To review the various biomarkers of dietary intakes of fatty acids in human populations, their measurement, limitations and analytical considerations.

Review of the literature.

Although there is no good biomarker of intake of total fat, a number of alternatives exist for assessing the intakes of exogenously produced fatty acids that are consumed. Adipose tissue, erythrocyte membrane concentrations and serum or plasma levels can reflect prior intakes over the past few hours to the past few years. The concentrations of individual fatty acids in these media generally reflect relative levels, and are influenced by a number of factors. Although relatively expensive to analyse, a single analysis by gas chromatography or high-performance liquid chromatography provides information on multiple fatty acids, and is superior to attempting to measure specific fatty acids using traditional dietary assessment methods.

Biomarkers of fatty acids that reflect long-term intake are available for nutritional epidemiology purposes. Analytical methods have become very accurate and able to detect and quantify smaller families, such as trans-fatty acids.

The purpose of this paper is to describe social and economic changes related to shifts in diet and activity and to present prevalences for chronic diseases associated with the nutrition transition.

Observations about social changes are descriptive, based on published reports and personal observations. Prevalence and trends data are based on a Ministry of Health published report and, for infants and toddlers, on primary data.

Disease prevalences for diabetes mellitus and hypertension are taken from four sites, representing underdeveloped, semi-developed and well-developed rural communities and Dar es Salaam, the largest city in Tanzania. The prevalences of underweight and overweight for infants and toddlers are taken from a small periurban clinic in Tanzania.

Adults over 15 years of age are included in the prevalence data for chronic disease. The urban sample is stratified by occupation and ethnicity. The data for infants and toddlers include newborns to those aged 23 months.

An increase in the prevalence of diabetes and hypertension was observed. Simultaneously, there have been rapid changes in diet and physical activity related to urbanisation and modernisation. The highest prevalences for diabetes and hypertension were among high-ranking executives.

The increase in chronic disease could be related to the rise in the number of high-ranking executives. Simultaneously, per capita income has gone down, and malnutrition prevalence has risen. Programmes are being developed to simultaneously monitor trends in overweight while preventing protein-energy malnutrition and micronutrient deficiency.

To assess the influence of different standards and restrained eating on underreporting in healthy, non-obese, weight-stable young subjects.

Eighty-three young adults (20–38 years, 55 women, 28 men) were assessed under weight-stable conditions with a 7-day dietary record and the three-factor eating questionnaire by Stunkard and Messick. Resting energy expenditure (REE; indirect calorimetry) plus data derived from physical activity records (PA) (Standard 1) or REE times an activity factor (AF) (Standard 2) was used as standard for total energy expenditure (TEE). For comparison, doubly labelled water (DLW) was used to measure TEE in a subgroup of subjects.

There was an association between self-reported energy intake and Standard 2 (r = 0.72) but not with Standard 1. When compared with DLW both calculated standards were inaccurate, but Standard 2 avoided high levels of overreporting. Using Standard 2 to identify ‘severe’ underreporting (SU; as defined by a deviation of energy intake (EI) and TEE of >20%), SU was seen in 37% of all subjects. It was more frequently found in women than in men (49% of women, 14.3% of men, P < 0.05). Underreporting subjects had a reduced EI (P < 0.01) but there were no significant differences in nutritional status (body weight and height, body mass index, fat mass and fat-free mass), energy expenditure and the proportion of energy from macronutrients between normal and underreporting subjects. However, high restraint was associated with a higher degree of underreporting in the total group, whereas disinhibition had an influence only in men.

A high prevalence of SU is seen in non-obese subjects. Characteristics of eating behaviour (restraint and disinhibition) were associated with underreporting but seemed to have a different influence in men and women.

To review existing methods and illustrate the use of a new, simple method for identifying inaccurate reports of dietary energy intake (rEI).

Comparison of rEI with energy requirements estimated by using total energy expenditure predicted (pTEE) from age, weight, height and sex using a previously published equation. Propagation of error calculations was performed and cut-offs for excluding rEI at plus or minus two standard deviations (±2 SD) and ±1 SD for the agreement between rEI and pTEE were established.

Dietary survey in a US national cohort: the Continuing Survey of Food Intakes by Individuals (CSFII), 1994–96.

Men and non-pregnant, non-lactating women aged 21–45 years in the CSFII who provided two multiple-pass 24-hour recalls, height and weight(n = 3755).

Average rEI was 77% of pTEE in men, and 64% of pTEE in women. Calculated cut-offs were rEI <40% or >160% of pTEE (±2 SD) and <70% or >130% of pTEE (±1 SD), respectively. Use of only the ±1 SD cut-offs, not the ±2 SD cut-offs, resulted in a relationship between rEI and body weight similar to what was expected (based on an independently calculated relationship between rEI and measured TEE). Exclusion of rEI outside either the ±2 SD (11% of subjects) or ±1 SD (57% of subjects) cut-offs did not affect mean reported macronutrient intakes, but did markedly affect relationships between dietary composition and body mass index.

When examining relationships between diet and health, use of ±1 SD cut-offs may be preferable to ±2 SD cut-offs for excluding inaccurate dietary reports.

The habitual intake of the conjugated linoleic acid (CLA) isomer C18:2 c9t11 (rumenic acid, RA) was assessed and compared with plasma biomarkers.

The newly developed food-frequency questionnaire (FFQ) comprised 46 food items and was validated by means of a 7-day estimated record (7-d ER). Additionally, the dietary intake results of the FFQ, 7-d ER, the last day (1-d ER) and the last two days (2-d ER) before blood sampling of the 7-d ER were compared to the content of C18:2 c9t11 in plasma phospholipids (PL) and triglycerides (TG) as possible biomarkers.

Metabolic unit of a university institute.

Fifty-seven students completed both dietary instruments. From all participants fasting blood samples were taken.

Mean daily intake of rumenic acid was 246 mg day−1 and 323 mg day−1 as measured by the FFQ and the 7-d-ER, respectively. The degree of correspondence between both assessment methods was acceptable; this is indicated by a total kappa value of κ = 0.31 (P < 0.01) and a Pearson correlation coefficient of r = 0.46 (P < 0.01). Rumenic acid content in plasma triglycerides was twice as high as found in phospholipids. The correlation between the intake results gained with the 7-d ER and the plasma PL contents of C18:2 c9t11 was statistically significant; this was also true for the C18:2 c9t11 values in plasma TG compared with the intake results of one or two days before blood sampling.

Regarding RA intake, the FFQ data revealed an acceptable degree of correspondence with the 7-d ER data but failed to show significant correlations to the potential biomarkers. However, with respect to the results of the 7-d ER, the RA content in plasma PL and TG are possible biomarkers of short-term and medium-term intake, respectively.

The aim of this study was to assess whether self-reported mental health status, measured using the SF-36 questionnaire, was associated with fish consumption, assessed using a food-frequency questionnaire.

The cross-national data were collected in the 1996/97 New Zealand Health Survey and 1997 Nutrition Survey, which were conducted using the same sampling frame. Survey respondents were categorised into those who consumed no fish of any kind and those who consumed some kind of fish, at any frequency. Data were adjusted for age, household income, eating patterns, alcohol use and smoking. Other demographic variables and potential confounding nutrients were included in the preliminary analyses but were not found to have a significant relationship with fish consumption.

Data from a nationally representative sample of 4644 New Zealand adults aged 15 years and over were used in this analysis.

Fish consumption was significantly associated with higher self-reported mental health status, even after adjustment for possible confounders. Differences between the mean scores for fish eaters and those who never eat fish were 8.2 for the Mental Health scale (P = 0.005) and 7.5 for the Mental Component score (P = 0.001). Conversely, the association between fish consumption and physical functioning was in the opposite direction (P = 0.045).

This is the first cross-sectional survey to demonstrate a significant relationship between fish intake and higher self-reported mental health status, therefore offering indirect support for the hypothesis that ω-3 polyunsaturated fatty acids may act as mood stabilisers.

To evaluate the reliability of alcohol consumption measured by five different dietary methods in the Catalan Nutrition Survey (1992–1993).

The different questionnaires used were: (1) two 7-day food records, (2) five items addressing alcoholic beverages in a 76-item food-frequency questionnaire, (3) a 1-week recall of 13 alcoholic beverages, (4) a 13-item alcoholic beverages frequency questionnaire and (5) two 24-hour recalls.

Ninety-three of the 120 adults (aged 20 to 70 years) initially recruited completed the questionnaires and provided a peripheral blood sample.

Mean daily alcohol intakes as assessed by the questionnaires were very similar. Beer was the alcoholic beverage most frequently consumed, followed by wine and liquor. Eighty-two per cent of the study population consumed less than 20 g of alcohol per day. No biochemical parameters were significantly correlated with alcohol intake estimated from the questionnaires.

We found a satisfactory level of reproducibility and validity in the pattern of alcohol consumption across different levels and types of alcoholic beverage intake. We also found that the self-administered 13-item questionnaire and the 1-week recall were the best techniques to measure moderate or low alcohol consumption, suggesting that the two methods are the most suitable to assess overall alcohol intake in the general population.

To assess the relative validity of the second version of a quantitative food-frequency questionnaire (QFFQ), designed to measure the habitual food and nutrient intake in one season in rural populations in Western Mali, West Africa.

The dietary intake during the previous week was assessed with the 164-item QFFQ administered by interview. This was compared with the intake from a 2-day weighed record (WR) with weighed recipes.

The village of Ouassala in the Kayes region, Western Mali.

Thirty-four women and 36 men aged 15–45 years, from 29 households.

The QFFQ gave a lower intake of lunch and dinner and a higher intake of snacks than the WR. The discrepancies were larger for women than for men. The median proportion of subjects classified in the same quartile of intake was 29% for food groups and 36% for energy and nutrients. For classification into extreme opposite quartiles, the median proportion was 6% for food groups and 7% for energy and nutrients. Spearman's rank correlation for energy and nutrients ranged from 0.16 (% energy from protein) to 0.62 (retinol equivalents).

The second version of the QFFQ tends to underestimate total food weight. The methods used for estimating food portion size should therefore be applied with caution. The changes made from the first version had little effect. The ability to rank subjects according to dietary intake is similar with both versions. The improved layout of the new QFFQ makes it a more user-friendly tool for comparing dietary intake between population groups and for measuring changes over time.

To evaluate meat intake patterns in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohorts.

24-Hour dietary recalls were assessed within the framework of a prospective cohort study in 27 centres across 10 European countries by means of standardised computer-assisted interviews.

In total, 22 924 women and 13 031 men aged 35–74 years.

Mean total meat intake was lowest in the ‘health-conscious’ cohort in the UK (15 and 21 g day−1 in women and men, respectively) and highest in the north of Spain, especially in San Sebastian (124 and 234 g day−1, respectively). In the southern Spanish centres and in Naples (Italy), meat consumption was distinctly lower than in the north of these countries. Central and northern European centres/countries showed rather similar meat consumption patterns, except for the British and French cohorts. Differences in the intake of meat sub-groups (e.g. red meat, processed meat) across EPIC were even higher than found for total meat intake. With a few exceptions, the Mediterranean EPIC centres revealed a higher proportion of beef/veal and poultry and less pork or processed meat than observed in central or northern European centres. The highest sausage consumption was observed for the German EPIC participants, followed by the Norwegians, Swedish, Danish and Dutch.

The results demonstrate distinct differences in meat consumption patterns between EPIC centres across Europe. This is an important prerequisite for obtaining further insight into the relationship between meat intake and the development of chronic diseases.

To evaluate the influence of dietary fibre on menarche in a cohort of pre-menarcheal girls.

Prospective cohort study.

Ontario, Canada.

Free-living pre-menarcheal girls (n = 637), 6 to 14 years of age.

Information on dietary intake, physical activity and date of menarche was collected at baseline and was updated annually by self-administered questionnaires for three years. Cox proportional hazards models were used to evaluate the association between dietary fibre and menarche, adjusting for age at entry to the study and potential confounders.

A higher intake of energy-adjusted dietary fibre was associated with a lower risk of (i.e. a later age at) menarche (relative hazard 0.54, 95% confidence interval (CI) 0.31–0.94 for highest vs. lowest quartile, P for trend = 0.027). At the fibre component level, a higher intake of energy-adjusted cellulose was associated with a lower risk of menarche (relative hazard 0.45, 95% CI 0.26–0.76, P for trend = 0.009).

The findings are consistent with the hypothesis that pre-menarcheal dietary intake can influence menarche.

To assess the validity of the food-frequency questionnaire used in the European Prospective Investigation of Cancer (EPIC FFQ) for estimating nutrient intake in an adolescent population.

Sixty-seven schoolchildren (mean age: 12.3±0.3 years) were recruited to complete a 7-day weighed dietary record (7-day WDR), the EPIC FFQ and supply one 24-hour urine collection.

Harris Academy in Dundee (UK).

Fifty subjects completed both dietary assessment methods. Thirteen of these were classified as underreporters with energy intake/basal metabolic rate<1.14. The EPIC FFQ showed higher estimates than the 7-day WDR for all nutrients. The median Spearman correlation coefficient for the nutrients examined was found to be 0.31 and increased to 0.48 after adjustment for total energy. The limits of agreement were as far apart as 13.4 MJ, 120 g, 270 g, 120 g and 1170 mg for energy, fat, sugar, protein and calcium, respectively. Correlations between urine and 7-day WDR dietary nitrogen and potassium were found to be statistically significant with r = 0.45 (P<0.05) and r = 0.78 (P<0.001), respectively. The median proportion of subjects that appeared in the same and opposite third of intake was found to be 45.9% and 10.8%, respectively.

The EPIC FFQ seems adequate to correctly classify low, medium and high consumers and might therefore be used to identify adolescent population groups at risk or for differences between populations. However, agreement between the EPIC FFQ and the 7-day WDR was very poor on both a group and an individual basis, and demonstrates that the EPIC FFQ is not an appropriate method for estimating absolute intakes in this age group.

To provide a framework for use of the doubly labelled water method to measure energy expenditure in order to validate dietary instruments for the assessment of energy.

Review and description of the use of doubly labelled water method for use as a biomarker for habitual energy intake.

The doubly labelled water method has a relative accuracy of 1% and within-subject precision of 5 to 8%. Comparison of self-reported energy intake with energy expenditure demonstrated that over one-third of individuals may underreport energy intake by more than 25%.

The doubly labelled water method, although expensive and dependent on non-routine laboratory instrumentation, is an excellent biomarker of energy intake.

The purpose of the study was to assess the validity of a 52-item semiquantitative food-frequency questionnaire (FFQ) by comparing it with multiple 24-hour dietary recalls.

Three non-consecutive 24-hour dietary recalls and one FFQ were administered over a one-month period.

Four communities of El Progreso, Guatemala.

Seventy-three individuals aged 22–55 years.

Intakes of energy and other nutrients as measured by the FFQ were higher than intakes measured by 24-hour recalls. Energy was overestimated by 361 kcal, and nutrient overestimates were particularly great for vitamin C and iron. Pearson correlation coefficients for crude energy and nutrients intakes ranged from 0.64 for energy to 0.12 for vitamin C. Exact agreement for both methods (measured by the concordance correlation coefficient) ranged from 0.59 (fat) to 0.06 (vitamin C). Pearson correlation coefficients for energy-adjusted nutrients ranged from 0.59 (carbohydrates) to 0.11 (thiamin). Pearson correlation coefficients for the proportion of total energy derived from specific foods ranged from 0.59 (tortillas) to 0.01 (sugared beverages). Cross-classification of quartiles of crude nutrient intakes for both methods indicated that <11% were grossly misclassified; after adjusting for energy intake, <13% were grossly misclassified.

This FFQ provides good measures of energy and macronutrient intakes and a reasonably reliable measure of micronutrient intake, indicating its suitability for comparing exposures within a study population in reference to heath-related endpoints. Our results highlight the need to adapt any FFQ to specific cultural needs – in this case, the Guatemalan ‘core foods’ (tortilla, bread and beans), for which inter-individual variability in intake is high.

To fully explore the long-term shifts in the nutrition transition and the full implications of these changes in the Chinese diet.

A descriptive, population-based study.

Data come from nationally representative surveys: the China Health and Nutrition Survey (1989–1997), the China National Nutrition Survey (1982 and 1992), the annual household consumption surveys of the State Statistical Bureau, and the Annual Death Report of China.

During the first part of the major economic transformation in China (before 1985), cereal intake increased but decreased thereafter. There was also a long-term reduction of vegetable consumption that has now stabilised. Intake of animal foods increased slowly before 1979 and more quickly after the economic reforms occurred. While the total energy intake of residents has decreased, as has energy expenditure, large changes in the composition of energy have occurred. The overall proportion of energy from fat increased quickly, reaching an overall average of 27.3% and 32.8% for urban residents in 1997. Over a third of all Chinese adults and 60.1% of those in urban areas consumed over 30% of their energy from fat in 1997. Large shifts towards increased inactivity at work and leisure occurred. These changes are linked with rapid increases of overweight, obesity and diet-related non-communicable diseases (DRNCDs) as well as total mortality for urban residents.

The long-term trend is a shift towards a high-fat, high-energy-density and low-fibre diet. The Chinese have entered a new stage of the nutrition transition.

To compare thyroid-stimulating hormone (TSH) levels in neonatal cord blood between study sites in Bangladesh, Guatemala and the United States. Also, to compare neonatal TSH results with indicators of iodine deficiency in school children.

Consecutive births and, in school children, cross-sectional surveys.

Savar, Bangladesh; San Pedro Sacatepequez, Guatemala; and Atlanta, United States.

In each study site, cord blood was spotted on to filter paper and TSH levels determined using a sensitive monoclonal assay. In the USA, heel stick blood specimens from newborns spotted on to filter paper were also obtained as well as exposure to iodine-containing antiseptics during the birthing process. Urine specimens were collected from mothers of newborns and tested for iodine concentration. School children in the same areas were surveyed for thyroid size by palpation and ultrasonography, and urine specimens collected for iodine concentration.

Between 141 and 243 cord blood specimens were collected from each study site. The prevalence of elevated cord blood TSH levels (>5 mU l−1) was high in all study sites, from 58% to 84%. All sites would be categorised as having ‘severe’ iodine deficiency based on WHO/UNICEF/ICCIDD criteria. Iodine-containing antiseptics were used during 98% of the births in the USA but not in Bangladesh or Guatemala. The neonatal TSH classification indicated more severe iodine deficiency levels than classifications based on urinary iodine and goitre in school children.

In the USA, elevated TSH levels may be partially attributed to use of beta-iodine-containing antiseptics prior to birth. We recommend the cautious interpretation of TSH results in newborns for the assessment of iodine deficiency disorders when iodine-containing antiseptics are used during the birthing process.

To assess longitudinal changes in the consumption of nutrients and the impact of socio-economic factors on diet transition in the Melbourne Chinese Health Study (MCHS) cohort.

Longitudinal study including two phases: baseline (1989/90) and follow-up (1995/97).

Melbourne metropolitan areas in Victoria, Australia.

Two hundred and sixty-two Chinese men and women aged 25 years and over, recruited at baseline, who had completed the both baseline and follow-up food-frequency questionnaires.

Women increased their daily intakes of energy (+549 kJ), protein (+7.8 g), fat (+7.3 g) and dietary fibre (+5.6 g) whereas men decreased their daily consumption of carbohydrate (-38.5 g) over an average period of 8 years. Energy contributions from protein and fat rose while that from carbohydrate dropped for all cohort subjects. Increased intakes of riboflavin, β-carotene and iron were observed in men, while an increased consumption of thiamine, riboflavin, niacin and minerals (except sodium) was observed in women. Socio-economic factors such as education, family income levels and occupational categories appeared to have a far more powerful influence on changes in individual daily nutrient intakes than age or length of stay in Australia. Changes in nutrient intake in women were less affected by sociodemographic variables.

The observed changes in nutrient intakes indicated a progressive approach towards the Australian Recommended Dietary Intakes within this Chinese cohort population.

The objective was to conduct a critical appraisal of research conducted within one of the UK government's research programmes, Optimal Nutrition Status, and to place the findings of this work in the context of the international research effort, to assist policy makers and advisers. Nine nutrients are addressed within the programme; the findings for three of these are reported here: folate/folic acid, iron and copper.

To conduct the review, the researchers had access to all unpublished progress reports, submitted to officials, arising from the projects. The overall assessment criterion was whether the information generated by the research programme could be regarded as reliable experimental data of direct relevance to setting optimal dietary requirements for the particular micronutrients. However, findings were also assessed against specific scientific criteria concerning understanding of the bioavailability, interactions, development of functional markers and inter-individual variations in metabolism, for each of the nutrients scrutinised.

The results of the review indicated that many important questions are indeed being addressed by the UK government's research programme, and that the work is contributing to the overall research effort being conducted world-wide on this important subject.

Many major questions still need to be addressed before it will be possible to identify optimal intakes for various sub-populations. These priorities are summarised in the paper.

To describe and compare the consumption of dairy products in cohorts included in the European Prospective Investigation into Cancer and Nutrition (EPIC).

Data from single 24-hour dietary recall interviews collected through a highly standardised computer-based program (EPIC-SOFT) in 27 redefined centres in 10 European countries between 1995 and 2000. From a total random sample of 36 900, 22 924 women and 13 031 men were selected after exclusion of subjects under 35 and over 74 years of age.

A high total consumption of dairy products was reported in most of the centres in Spain and in the UK cohort sampled from the general population, as well as in the Dutch, Swedish and Danish centres. A somewhat low consumption was reported in the Greek centre and in some of the Italian centres (Ragusa and Turin). In all centres and for both sexes, milk constituted the dairy sub-group with the largest proportion (in grams) of total dairy consumption, followed by yoghurt and other fermented milk products, and cheese. Still, there was a wide range in the contributions of the different dairy sub-groups between centres. The Spanish and Nordic centres generally reported a high consumption of milk, the Swedish and Dutch centres reported a high consumption of yoghurt and other fermented milk products, whereas the highest consumption of cheese was reported in the French centres.

The results demonstrate both quantitative and qualitative disparities in dairy product consumption among the EPIC centres. This offers a sound starting point for analyses of associations between dairy intake and chronic diseases such as cancer.

To describe and compare the consumption of total fish (marine foods) and the fish sub-groups – white fish, fatty fish, very fatty fish, fish products and crustacea, in participants from the European Investigation into Cancer and Nutrition (EPIC) study.

Cross-sectional analysis of dietary intake using a computerised standardised 24-hour recall interview. Crude means, means and standard errors adjusted by age, season and day of the week were calculated, stratified by centre and gender.

Twenty-seven redefined centres in the 10 European countries participating in the EPIC study.

In total, 35 955 subjects (13 031 men and 22 924 women), aged 35–74 years, selected from the main EPIC cohort.

A six- to sevenfold variation in total fish consumption exists in women and men, between the lowest consumption in Germany and the highest in Spain. Overall, white fish represented 49% and 45% of the intake of total fish in women and men, respectively, with the greatest consumption in centres in Spain and Greece and the least in the German and Dutch centres. Consumption of fatty fish reflected that of total fish. However, the greatest intake of very fatty fish was in the coastal areas of northern Europe (Denmark, Sweden and Norway) and in Germany. Consumption of fish products was greater in northern than in southern Europe, with white fish products predominating in centres in France, Italy, Spain, The Netherlands and Norway. Intake of roe and roe products was low. The highest consumption of crustacea was found in the French, Spanish and Italian centres. The number of fish types consumed was greater in southern than in northern Europe. The greatest variability in consumption by day of the week was found in the countries with the lowest fish intake.

Throughout Europe, substantial geographic variation exists in total fish intake, fish sub-groups and the number of types consumed. Day-to-day variability in consumption is also high.