1) the further development of the EPIC-Soft software (the software developed to conduct 24-h dietary recalls (24-HDRs) in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) and the validation of the 2-day non-consecutive 24-HDR method using EPIC-Soft, (2) defining and investigating the applicability of the most appropriate dietary assessment method to younger age groups and expanding the applicability of the software for use in exposure assessment of some potentially hazardous chemicals and (3) to improve the methodology and statistical methods that estimate usual intake distributions from short-term dietary intake information and develop a methodology to quantify uncertainty in usual intake distributions. RESULTS: The preexisting EPIC-Soft application was reprogrammed into a Windows environment and more than 60 new specifications were implemented in the software. A validation study showed that two non-consecutive EPIC-Soft 24-HDRs are suitable to estimate the usual intake distributions of protein and potassium of European adult populations. The 2-day non-consecutive 24-HDRs in combination with a food propensity questionnaire also appeared to be appropriate to rank individuals according to their fish and fruit and vegetable intake in a comparable way in five European centers. Dietary intake of (young) children can be assessed by the combination of EPIC-Soft 24-HDRs and food recording booklets. The EPIC-Soft-standardized method of describing foods is useful to estimate dietary exposure to potentially hazardous chemicals such as specific flavoring substances. With the developed Multiple Source Method, repeated non-consecutive 24-HDR data in combination with food propensity data can be used to estimate the population distribution of the usual intake by estimating the individual usual intakes. CONCLUSIONS: The findings provide sufficient evidence to conclude that the repeated 24-HDR using EPIC-Soft for standardization in combination with a food propensity questionnaire and modeling of usual intake is a suitable method for pan-European surveillance of nutritional adequacy and food safety among healthy adults and maybe in children aged 7 years and older. To facilitate this methodology in other European countries, the next step is to provide and standardize an implementation plan that accounts for maintenance and updates, sampling designs, national surveillance programs, tailored capacity building and training, and linkage to food composition and occurrence databases.

Current status of endemic goiter in Croatia: the results of a nationwide study (1995).

In the beginning of the nineties, 40 years after introduction of iodine prophylaxis in Croatia, on a basis of a frequent reports coming from general practitioners about the presence of a rather high prevalence of goiter among schoolchildren, a nationwide study was initiated with the aim to determine the real prevalence of goiter in the country. A total of 2856 schoolchildren of both sexes, aged 7-15 years, were included into the study. Investigations were designed in a way to cover most of geographical regions in Croatia and subjects were randomly selected. The prevalence of goiter in schoolchildren was assessed by palpation and in part by ultrasonography of the neck. At the same time urinary iodine excretion was measured and iodine content in salt samples was determined. The results have revealed the persistence of mild endemic goiter in inland parts of Croatia with the prevalence of 6-29% in the age group 7-11 years and those of 10-43% among the age group 12-15 years. The overall goiter prevalence in schoolchildren in Croatia fluctuates from 8% to 35%. Such prevalence, most probably due to less than optimum iodine intake, is unlikely to change until iodine content of the salt is increased from its present level of 10 mg of Kl per kg of salt.

Croatia has reached iodine sufficiency.

This study was performed in 2002, 6 yr after the introduction of a new regulation on salt iodination with 25 mg KI/kg of salt. The aim of the study was to evaluate whether further significant positive results of improved iodine intake could be observed among schoolchildren in Croatia. A total of 927 schoolchildren of both sexes, aged 6-12 yr, were included in the study. In Croatia, with a population of 4,437,460 the research was implemented in four major geographical regions: the Northwestern, Slavonia, Northern Adriatic and Dalmatian regions. Investigations included randomly selected pupils from regional centers and neighboring smaller towns or villages. The results have revealed that thyroid volumes were within the normal range according to the provisional WHO/ICCIDD reference values for sonographic thyroid volume in iodine-replete school-age children, updated in 2001. A significant improvement in medians of urinary iodine excretion was detected in 2002: from 9 microg/dl in 1991 to 14.6 microg/dl in Zagreb, from 4.3 microg/dl in 1995 to 13.1 microg/dl in Split, from 9.4 microg/dl in 1997 to 14.2 microg/dl in Rijeka and from 13.4 microg/dl in 1997 to 14.7 microg/dl in Osijek. An overall median of 14.0 microg/dl of urinary iodine excretion was detected in Croatian schoolchildren. The control of salt at different levels, from production to consumption, including salt produced in all three Croatian salt plants and imported salt, revealed that Croatian salt is adequately iodized. From severe iodine deficiency before the 1950s, through mild-to-moderate iodine deficiency in the 1990s, Croatia has now reached iodine sufficiency.