Combined chronic dietary exposure to four nephrotoxic metals exceeds tolerable intake levels in the adult population of 10 European countries.

A mixture risk assessment (MRA) for four metals relevant to chronic kidney disease (CKD) was performed. Dietary exposure to cadmium or lead alone exceeded the respective reference values in the majority of the 10 European countries included in our study. When the dietary exposure to those metals and inorganic mercury and inorganic arsenic was combined following a classical or personalised modified reference point index (mRPI) approach, not only high exposure (95th percentile) estimates but also the mean exceeded the tolerable intake of the mixture in all countries studied. Cadmium and lead contributed most to the combined exposure, followed by inorganic arsenic and inorganic mercury. The use of conversion factors for inorganic arsenic and inorganic mercury from total arsenic and total mercury concentration data was a source of uncertainty. Other uncertainties were related to the use of different principles to derive reference points. Yet, MRA at the target organ level, as performed in our study, could be used as a way to efficiently prioritise assessment groups for higher-tier MRA. Since the combined exposure to the four metals exceeded the tolerable intake, we recommend a refined MRA based on a common, specific nephrotoxic effect and relative potency factors (RPFs) based on a similar effect size.

A case study of neurodevelopmental risks from combined exposures to lead, methyl-mercury, inorganic arsenic, polychlorinated biphenyls, polybrominated diphenyl ethers and fluoride.

We performed a mixture risk assessment (MRA) case study of dietary exposure to the food contaminants lead, methylmercury, inorganic arsenic (iAs), fluoride, non-dioxin-like polychlorinated biphenyls (NDL-PCBs) and polybrominated diphenyl ethers (PBDEs), all substances associated with declines in cognitive abilities measured as IQ loss. Most of these chemicals are frequently measured in human biomonitoring studies. A component-based, personalised modified reference point index (mRPI) approach, in which we expressed the exposures and potencies of our chosen substances as lead equivalent values, was applied to perform a MRA for dietary exposures. We conducted the assessment for four different age groups (toddlers, children, adolescents, and women aged 18-45 years) in nine European countries. Populations in all countries considered exceeded combined tolerable levels at median exposure levels. NDL-PCBs in fish, other seafood and dairy, lead in grains and fruits, methylmercury in fish and other seafoods, and fluoride in water contributed most to the combined exposure. We identified uncertainties for the likelihood of co-exposure, assessment group membership, endpoint-specific reference values (ESRVs) based on epidemiological (lead, methylmercury, iAs, fluoride and NDL-PCBs) and animal data (PBDE), and exposure data. Those uncertainties lead to a complex pattern of under- and overestimations, which would require probabilistic modelling based on expert knowledge elicitation for integration of the identified uncertainties into an overall uncertainty estimate. In addition, the identified uncertainties could be used to refine future MRA for cognitive decline.

Fish - a source of dietary exposure to iodine and other chemicals.

Fish, fish products and seafood are an important part of a healthy diet. They make an important contribution as a dietary source of iodine, but also of other substances that have a positive effect on the human body. On the other hand, they contain contaminants (especially mercury/methylmercury) whose toxic properties affect food safety. Based on the results of dietary exposure monitoring and specialised studies by the National Institute of Health - Centre for Health, Nutrition and Food and international activities it can be concluded that there are clear benefits in terms of human health from the consumption of fishery products. Women and children should take care to include these products in their diets. The mercury/methylmercury content of common products in the Czech Republic is under control and the concentration levels are practically below the legislative limits. Care should be taken with fish and fish products where mercury may accumulate. The response of the European Commission, which is currently calling for a review of the maximum permissible limits for mercury/methylmercury in various fish species, is appropriate. This could help to further reduce dietary exposure to mercury in food and encourage fish consumption.

Cumulative dietary risk assessment overarching different regulatory silos using a margin of exposure approach: A case study with three chemical silos.

Risk assessment of chemicals occurring in our diet is commonly performed for single chemicals without considering exposure to other chemicals. We performed a case study on risk assessment of combined dietary exposure to chemicals from different regulatory silos, i.e. pesticides (PPRs), persistent organic pollutants (POPs) and food additives (FAs). Chemicals were grouped into the cumulative assessment group (CAG) liver steatosis using a component-based approach. Based on literature, the CAG included 144 PPRs, 49 POPS and 7 FAs for which concentration data were available. For each silo, chronic combined dietary exposure was assessed for adults and children of nine European countries following the most commonly used exposure methodologies in Europe and by using a relative potency factor approach. For risk characterization, a Margin of Exposure (MOE) was calculated. To overarch the risk across silos, a normalised combined margin of exposure (nMOET) approach was proposed. This case study demonstrated that risk assessment of combined exposure to chemicals can be performed within regulatory silos. It also highlighted important differences in the conservatism of exposure scenarios, the derivation of point of departures and the subsequent acceptable MOEs between the silos. To overarch the risk despite these differences, a nMOET approach can be used.

Dietary exposure assessment of sum deoxynivalenol forms, sum T-2/HT-2 toxins and zearalenone from cereal-based foods and beer.

A dietary exposure assessment to sum of deoxynivalenol (DON) forms, sum of T-2/HT-2 toxins (T2/HT2) and zearalenone (ZEA) was conducted for Czech children 4-6 years and Czech men and women 18-59 years. Retail foods (25 different commodities, n = 336) were assessed by LC-MS/MS methods. The 95th percentile chronic exposure to sum of DON forms was determined in children from 648 to 1030 ng/kg bw/day (LB/lower bound/and UB/upper bound/), in men from 362 to 923 ng/kg bw/day and in women from 272 to 490 ng/kg bw/day. The 95th percentile chronic exposure to sum T2/HT2 was determined in children from 6.5 to 31 ng/kg bw/day, in men from 1.9 to 11.2 ng/kg bw/day and in women from 2.5 to 11.5 ng/kg bw/day. The 95th percentile chronic exposure to ZEA was determined in children from 11.9 to 24.9 ng/kg bw/day, in men from 5.9 to 27.5 ng/kg bw/day and in women from 4.8 to 12.6 ng/kg bw/day. The risk linked with the mean and the 95th percentile chronic exposure (LB scenario) to the sum of DON forms, sum of T2/HT2 and ZEA is considered to be out of health concern for the selected population groups.

Mycotoxin exposure assessments in a multi-center European validation study by 24-hour dietary recall and biological fluid sampling.

The European Food Consumption Validation (EFCOVAL) project includes 600 men and women from Belgium, the Czech Republic, France, the Netherlands, and Norway, who had given serum and 24-hour urine samples, and completed 24-hour dietary recall (24-HDR) interviews. Consumption, according to 24-HDR, was matched against the European Food Safety Authority (EFSA) databases of mycotoxin contaminations, via the FoodEx1 standard classifications, producing an indirect external estimate of dietary mycotoxin exposure. Direct, internal measurements of dietary mycotoxin exposure were made in serum and urine by ultra-performance liquid chromatography coupled to tandem mass spectrometry. For the first time, mycotoxin exposures were thoroughly compared between two 24-HDRs, and two 24-hour urine samples collected during the same days covered by the 24-HDRs. These measurements were compared to a single-time point serum measurement to investigate evidence of chronic mycotoxin exposure. According to 24-HDR data, all 600 individuals were exposed to between 4 and 34 mycotoxins, whereof 10 found to exceed the tolerable daily intake. Correlations were observed between two time points, and significant correlations were observed between concentrations in serum and urine. However, only acetyldeoxynivalenol, ochratoxin A, and sterigmatocystin were found to have significant positive correlations between 24-HDR exposures and serum, while aflatoxin G1 and G2, HT-2 toxin, and deoxynivalenol were associated between concurrent 24-HDR and 24-hour urine. Substantial agreements on quantitative levels between serum and urine were observed for the groups Type B Trichothecenes and Zearalenone. Further research is required to bridge the interpretation of external and internal exposure estimates of the individual on a time scale of hours. Additionally, metabolomic profiling of dietary mycotoxin exposures could help with a comprehensive assessment of single time-point exposures, but also with the identification of chronic exposure biomarkers. Such detailed characterization informs population exposure assessments, and aids in the interpretation of epidemiological health outcomes related to multi-mycotoxin exposure.

Selecting mixtures on the basis of dietary exposure and hazard data: application to pesticide exposure in the European population in relation to steatosis.

Populations are exposed to mixtures of pesticides through their diet on a daily basis. The question of which substances should be assessed together remains a major challenge due to the complexity of the mixtures. In addition, the associated risk is difficult to characterise. The EuroMix project (European Test and Risk Assessment Strategies for Mixtures) has developed a strategy for mixture risk assessment. In particular, it has proposed a methodology that combines exposures and hazard information to identify relevant mixtures of chemicals belonging to any cumulative assessment group (CAG) to which the European population is exposed via food. For the purposes of this study, food consumption and pesticide residue data in food and drinking water were obtained from national surveys in nine European countries. Mixtures of pesticides were identified by a sparse non-negative matrix underestimation (SNMU) applied to the specific liver steatosis effect in children from 11 to 15 years of age, and in adults from 18 to 64 years of age in nine European countries. Exposures and mixtures of 144 pesticides were evaluated through four different scenarios: (1) chronic exposure with a merged concentration dataset in the adult population, (2) chronic exposure with country-specific concentration datasets in the adult population, (3) acute exposure with a merged concentration dataset in the adult population, and (4) chronic exposure with a merged concentration dataset in the paediatric population. The relative potency factors of each substance were calculated to express their potency relative to flusilazole, which was chosen as the reference compound. The selection of mixtures and the evaluation of exposures for each country were carried out using the Monte Carlo Risk Assessment (MCRA) software. Concerning chronic exposure, one mixture explained the largest proportion of the total variance for each country, while in acute exposure, several mixtures were often involved. The results showed that there were 15 main pesticides in the mixtures, with a high contribution of imazalil and dithiocarbamate. Since the concentrations provided by the different countries were merged in the scenario using merged concentration data, differences between countries result from differences in food consumption behaviours. These results support the approach that using merged concentration data to estimate exposures in Europe seems to be realistic, as foods are traded across European borders. The originality of the proposed approach was to start from a CAG and to integrate information from combined exposures to identify a refined list of mixtures with fewer components. As this approach was sensitive to the input data and required significant resources, efforts should continue regarding data collection and harmonisation among the different aspects within the pesticides regulatory framework, and to develop methods to group substances and mixtures to characterise the risk.

Dietary Intake of Vitamin D in the Czech Population: A Comparison with Dietary Reference Values, Main Food Sources Identified by a Total Diet Study.

The usual dietary intake of vitamin D was studied in 10 subgroups of the Czech population. Food consumption data was collected using repeated 24 h recall in a national cross-sectional survey (the Study of Individual Food Consumption, SISP04), and the vitamin D content in marketed foods was quantified within the national Total Diet Study (2014⁻2015). The Monte Carlo Risk Assessment computational model (version MCRA 8.2) was used to assess usual intake. The median vitamin D intakes for the Czech population (aged 4⁻90 years, both genders) were within a range of 2.5⁻5.1 µg/day. The highest median intake, excluding dietary supplements, was observed in men aged 18⁻64, and the lowest was observed in children aged 4⁻6 and girls aged 11⁻17. The main sources in the diet were hen eggs (21⁻28% of usual dietary intake), fine bakery wares (11⁻19%), cow's milk and dairy products (7⁻23%), meat and meat products (4⁻12%), fish (6⁻20%), and margarines (7⁻18%). The dietary intake of vitamin D for more than 95% of the Czech population was below the recommended Dietary Reference Values (DRVs). These findings should encourage public health authorities to support interventions and education and implement new regulatory measures for improving intake.

Investigation of patulin and citrinin in grape must and wine from grapes naturally contaminated by strains of Penicillium expansum.

Twenty three strains of Penicillium expansum, as a predominant species, were isolated from 23 (92%) out of 25 grape samples of 17 different grape varieties. The results of the identification of P. expansum strains were confirmed by a PCR method. Most of the isolates of P. expansum (21/23, 91%), when tested for toxigenicity, were bi-toxigenic: they produced citrinin (CIT) and particularly high amounts of patulin (PAT). A validated UPLC-MS/MS method for the determination of PAT and CIT was applied. The limits of quantification (LOQ) for PAT and CIT in grape must and toxigenicity testing samples were 100 and 2 ng/g, respectively. The results of PAT and CIT quantification in 23 grape must samples demonstrated the occurrence of PAT in 10 (43%) grape must samples (mean: 171 ng/g; median: 50 ng/g; and range: 143-644 ng/g) and the occurrence of CIT in two (9%) grape must samples (mean: 1 ng/g; median: 1 ng/g; and range: 2.5-3.5 ng/g). This is the first report on the natural occurrence of CIT in grape must. A validated HPLC-UV-VIS method for the determination of PAT in wine samples was applied, and concentrations in all 23 wine samples were below the LOQ (<10 ng/g).

Quality Management Framework for Total Diet Study centres in Europe.

A Quality Management Framework to improve quality and harmonization of Total Diet Study practices in Europe was developed within the TDS-Exposure Project. Seventeen processes were identified and hazards, Critical Control Points and associated preventive and corrective measures described. The Total Diet Study process was summarized in a flowchart divided into planning and practical (sample collection, preparation and analysis; risk assessment analysis and publication) phases. Standard Operating Procedures were developed and implemented in pilot studies in five organizations. The flowchart was used to develop a quality framework for Total Diet Studies that could be included in formal quality management systems. Pilot studies operated by four project partners were visited by project assessors who reviewed implementation of the proposed framework and identified areas that could be improved. The quality framework developed can be the starting point for any Total Diet Study centre and can be used within existing formal quality management approaches.

Development of harmonised food and sample lists for total diet studies in five European countries.

A total diet study (TDS) is a public health tool for determination of population dietary exposure to chemicals across the entire diet. TDSs have been performed in several countries but the comparability of data produced is limited. Harmonisation of the TDS methodology is therefore desirable and the development of comparable TDS food lists is considered essential to achieve the consistency between countries. The aim of this study is to develop and test the feasibility of a method for establishing harmonised TDS food and sample lists in five European countries with different consumption patterns (Czech Republic, Finland, Germany, Iceland and Portugal). The food lists were intended to be applicable for exposure assessment of wide range of chemical substances in adults (18-64 years) and the elderly (65-74 years). Food consumption data from recent dietary surveys measured on individuals served as the basis for this work. Since the national data from these five countries were not comparable, all foods were linked to the EFSA FoodEx2 classification and description system. The selection of foods for TDS was based on the weight of food consumed and was carried out separately for each FoodEx2 level 1 food group. Individual food approach was respected as much as possible when the TDS samples were defined. TDS food lists developed with this approach represented 94.7-98.7% of the national total diet weights. The overall number of TDS samples varied from 128 in Finland to 246 in Germany. The suggested method was successfully implemented in all five countries. Mapping of data to the EFSA FoodEx2 coding system was recognised as a crucial step in harmonisation of the developed TDS food lists.

Ochratoxin A Dietary Exposure of Ten Population Groups in the Czech Republic: Comparison with Data over the World.

Ochratoxin A is a nephrotoxic and renal carcinogenic mycotoxin and is a common contaminant of various food commodities. Eighty six kinds of foodstuffs (1032 food samples) were collected in 2011-2013. High-performance liquid chromatography with fluorescence detection was used for ochratoxin A determination. Limit of quantification of the method varied between 0.01-0.2 µg/kg depending on the food matrices. The most exposed population is children aged 4-6 years old. Globally for this group, the maximum ochratoxin A dietary exposure for "average consumer" was estimated at 3.3 ng/kg bw/day (lower bound, considering the analytical values below the limit of quantification as 0) and 3.9 ng/kg bw/day (middle bound, considering the analytical values below the limit of quantification as 1/2 limit of quantification). Important sources of exposure for this latter group include grain-based products, confectionery, meat products and fruit juice. The dietary intake for "high consumers" in the group 4-6 years old was estimated from grains and grain-based products at 19.8 ng/kg bw/day (middle bound), from tea at 12.0 ng/kg bw/day (middle bound) and from confectionery at 6.5 ng/kg bw/day (middle bound). For men aged 18-59 years old beer was the main contributor with an intake of 2.60 ng/kg bw/day ("high consumers", middle bound). Tea and grain-based products were identified to be the main contributors for dietary exposure in women aged 18-59 years old. Coffee and wine were identified as a higher contributor of the OTA intake in the population group of women aged 18-59 years old compared to the other population groups.

Reporting accuracy of population dietary sodium intake using duplicate 24 h dietary recalls and a salt questionnaire.

High dietary Na intake is associated with multiple health risks, making accurate assessment of population dietary Na intake critical. In the present study, reporting accuracy of dietary Na intake was evaluated by 24 h urinary Na excretion using the EPIC-Soft 24 h dietary recall (24-HDR). Participants from a subsample of the European Food Consumption Validation study (n 365; countries: Belgium, Norway and Czech Republic), aged 45-65 years, completed two 24 h urine collections and two 24-HDR. Reporting accuracy was calculated as the ratio of reported Na intake to that estimated from the urinary biomarker. A questionnaire on salt use was completed in order to assess the discretionary use of table and cooking salt. The reporting accuracy of dietary Na intake was assessed using two scenarios: (1) a salt adjustment procedure using data from the salt questionnaire; (2) without salt adjustment. Overall, reporting accuracy improved when data from the salt questionnaire were included. The mean reporting accuracy was 0·67 (95 % CI 0·62, 0·72), 0·73 (95 % CI 0·68, 0·79) and 0·79 (95 % CI 0·74, 0·85) for Belgium, Norway and Czech Republic, respectively. Reporting accuracy decreased with increasing BMI among male subjects in all the three countries. For women from Belgium and Norway, reporting accuracy was highest among those classified as obese (BMI ≥ 30 kg/m2: 0·73, 95 % CI 0·67, 0·81 and 0·81, 95 % CI 0·77, 0·86, respectively). The findings from the present study showed considerable underestimation of dietary Na intake assessed using two 24-HDR. The questionnaire-based salt adjustment procedure improved reporting accuracy by 7-13 %. Further development of both the questionnaire and EPIC-Soft databases (e.g. inclusion of a facet to describe salt content) is necessary to estimate population dietary Na intakes accurately.

Feasibility of dietary assessment methods, other tools and procedures for a pan-European food consumption survey among infants, toddlers and children.

PURPOSE: To test the feasibility of tools and procedures for a pan-European food consumption survey among children 0-10 years and to recommend one of two tested dietary assessment methods. METHODS: Two pilot studies including 378 children were conducted in Belgium and the Czech Republic in the Pilot studies for Assessment of Nutrient intake and food Consumption among Kids in Europe. One protocol included a 3-day food diary which was checked with a parent, and data were entered afterwards using EPIC-Soft. The alternative protocol consisted of two non-consecutive 1-day food diaries followed by EPIC-Soft completion interviews. Both protocols included general and food propensity questionnaires and anthropometric measurements. The protocols were compared using evaluation questionnaires among the participating parents and study personnel. RESULTS: The parents found the questionnaires and instructions for filling in the food diaries understandable. Food description and food quantification was evaluated as problematic by 29 and 15% of the participants for the 3-day diaries versus 15 and 12% for the 1-day diaries. The protocol with 1-day food diaries was evaluated as less burdensome by the parents and logistically more challenging by the interviewers. CONCLUSIONS: Both dietary assessment methods with related tools and administration protocols were evaluated as feasible. The administration protocol with two 1-day food diaries with completion interviews offers more advantages for the future pan-European survey in children 0-10 years. The positive evaluation of feasibility of tools and materials is an important step towards harmonised food consumption data at European level among the younger age groups.

Cumulative dietary exposure to a selected group of pesticides of the triazole group in different European countries according to the EFSA guidance on probabilistic modelling.

The practicality was examined of performing a cumulative dietary exposure assessment according to the requirements of the EFSA guidance on probabilistic modelling. For this the acute and chronic cumulative exposure to triazole pesticides was estimated using national food consumption and monitoring data of eight European countries. Both the acute and chronic cumulative dietary exposures were calculated according to two model runs (optimistic and pessimistic) as recommended in the EFSA guidance. The exposures obtained with these model runs differed substantially for all countries, with the highest exposures obtained with the pessimistic model run. In this model run, animal commodities including cattle milk and different meat types, entered in the exposure calculations at the level of the maximum residue limit (MRL), contributed most to the exposure. We conclude that application of the optimistic model run on a routine basis for cumulative assessments is feasible. The pessimistic model run is laborious and the exposure results could be too far from reality. More experience with this approach is needed to stimulate the discussion of the feasibility of all the requirements, especially the inclusion of MRLs of animal commodities which seem to result in unrealistic conclusions regarding their contribution to the dietary exposure.

Comparison of two food record-based dietary assessment methods for a pan-European food consumption survey among infants, toddlers, and children using data quality indicators.

PURPOSE: We aimed (1) to describe and evaluate the "EPIC-Soft DataEntry" application developed as a user-friendly data entry tool for pan-European and national food consumption surveys among infants and children, and (2) to compare two food record-based dietary assessment methods in terms of food description and quantification using data quality indicators. EPIC-Soft DataEntry was used for both methods. METHODS: Two pilot studies were performed in both Belgium and Czech Republic in a total of 376 children (3 months to 10 year olds): one using a consecutive 3-day food diary; and the second with two non-consecutive 1-day food diaries with data entry during a completion interview. The collected dietary data were compared between the two dietary assessment methods by country and by age groups: (i) <1 year; (ii) 1-3 years; (iii) >3-10 years. RESULTS: Overall, 70% of the interviewers evaluated the work with EPIC-Soft DataEntry as easy. With both dietary assessment methods, an equally high proportion of specific food names (e.g., "yoghurt, strawberry") were reported, where only between 5 and 15% of foods were non-specified (e.g., "yoghurt, n.s."). The two 1-day food diaries yielded a higher proportion of foods with detailed description. For example, in the age category of 1-3 year olds in Belgium, for 7 out of 16 systematic questions on food description (e.g., "preservation method,") specific answers were significantly higher (all P < 0.03). The proportion of missing quantities of consumed foods was comparable between the two methods. CONCLUSIONS: The EPIC-Soft DataEntry application was positively evaluated by the majority of the interviewers. Two non-consecutive 1-day food diaries with data entry during a completion interview provide a more detailed description of consumed foods as compared with a 3-day food diary.

Computational tool for usual intake modelling workable at the European level.

In this paper two models present in the computational tool Monte Carlo Risk Assessment (MCRA) were compared for assessing the usual intake of lead in five countries. For this, we used national food consumption data organised according to the format of the European Food Safety Authority (EFSA) Comprehensive database and a single lead concentration database in which analysed commodities were organised according to EFSA's Standard Sampling Description (SSD) system. This meant that both input data were coded according to the hierarchical FoodEx1 classification system. We demonstrate that the naïve Observed Individual Means model resulted in more conservative estimates of the exposure in the right tail of the exposure distribution compared to a refined usual intake model, the LogisticNormal­Normal model. With MCRA, the usual intake could be estimated with both models using food consumption and concentration data that were coded according to the hierarchical FoodEx1 classification system demonstrating that this tool can be used in EFSA's data environment. Additionally, the computational tool has functionalities 1) to check the input data quality by presenting detailed information about these data around a specified percentile of exposure and 2) to decide whether the use of a more refined usual intake model is appropriate.

Producers and important dietary sources of ochratoxin A and citrinin.

Ochratoxin A (OTA) is a very important mycotoxin, and its research is focused right now on the new findings of OTA, like being a complete carcinogen, information about OTA producers and new exposure sources of OTA. Citrinin (CIT) is another important mycotoxin, too, and its research turns towards nephrotoxicity. Both additive and synergistic effects have been described in combination with OTA. OTA is produced in foodstuffs by Aspergillus Section Circumdati (Aspergillus ochraceus, A. westerdijkiae, A. steynii) and Aspergillus Section Nigri (Aspergillus carbonarius, A. foetidus, A. lacticoffeatus, A. niger, A. sclerotioniger, A. tubingensis), mostly in subtropical and tropical areas. OTA is produced in foodstuffs by Penicillium verrucosum and P. nordicum, notably in temperate and colder zones. CIT is produced in foodstuffs by Monascus species (Monascus purpureus, M. ruber) and Penicillium species (Penicillium citrinum, P. expansum, P. radicicola, P. verrucosum). OTA was frequently found in foodstuffs of both plant origin (e.g., cereal products, coffee, vegetable, liquorice, raisins, wine) and animal origin (e.g., pork/poultry). CIT was also found in foodstuffs of vegetable origin (e.g., cereals, pomaceous fruits, black olive, roasted nuts, spices), food supplements based on rice fermented with red microfungi Monascus purpureus and in foodstuffs of animal origin (e.g., cheese).

EURRECA-A framework for considering evidence in public health nutrition policy development.

A key step toward developing appropriate evidence-based public health nutrition policies is determining exactly how that evidence should be collected and assessed. Despite this the extent to which different evidence bases influence policy selection is rarely explored. This article presents an epistemological framework which offers a range of considerations affecting this process generally and with particular implications for both micronutrient requirements and the role of behavior in the policy-making process. Qualitative case study data covering 6 European countries/regions (Czech Republic, Italy, the Netherlands, Nordic countries, Poland, and Spain), and three micronutrients (folate, iodine, and vitamin D), have been presented to illustrate the relevance of the Framework.

Validation of a food quantification picture book targeting children of 0-10 years of age for pan-European and national dietary surveys.

The aim of the present study was to validate thirty-eight picture series of six pictures each developed within the PANCAKE (Pilot study for the Assessment of Nutrient intake and food Consumption Among Kids in Europe) project for portion size estimation of foods consumed by infants, toddlers and children for future pan-European and national dietary surveys. Identical validation sessions were conducted in three European countries. In each country, forty-five foods were evaluated; thirty-eight foods were the same as the depicted foods, and seven foods were different, but meant to be quantified by the use of one of the thirty-eight picture series. Each single picture within a picture series was evaluated six times by means of predefined portions. Therefore, thirty-six pre-weighed portions of each food were evaluated by convenience samples of parents having children aged from 3 months to 10 years. The percentages of participants choosing the correct picture, the picture adjacent to the correct picture or a distant picture were calculated, and the performance of individual pictures within the series was assessed. For twenty foods, the picture series performed acceptably (mean difference between the estimated portion number and the served portion number less than 0.4 (SD < 1.1)). In addition, twelve foods were rated acceptable after adjustment for density differences. Some other series became acceptable after analyses at the country level. In conclusion, all picture series were acceptable for inclusion in the PANCAKE picture book. However, the picture series of baby food, salads and cakes either can only be used for foods that are very similar to those depicted or need to be substituted by another quantification tool.