Perceiving a need for dietary change in adults living with and beyond cancer: A cross-sectional study.

BACKGROUND: Many people living with and beyond cancer (LWBC) do not meet dietary recommendations. To implement a healthier diet, people LWBC must perceive a need to improve their diet. METHODS: Participants included people diagnosed with breast, prostate or colorectal cancer in the UK. Two binary logistic regression models were conducted with perceived need for dietary change as the outcome (need to improve vs. no need). Predictor variables included demographic and clinical characteristics, receipt of dietary advice, and either body mass index (BMI) or adherence to seven relevant World Cancer Research Fund (WCRF) dietary recommendations. RESULTS: The sample included 5835 responses. Only 31% perceived a need to improve their diet. Being younger (odds ratio [OR] 0.95, 95% confidence interval [CI] = 94-0.95), female (OR = 1.33, 95% CI = 1.15-1.53), not of white ethnicity (OR = 1.8, 95% CI = 1.48-2.27), not married/cohabiting (OR = 1.32, 95% CI = 1.16-1.52) and having received dietary advice (OR = 1.36, 95% CI = 1.43-1.86) was associated with an increased odds of perceiving a need to improve diet. This association was also seen for participants with two or more comorbidities (OR = 1.31, 95% CI = 1.09-1.57), those not meeting the recommendations for fruit and vegetables (OR = 0.47, 95% CI = 0.41-0.55), fat (OR = 0.67, 95% CI = 0.58-0.77), and sugar (OR = 0.86, 95% CI = 0.75-0.98) in the dietary components model and those who had a higher BMI (OR = 1.53, 95% CI = 1.32-1.77) in the BMI model. CONCLUSIONS: Most of this sample of people LWBC did not perceive a need to improve their diet. More research is needed to understand the reasons for this and to target these reasons in dietary interventions.

Perceived influence of commercial milk formula labelling on mothers' feeding choices in Great Britain: a qualitative study.

OBJECTIVE: To understand how mothers use commercial milk formula (CMF) labels to inform their feeding choices and explore mothers' understanding of differences between CMF products. DESIGN: Qualitative study with recruitment via social media. Online semistructured interviews, including a product mapping exercise and thematic analysis. PARTICIPANTS: Mothers (n=25) using CMF for children <3 years living in Great Britain (GB). RESULTS: Mothers were drawn to brands they recognised from years of exposure to CMF advertising. CMF products were assumed to vary according to brand and stage, but participants found on-pack information did not explain how. This added to anxiety about choosing 'the best one' and mothers would have liked guidance from healthcare professionals (HCPs). Wide availability of CMF for older infants and children, and on-pack messaging suggesting progression from one product to the next, led many to believe these products were necessary. There was confusion over the appropriate use of specialist products. While mothers rarely mentioned on-pack health and nutrition claims, they were attracted to the overall appearance of packs and messaging relating to science, research and nature. References to breast milk and a logo perceived to represent a breastfeeding mother were taken as indicators of closer similarity to breast milk. CONCLUSIONS: CMF legislation in GB should be updated to restrict brand advertising and the use of on-pack text and images that mothers perceive as indicating products have a closer similarity to breast milk. Greater input from HCPs was desired by new mothers and would support them to make more informed choices about CMF.

Fatigue, quality of life and associations with adherence to the World Cancer Research Fund guidelines for health behaviours in 5835 adults living with and beyond breast, prostate and colorectal cancer in England: A cross-sectional study.

BACKGROUND: Many individuals living with and beyond cancer (LWBC) have ongoing quality of life (QoL) issues, including fatigue. The World Cancer Research Fund (WCRF) provides health behaviour recommendations for people LWBC, and there is some evidence linking adherence to these with improved QoL. METHODS: Adults LWBC (specifically breast, colorectal or prostate cancer) completed a survey covering health behaviours (diet, physical activity, alcohol consumption and smoking), fatigue (FACIT-Fatigue Scale, version 4) and a broad measure of QoL (EQ-5D-5L descriptive scale). Participants were categorised as meeting/not meeting WCRF recommendations, using the following cut-offs classified as meeting the guidelines: ≥150 min physical activity/week, fruit and vegetables (≥5 portions/day), fibre (≥30 g fibre per day), free sugar (<5% of total calories from free sugar), fat (<33% total energy), red meat (<500 g/week), processed meat (none), alcohol consumption (<14 units/week) and not a current smoker. Logistic regression analyses explored associations between WCRF adherence and fatigue and QoL issues, controlling for demographic and clinical variables. RESULTS: Among 5835 individuals LWBC (mean age: 67 years, 56% female, 90% white, breast 48%, prostate 32% and colorectal 21%), 22% had severe fatigue and 72% had 1+ issue/s on the EQ-5D-5L. Adhering to physical activity recommendations (odds ratio [OR] = 0.88, confidence interval [CI] = 0.77-0.99), meeting various dietary recommendations (fruit and vegetables OR = 0.79; CI = 0.68-0.91, free sugar OR = 0.85; CI = 0.76-0.96, fat OR = 0.71; CI = 0.62-0.82, red meat OR = 0.65; CI = 0.50-0.85) and not smoking (OR = 0.53, CI = 0.41-0.67) were associated with decreased odds of experiencing severe fatigue. Adhering to physical activity guidelines (OR = 0.71, CI = 0.62-0.82) was also associated with decreased odds of having 1+ QoL issue/s. CONCLUSIONS: Adherence to various WCRF recommendations, particularly the recommendation for physical activity, was associated with less fatigue and better QoL in a large UK cohort of people living with and beyond breast, colorectal or prostate cancer. Multi-component interventions designed to support people LWBC to improve health behaviours, in line with the levels recommended by the WCRF, may also improve QoL.

Content analysis of on-package formula labelling in Great Britain: use of marketing messages on infant, follow-on, growing-up and specialist formula.

OBJECTIVE: To explore on-package formula messaging with reference to legislation and government-issued guidance in Great Britain (GB). DESIGN: Formula products were identified, pictures of all sides of packs collated and on-package text and images were coded. Compliance with both GB legislation and guidance issued by the Department of Health and Social Care (DHSC) was assessed. SETTING: All formula packs that were available for sale over the counter in GB between April and October 2020. PARTICIPANTS: Formula packs (n 71) including infant formula, follow-on formula, growing-up formula and specialist formula were identified, coded and analysed. RESULTS: In total, 41 % of formula packs included nutrition claims, and 18 % included health claims that may be considered non-permitted, according to DHSC guidance. Additionally, 72 % of products showed images considered 'non-permitted'. Breast Milk Substitute (BMS) legislation states infant and follow-on formula packs should be clearly distinguishable but does not provide criteria to assess similarity. Based on DHSC guidance, 72 % of infant and follow-on formula packs were categorised as showing a high degree of similarity. Marketing practices not covered by current legislation were widespread, such as 94 % of infant formula packs including advertisements for follow-on or growing-up formula. CONCLUSIONS: Text and images considered non-permitted according to DHSC guidance for implementing BMS legislation were widespread on formula products available in GB. As terms such as 'similarity' are not defined in BMS legislation, it was unclear if breaches had occurred. Findings support the WHO call for loopholes in domestic legislation to be closed as a matter of urgency.

Perception of a need to change weight in individuals living with and beyond breast, prostate and colorectal cancer: a cross-sectional survey.

PURPOSE: People living with and beyond cancer (LWBC) are advised to achieve a body mass index (BMI) within the healthy range (≥ 18.5 and < 25). Not perceiving a need for weight change may be a barrier to achieving a healthy weight. This study aimed to explore factors associated with perceived need for weight change among people LWBC. METHODS: Adults diagnosed with breast, prostate, or colorectal cancer were recruited through National Health Service sites in Essex and London. Participants (N = 5835) completed the 'Health and Lifestyle After Cancer' survey, which included a question on perceived need to change weight. Associations between perceived need for weight change and BMI, and perceived need for weight change and health and demographic variables, were analyzed using chi-square tests and logistic regression, respectively. RESULTS: The proportion of participants perceiving a need to lose weight differed according to BMI category: healthy weight (23%), overweight (64%), obese (85%) (P < 0.001). Having overweight or obesity but not perceiving a need to lose weight was associated with being older, male, non-white, not married or cohabiting, and having cancer that had spread, no formal qualifications, no comorbidities, and having received chemotherapy. CONCLUSIONS: Perceived need to lose weight is prevalent among people LWBC with obesity and overweight. This group may be interested in weight management support. Demographic and health factors were associated with having obesity or overweight but not perceiving a need to lose weight. IMPLICATIONS FOR CANCER SURVIVORS: Weight loss interventions for people LWBC are needed. A subset of people LWBC with overweight and obesity may need additional information or motivators to engage with weight management.

Comparison between Self-Completed and Interviewer-Administered 24-Hour Dietary Recalls in Cancer Survivors: Sampling Bias and Differential Reporting.

Self-completed 24 h dietary recalls (24-HRs) are increasingly used for research and national dietary surveillance. It is unclear how difficulties with self-completion affect response rates and sample characteristics. This study identified factors associated with being unable to self-complete an online 24-HR but willing to do so with an interviewer. Baseline 24-HRs from the ASCOT Trial were analysed (n = 1224). Adults who had been diagnosed with cancer in the past seven years and completed treatment, were invited to self-complete 24-HRs online using myfood24®. Non-completers were offered an interviewer-administered 24-HR. One third of participants willing to provide dietary data, were unable to self-complete a 24-HR. This was associated with being older, non-white and not educated to degree level. Compared to interviewer-administered 24-HRs, self-completed 24-HRs included 25% fewer items and reported lower intakes of energy, fat, saturated fat and sugar. This study highlights how collection of dietary data via online self-completed 24-HRs, without the provision of an alternative method, contributes to sampling bias. As dietary surveys are used for service and policy planning it is essential to widen inclusion. Optimisation of 24-HR tools might increase usability but interviewer-administered 24-HRs may be the only suitable option for some individuals.

The role of partner support for health behaviours in people living with and beyond cancer: A qualitative study.

OBJECTIVE: This study aimed to qualitatively explore how partner support for health behaviours is perceived, received, and utilised in people living with and beyond cancer (LWBC). METHODS: Semi-structured audio interviews were conducted with 24 participants, 15 men and nine women, living with and beyond breast, prostate, and colorectal cancer. Inductive and deductive Thematic Analysis was used to analyse the data. RESULTS: Three key themes with six subthemes were identified relating to partner support for health behaviours: (1) Interdependence (Reciprocity, Overt Control, Influence & Motivation) (2) Concordance (Shared Attitudes & Health Beliefs, Shared Health Behaviour) and (3) Communal Coping (Communal Orientation towards Health and Decision Making, Co-operative Action in Health Behaviour). CONCLUSIONS: Partner support plays a unique and significant role in the health behaviours of people LWBC. Partners play a collaborative role in managing health and facilitating health behaviours, while the high level of concordance in couples may represent a potential barrier to change via the reinforcement of maladaptive health beliefs and behaviours. IMPLICATIONS FOR CANCER SURVIVORS: Overall, findings demonstrate that partners should be considered and included where possible when designing future behaviour change interventions for people LWBC.

Exploring the perceived impact of social support on the health behaviours of people living with and beyond cancer during the COVID-19 pandemic: a qualitative study.

PURPOSE: Social support facilitated healthy behaviours in people living with and beyond cancer (LWBC) before the COVID-19 pandemic. Little is known about how social support impacted their health behaviours during the pandemic when social restrictions were imposed. The aim of this study was to qualitatively explore how social support was perceived to impact the health behaviours of people LWBC during the COVID-19 pandemic. METHODS: Semi-structured interviews were conducted via telephone with 24 adults living with and beyond breast, prostate and colorectal cancer. Inductive and deductive framework analysis was used to analyse the data. RESULTS: Five themes developed. These were (1) Companionship and accountability as motivators for physical activity, (2) Social influences on alcohol consumption, (3) Instrumental support in food practices, (4) Informational support as important for behaviour change and (5) Validation of health behaviours from immediate social networks. CONCLUSION: This study described how companionship, social influence, instrumental support, informational support and validation were perceived to impact the health behaviours of people LWBC during the COVID-19 pandemic. Interventions for people LWBC could recommend co-participation in exercise with friends and family; promote the formation of collaborative implementation intentions with family to reduce alcohol consumption; and encourage supportive communication between partners about health behaviours. These interventions would be useful during pandemics and at other times. Government policies to help support clinically extremely vulnerable groups of people LWBC during pandemics should focus on providing access to healthier foods.

Determinants of sleep quality in 5835 individuals living with and beyond breast, prostate, and colorectal cancer: a cross-sectional survey.

PURPOSE: The present study aimed to quantify the level of sleep problems in 5835 breast, prostate, and colorectal cancer survivors, and explore a number of potential determinants of poor sleep quality in the present sample. BMI, diet, and physical activity were of particular interest as potential determinants. METHODS: Participants who completed the 'Health and Lifestyle after Cancer' survey were adults who had been diagnosed with breast, prostate, or colorectal cancer (mean time since cancer diagnosis was 35.5 months, SD=13.56). Sleep quality was assessed using the Pittsburgh Sleep Quality Index. BMI was calculated from self-reported height and weight. Participants were categorised as meeting/not meeting the World Cancer Research Fund (WCRF) recommendations for fibre, fruit and vegetables, added sugar, red meat, processed meat, fat, alcohol, and physical activity. Analyses accounted for demographic and clinical factors. RESULTS: Fifty-seven percent of those with sleep data were classified as poor sleepers (response rate 79%). Being female, having a higher number of cancer treatments, more comorbid conditions, and being more anxious/depressed increased the odds of being a poor sleeper. After adjustment for these factors, there were no associations between diet/alcohol/physical activity and sleep. However, BMI was associated with sleep. Individuals in the overweight and obese categories had 22% and 79% higher odds of being poor sleepers than individuals in the underweight/healthy weight category, respectively. CONCLUSIONS: The findings suggest that there may be a need to develop sleep quality interventions for cancer survivors with obesity. Even after adjustment for multiple clinical and demographic factors, BMI (particularly obesity) was associated with poor sleep. Thus, researchers and health professionals should find ways to support individuals with overweight and obesity to improve their sleep quality. IMPLICATIONS FOR CANCER SURVIVORS: The present findings highlight that poor sleep is a common issue in cancer survivors. Interventions seeking to improve outcomes for cancer survivors over the longer term should consider sleep quality.

Dietary supplement use by individuals living with and beyond breast, prostate, and colorectal cancer: A cross-sectional survey.

BACKGROUND: Dietary supplements (DSs) are not recommended for the prevention of cancer recurrence. Although DS use is common in individuals living with and beyond cancer, its associations with beliefs about reduced cancer recurrence risk and demographic and health behaviors are unclear. METHODS: Adults (18 years old or older) who had been diagnosed with breast, prostate, or colorectal cancer were recruited through National Health Service sites in Essex and London. Participants completed a mailed survey and telephone or online 24-hour dietary recalls (MyFood24). Supplement use was collected during the dietary recalls. Associations between DS use and demographics, health behaviors, and beliefs about DSs and cancer were explored. RESULTS: Nineteen percent of 1049 individuals believed that DSs were important for the reduction of cancer recurrence risk, and 40% of individuals reported DS use. DS use was positively associated with being female (odds ratio [OR], 2.48; confidence interval [CI], 1.72-3.56), meeting 5-a-day fruit and vegetable recommendations (OR, 1.36; CI, 1.02-1.82), and believing that DSs were important for reducing cancer recurrence risk (OR, 3.13; CI, 2.35-4.18). DS use was negatively associated with having obesity (OR, 0.58; CI, 0.38-0.87). The most commonly taken DSs overall were fish oils (taken by 13%). Calcium with or without vitamin D was the most common DS taken by individuals with breast cancer (15%). CONCLUSIONS: DS use by individuals living with and beyond cancer is associated with demographic factors and health behaviors. A belief that DSs reduce the risk of cancer recurrence is common and positively associated with DS use. There is a need for health care professionals to provide advice about DS use and cancer recurrence risk.

An algorithm to assess intestinal iron availability for use in dietary surveys.

In nutritional epidemiology, it is often assumed that nutrient absorption is proportional to nutrient intake. For several nutrients, including non-haem Fe, this assumption may not hold. Depending on the nutrients ingested with non-haem Fe, its availability for absorption varies greatly. Therefore, using Fe intake to examine associations between Fe and health can impact upon the validity of findings. Previous algorithms that adjust Fe intakes for dietary factors known to affect absorption have been found to underestimate Fe absorption and, in the present study, perform poorly on independent dietary data. We have designed a new algorithm to adjust Fe intakes for the effects of ascorbic acid, meat, fish and poultry, phytate, polyphenols and Ca, incorporating not only absorption data from test meals but also current understanding of Fe absorption. In so doing, we have created a robust and universal Fe algorithm with potential for use in large cohorts. The algorithm described aims not to predict Fe absorption but available Fe in the gut, a measure we believe to be of greater use in epidemiological research. Available Fe is Fe available for absorption from the gastrointestinal tract, taking into account enhancing or inhibiting effects of dietary modifiers. Our algorithm successfully estimated average Fe availability in test meal data used to construct the algorithm and, unlike other algorithms tested, also provided plausible predictions when applied to independent dietary data. Future research is needed to evaluate the extent to which this algorithm is useful in epidemiological research to relate Fe to health outcomes.

Post-prandial iron absorption in humans: comparison between HFE genotypes and iron deficiency anaemia.

BACKGROUND & AIMS: Measurement of serum iron increase after ingestion of a meal could be an efficient method of comparing post-prandial iron absorption between groups of individuals. We determined whether the rise in post-prandial serum iron is increased in fully treated patients with hereditary haemochromatosis (HFE C282Y+/+; HH) compared to iron deficiency anaemia (IDA), iron-replete heterozygous subjects (HFE C282Y+/-) and iron-replete controls (HFE C282Y-/-). METHODS: Serum iron increase was measured over 4h after a meal containing 13.1 mg non-haem iron. RESULTS: Post-prandial increase in serum iron was similar in treated HH versus IDA (P=0.54), but greater than control subjects (P<0.0001). In five HH patients, using (58)Fe as a tracer, the rate of iron absorption was increased (P<0.05) and serum non-transferrin bound iron showed a tendency to increase (P=0.06). Serum iron curves did not differ for heterozygous subjects and controls (P=0.65). CONCLUSIONS: Using the serum iron method we found a comparable increase in post-prandial iron absorption in treated HH and IDA compared with controls. While post-prandial iron absorption in the group heterozygous for the C282Y mutation was modestly increased relative to controls, this difference was not statistically significant.

A food-group based algorithm to predict non-heme iron absorption.

OBJECTIVE: To develop an algorithm to predict the percentage non-heme iron absorption based on the foods contained in a meal (wholemeal cereal, tea, cheese, etc.). Existing algorithms use food constituents (phytate, polyphenols, calcium, etc.), which can be difficult to obtain. DESIGN: A meta-analysis of published studies using erythrocyte incorporation of radio-isotopic iron to measure non-heme iron absorption. METHODS: A database was compiled and foods were categorized into food groups likely to modify non-heme iron absorption. Absorption data were then adjusted to a common iron status and a weighted multiple regression was performed. RESULTS: Data from 53 research papers (3,942 individual meals) were used to produce an algorithm to predict non-heme iron absorption (R(2) =0.22, P < 0.0001). CONCLUSIONS: The percentage non-heme iron absorption can be predicted from information on the types of foods contained in a meal with similar efficacy to that of food-constituent-based algorithms (R(2) = 0.16, P= 0.0001).

Serum iron curves can be used to estimate dietary iron bioavailability in humans.

Erythrocyte incorporation of isotopic iron (Fe) is the standard method for assessing iron bioavailability, but the process is expensive, technically difficult, and gives no information on the kinetics of absorption. The main objective of this study was to validate serum Fe curves as measures of dietary iron absorption because previous work demonstrated that serum iron curves can be generated with iron doses as low as 5-20 mg and that up to 20 mg iron can be added to meals without affecting relative absorption. In 3 studies, groups (n = 10, 10, 21) of Fe-deficient, mildly anemic women consumed meals of varying calculated Fe bioavailability, with and without added ferric chloride (10 mg Fe). Blood samples were collected at baseline and every 30 min for 4 h after the meal. Serum Fe concentrations were measured. Areas under the serum Fe curves and peak concentrations were used in different models to estimate Fe absorption and uptake. In 21 subjects, (58)Fe-enriched ferric chloride was added to the meals, and blood was taken 2 wk later to calculate red cell isotope incorporation. The addition of 10 mg Fe to test meals produced measurable serum iron curves even when the meal Fe bioavailability was low. Serum Fe curves were highly reproducible and were affected as expected by food composition. Even the single measurement at the estimated time of peak iron concentration was correlated significantly with erythrocyte incorporation of (58)Fe (r = 0.72, P < 0.0001). Hence the extent and rate of absorption of nonheme iron from meals, rather than in individuals, can be investigated with such subjects without the need for isotopes.

Attainment of precision in implementation of 24 h dietary recalls: INTERMAP UK.

Collection of complete and accurate dietary intake data is necessary to investigate the association of nutrient intakes with disease outcomes. A standardised multiple-pass 24 h dietary recall method was used in the International Collaborative Study of Macro- and Micronutrients and Blood Pressure (INTERMAP) to obtain maximally objective data. Dietary interviewers were intensively trained and recalls taped, with consent, for randomly selected evaluations by the local site nutritionist (SN) and/or country nutritionists (CN) using a twelve-criterion checklist marked on a four-point scale (1, retrain, to 4, excellent). In the Belfast centre, seven dietary interviewers collected 932 24 h recalls from 40-59-year-old men and women. Total scores from the 134 evaluated recalls ranged from thirty-four to the maximum forty-eight points. All twelve aspects of the interviews were completed satisfactorily on average whether scored by the SN (n 53, range: probing 3.25 to privacy of interview 3.98) or CN (n 19, range: probing 3.26 to pace of interview and general manner of interviewer 3.95); the CN gave significantly lower scores than the SN for recalls evaluated by both nutritionists (n 31, Wilcoxon signed rank test, P=0.001). Five evaluations of three recalls identified areas requiring retraining or work to improve performance. Reporting accuracy was estimated using BMR; energy intake estimates less than 1.2 x BMR identifying under-reporting. Mean ratios in all age, sex and body-mass groups were above this cut-off point; overall, 26.1 % were below. Experiences from the INTERMAP Belfast centre indicate that difficulties in collection of dietary information can be anticipated and contained by the systematic use of methods to prevent, detect and correct errors.

Standardised coding of diet records: experiences from INTERMAP UK.

Coding diet records is a basic element of most dietary surveys, yet it often receives little attention even though errors in coding can lead to flawed study results. In the INTERnational study of MAcro- and micronutrients and blood Pressure (INTERMAP study), efforts were made to minimise errors in coding the 18, 720 diet records. Staff were centrally trained and certified before being able to process study data and ongoing quality control checks were performed. This involved the senior (site) nutritionist re-coding randomly selected diet records. To facilitate standardisation of coding in the UK, a code book was designed; it included information about coding brand items, density and portion size information, and default codes to be assigned when limited information was available for food items. It was found that trainees, despite previous experience in coding elsewhere, made coding errors that resulted in errors in estimates of daily energy and nutrient intakes. As training proceeded, the number of errors decreased. Compilation of the code book was labour-intensive, as information from food manufacturers and retailers had to be collected. Strategies are required to avoid repetition of this effort by other research groups. While the methods used in INTERMAP to reduce coding errors were time consuming, the experiences suggest that such errors are important and that they can be reduced.

Enhancing data on nutrient composition of foods eaten by participants in the INTERMAP study in China, Japan, the United Kingdom, and the United States.

The International Study of Macronutrients and Blood Pressure (INTERMAP) is a four-country study investigating relationships between individual dietary intakes and blood pressure. Dietary intake patterns of individuals were estimated for macronutrients (proteins, lipids, carbohydrates, alcohol) and their components (amino acids, fatty acids, starch), as well as minerals, vitamins, caffeine, and dietary fiber. The dietary assessment phase of the study involved collection of four 24-h recalls and two 24-h urine specimens from each of 4680 adults, ages 40-59, at 16 centers located in the People's Republic of China, Japan, the United Kingdom and the United States. For each country, an available database of nutrient composition of locally consumed foods was updated for use in the analysis of dietary data collected within the country. The four original databases differed in number and types of foods and nutrients included, analytic methods used to derive nutrients, and percentage of missing nutrient values. The Nutrition Coordinating Center at the University of Minnesota updated the original databases in several ways to overcome the foregoing limitations and increase comparability in the analyses of nutrient intake of individuals across the four countries: (1) addition of new foods and preparation methods reported by study participants; (2) addition of missing nutrient fields important to the study objectives; (3) imputation of missing nutrient values to provide complete nutrient data for each food reported by participants; and (4) use of adjustment factors to enhance comparability among estimates of nutrient intake obtained through each country's nutrient-coding methodology. It was possible to expand, enhance, and adjust the nutrient databases from the four countries to produce comparable (60 nutrients) or nearly comparable (ten nutrients) data on composition of all foods reported by INTERMAP participants.