To evaluate under- and overreporting and their determinants in the EPIC 24-hour diet recall (24-HDR) measurements collected in the European Prospective Investigation into Cancer and Nutrition (EPIC).

Cross-sectional analysis. 24-HDR measurements were obtained by means of a standardised computerised interview program (EPIC-SOFT). The ratio of reported energy intake (EI) to estimated basal metabolic rate (BMR) was used to ascertain the magnitude, impact and determinants of misreporting. Goldberg's cut-off points were used to identify participants with physiologically extreme low or high energy intake. At the aggregate level the value of 1.55 for physical activity level (PAL) was chosen as reference. At the individual level we used multivariate statistical techniques to identify factors that could explain EI/BMR variability. Analyses were performed by adjusting for weight, height, age at recall, special diet, smoking status, day of recall (weekday vs. weekend day) and physical activity.

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

In total, 35955 men and women, aged 35–74 years, participating in the nested EPIC calibration sub-studies.

While overreporting has only a minor impact, the percentage of subjects identified as extreme underreporters was 13.8% and 10.3% in women and men, respectively. Mean EI/BMR values in men and women were 1.44 and 1.36 including all subjects, and 1.50 and 1.44 after exclusion of misreporters. After exclusion of misreporters, adjusted EI/BMR means were consistently less than 10% different from the expected value of 1.55 for PAL (except for women in Greece and in the UK), with overall differences equal to 4.0% and 7.4% for men and women, respectively. We modelled the probability of being an underreporter in association with several individual characteristics. After adjustment for age, height, special diet, smoking status, day of recall and physical activity at work, logistic regression analyses resulted in an odds ratio (OR) of being an underreporter for the highest vs. the lowest quartile of body mass index (BMI) of 3-52 (95% confidence interval (CD 2.91–4.26) in men and 4.80 (95% CI 4.11–5.6l) in women, indicating that overweight subjects are significantly more likely to underestimate energy intake than subjects in the bottom BMI category. Older people were less likely to underestimate energy intake: ORs were 0.58 (95% CI 0.45–0.77) and 0.74 (95% CI 0.63–0.88) for age (≥ 65 years vs. < 50 years). Special diet and day of the week showed strong effects.

EI tends to be underestimated in the vast majority of the EPIC centres, although to varying degrees; at the aggregate level most centres were below the expected reference value of 1.55. Underreporting seems to be more prevalent among women than men in the EPIC calibration sample. The hypothesis that BMI (or weight) and age are causally related to underreporting seems to be confirmed in the present work. This introduces further complexity in the within-group (centre or country) and between-group calibration of dietary questionnaire measurements to deattenuate the diet—disease relationship.

This paper investigates the roles of the individual stakeholders involved in the development of functional foods and the implications of their actions for public perception of this new food concept.

At a time when consumer awareness of the link between diet and health is strong, a new food concept incorporating of a wide spectrum of foods has captured the imagination of the food industry and consumers alike. Functional foods provide a new category of foods that appear to be offering the public the opportunity to achieve a healthy lifestyle with minimal effort. Public perception may determine whether this new food concept is to become the next successful breakthrough in nutritional science or just another marketing gimmick devised by food manufacturers. The paper also addresses issues that arise directly as a result of the emergence of functional foods, such as appropriate legislation in connection to health claims in order to ensure consumer protection and also the lack of clarity in relation to definitions of what constitutes a functional food.

The paper concludes that functional foods can only reach their maximum potential if the food industry, government and health professionals work together to improve communication between themselves and consumers and also to educate consumers, thereby allowing them to make informed decisions about dietary choices.

This paper explores the unique nutrition transition shifts in diet and activity patterns from the period termed the receding famine pattern to the one dominated by nutrition-related non-communicable diseases (NR-NCDs). The paper examines the speed and timing of these changes; unique components, such as the issue of finding both under- and overnutrition in the same household; potential exacerbating biological relationships that contribute to differences in the rates of changes; and political issues.

The focus is on lower-and middle-income countries of Asia, Africa, the Middle East and Latin America.

These changes are occurring at great speed and at earlier stages of these countries economic and social development. There are some unique issues that relate to body composition and potential genetic factors. The significance of the high number of persons exposed to heavy insults during pregnancy and infancy (foetalorigins hypothesis) and the subsequent rapid shifts in energy imbalance remains to be understood. Countries that are still addressing major concerns of undernutrition are not ready to address these NR-NCDs.

The developing world needs to give far greater emphasis to addressing the prevention of the adverse health consequences of this shift to the nutrition transition stage of degenerative diseases.

To investigate how the priorities of high consumers of fruit and vegetables differ from those of low consumers, with respect to food choice motivations, and to identify what value high and low consumers place on different aspects of food choice behaviour.

A 4-day food diary and a questionnaire, including The Food Choice Questionnaire (FCQ) and a measure of Stage of Change (SOC) for fruit and vegetable consumption, were administered to subjects. Motivation scores from the FCQ were compared with fruit and vegetable intake and SOC data.

Nine hundred and ninety-eight females, aged 35–69 years, participating in the UK Women's Cohort Study.

In a multiple linear regression model, including age, education level and all FCQ motivations, the strongest motivations specifically affecting fruit and vegetable intake were health and natural content. It was found that, for a one point increase (measured on a scale of 0–4) in health and natural content scores, fruit and vegetable consumption increased by 1.11 portions (95% confidence interval (CI) 0.5–1.7) and 0.84 portions (95% CI 0.4–1.3), respectively (P>0.01). The SOC evaluation showed significant associations with portions of fruit and vegetables consumed (P>0.01). Women whose SOC was classed as maintenance phase were found to score higher on health, natural content, weight control and ethical concern factors (P>0.01). These women also scored lower on convenience questions (P>0.01).

In this particular group of women the most important motivating factors for food choice, within the high fruit and vegetable consumers, were health and natural content of the food.

To evaluate measurement error structure in dietary assessment instruments and to investigate its implications for nutritional studies, using urinary nitrogen excretion as a reference biomarker for protein intake.

The dietary assessment methods included different food-frequency questionnaires (FFQs) and such conventional dietary-report reference instruments as a series of 24-hour recalls, 4-day weighed food records or 7-day diaries.

Six original pilot validation studies within the European Prospective Investigation of Cancer (EPIC), and two validation studies conducted by the British Medical Research Council (MRC) within the Norfolk cohort that later joined as a collaborative component cohort of EPIC.

A sample of approximately 100 to 200 women and men, aged 35–74 years, from each of eight validation studies.

In assessing protein intake, all conventional dietary-report reference methods violated the critical requirements for a valid reference instrument for evaluating, and adjusting for, dietary measurement error in an FFQ. They displayed systematic bias that depended partly on true intake and partly was person-specific, correlated with person-specific bias in the FFQ. Using the dietary-report methods as reference instruments produced substantial overestimation (up to 230%) of the FFQ correlation with true usual intake and serious underestimation (up to 240%) of the degree of attenuation of FFQ-based log relative risks.

The impact of measurement error in dietary assessment instruments on the design, analysis and interpretation of nutritional studies may be much greater than has been previously estimated, at least regarding protein intake.

The goal of this paper is to explore the hypothesis that the nutrition transition is related to households having an underweight and an overweight member simultaneously (under/over households and under/over pairs).

The 1993 China Health and Nutrition Survey (CHNS) was used to test the association between being an under/over household and household characteristics related to the nutrition transition. Sociodemographic and diet patterns were tested for the main age combination of the under/over pairs.

In China, 8.1% of all households were found to have underweight and overweight members within the same household.

Results are from the 1993 China Health and Nutrition Survey and are based on a sample of 13814 persons from 3340 households.

The under/over household was more urban, had a higher income and was more likely to have assets such as a television, a motor vehicle and a washing machine, even after controlling for sociodemographic confounders. The under/over household had a diet that was higher in fat and protein compared with the underweight and normal weight households. There were no significant differences between the under/over and overweight households, with many of the associations near unity. Comparisions of the under/over subgroups by age of the under/over pairs showed some differences by income and occupation, but not for diet.

It is imperative, as more individuals become exposed to the diet and lifestyle patterns of the nutrition transition, to find effective public health programmes that can simultaneously promote a healthy lifestyle, improve diet quality and address both undernutrition and chronic disease.

Flavonoids are phytochemicals with potentially beneficial biological effects that are poorly characterised in existing tables of food composition.

To describe new techniques for analysis, absorption, informatics and dietary assessment that are important in measuring the flavonoid content in foods and in developing a flavonoid food composition database.

Data on chemical analyses of the major flavonoid compounds that exist in the food science literature are being located, collated and compiled into a preliminary flavonoid food composition database.

The analytical process begins with preparation of the food for flavonoid analysis using techniques to disrupt the food matrix, alcoholic extraction, and enzymatic or acidic hydrolysis to remove sugars. Separation is usually accomplished using high-performance liquid chromatography. Flavonoids are identified by diode array spectrometry, mass spectrometry or nuclear magnetic resonance spectroscopy. Quantification usually employs comparison of the sample with standards, if available, using the area under the curve of the chromatogram to estimate quantity. Absorption studies are useful since flavonoids vary in their absorption. Finally, information management technologies (informatics) are used to translate flavonoid data information into food composition databases. This process involves identification of foods containing the compounds of interest, collection and organisation of sources of existing analytical data, assignment of quality scores or aggregation of acceptable data for each component and food, calculation of appropriate statistics, assignment of food codes and verification, and finalisation. The resulting food flavonoid database can be used with state-of-the-art dietary assessment methods to develop estimates of flavonoid intakes in foods and to correlate these with estimates of disease risk.

A provisional flavonoid database, including at least two components from each of six classes of flavonoids, should be completed in 2002.

To evaluate the reproducibility of, and to compare and calibrate, diet measures by the Northern Sweden 84-item food-frequency questionnaire (FFQ) with measures from 24-hour diet recalls (24-HDR).

Randomly selected respondents (n=246) from the EPIC (diet-cancer) and MONICA (diet-cardiovascular disease) study cohort in Northern Sweden were invited to answer the FFQ twice over a one-year interval (FFQ1 and FFQ2), and to complete ten 24-hour recalls (reference method) in the months between. Plasma β-carotene concentrations were determined from a subset of 47 participants.

Vasterbotten and Norrbotten, Northern Sweden.

Ninety-six men and 99 women, who completed the study.

The reproducibility of the FFQ was high in terms of both mean energy and nutrient intakes and relative ranking of participants by intake levels (median Pearson correlation of 0.68). Moderately higher food intake frequencies were recorded by FFQ1 compared with 24-hour recalls for dairy products, bread/cereals, vegetables, fruits and potato/rice/pasta, whereas meat, fish, sweet snacks and alcoholic beverage intakes were lower. The median Spearman coefficient of correlation between FFQ1 and the average of ten 24-HDR measurements was 0.50. Daily energy and nutrient intakes were similar for FFQ1 and 24-HDR measurements, except for fibre, vitamin C, β-carotene and retinol (FFQ1<24-HDR) and sucrose and cholesterol (FFQ1>4-HDR). Pearson coefficients of correlation between FFQ1 and 24-HDR corrected for attenuation due to residual day-to-day variation in the 24-HDR measurements ranged from 0.36 to 0.79 (median 0.54). Adjustment for energy had only very moderate effects on the correlation estimates. Calibration coefficients estimated by linear regression of the 24-HDR on the FFQ1 measurements varied between 0.30 and 0.59 for all nutrients except alcohol, which had calibration coefficients close to 1.0. These low calibration coefficients indicate that relative risk estimates corresponding to an absolute difference in dietary intake levels measured by the FFQ will generally be biased towards 1.0. Plasma β-carotene levels had a Pearson coefficient of correlation of 0.47 with the 24-HDR measurements, and of 0.23 with FFQ1 measurements.

The Northern Sweden FFQ measurements have good reproducibility and an estimated level of validity similar to that of FFQ measurements in other prospective cohort studies. The results from this study will form the basis for the correction of attenuation and regression dilution biases in relative risk estimates, in future studies relating FFQ measurements to disease outcomes.

Trends in the nutritional status for developing countries that are undergoing rapid economic growth indicate a decrease in protein-energy malnutrition (PEM) with an associated rise in obesity prevalence.

This paper analyses how supplementary feeding programmes may contribute to rising obesity trends, what factors may explain this phenomenon, and potential strategies to avoid obesity in malnutrition prevention efforts.

Design and setting: This is a descriptive study of changes in nutritional status of infants and young children in Chile and the possible impact of supplementary feeding programmes on the rise in prevalence of obesity. We explored the changes in anthropometric indices before and after receiving food programme benefits and the use of targeting strategies as a way to combine the need to promote optimal growth while preventing obesity.

Evaluation of the change in nutritional status from participants in Chilean supplementary feeding programmes has shown that targeting strategies have been inadequate as children mainly modify their weight-for-age and weight-for-height, while their length-for-age remains practically unchanged.

Monitoring length-for-age as well as weight-for-length is necessary to permit the identification of stunted overweight and obese children, as they should not be given excess energy. Energy supplementation should be adjusted according to activity level, securing adequate micronutrient density. PEM prevention programmes need periodic evaluation, including targeting of beneficiaries, definition of real needs and possible effect on obesity.

This study describes an evaluation of validity and reliability measures in a questionnaire designed to assess knowledge of applied nutrition in children participating in an after-school care dietary intervention programme being undertaken in an area of high social disadvantage.

Three domains were assessed: Knowledge of Applied Nutrition (KN), Knowledge of Food Preparation (KP) and Perceived Confidence in Cooking Skills (PC). Four pilot studies were undertaken to determine item reliability, test–retest reliability, discrimination and difficulty indices, and content, cognitive and face validity.

Primary schools in Dundee, Scotland and Newcastle upon Tyne, England.

Ninety-eight children aged 11 years.

The final instrument comprised 36 questions (18 KN items, 9 KP items and 9 PC items) presented on four sides of paper, which could be self-completed in less than 15 minutes. Question formatting included open and closed structures (KP) and multiple choice (KN and PC) items. All knowledge questions could be answered correctly by 5 to 95% of the target population, with discrimination scores ranging from 0.06 to 0.83. Retest reliability scores were significant (KN 0.458, P>0.001; KP 0.577, P>0.001; PC 0.381, P>0.001) and internal reliability (Cronbach's alpha) of each component was also significant.

The test meets basic psychometric criteria for reliability and validity and forms a suitable instrument for measuring changes associated with intervention work aimed at improving food and dietary knowledge.

To evaluate the validity of a food-frequency questionnaire (FFQ) for assessment of the dietary intakes of polyunsaturated fatty acids (PUFAs) against a biochemical marker of fat intake, erythrocyte cell membrane phospholipid levels, during pregnancy.

Cross-sectional analysis.

Developmental Neurobiology Department, National Institute of Perinatology, Mexico City.

One hundred forty-six healthy pregnant women during the last trimester of pregnancy. Among women enrolled, the first 35 pregnant women (24%) had their erythrocytes analysed for fatty acid status.

We administered an FFQ and compared intakes of PUFAs against their erythrocyte cell membrane concentrations, processed by gas chromatography.

Pearson correlation coefficients among α-linolenic acid (ALN), docosahexaenoic acid (DHA) and eicosapentaenoic acid in erythrocyte cell membranes against their crude dietary counterparts were 0.32, 0.35 and 0.36 (each P < 0.05). In a simple linear regression, erythrocyte DHA and arachidonic acid (AA) were significantly related to their respective dietary intakes (β = 0.30, 95% confidence interval (CI): 0.007–0.60, P = 0.045 for DHA; β = 0.49, 95% CI: 0.010–0.98, P = 0.044 for AA). Erythrocyte cell membrane ALN concentration (%/total) was only marginally related to ALN dietary intake (mg day−1) (β = 0.52, 95% CI: −0.020–1.10, P = 0.061). However, after adjustment for long-chain n–3 PUFA/AA, this association reached significance (β = 0.44, 95% CI: 0.026–0.825, P = 0.038). Main dietary sources for n–3 PUFAs were canned tuna fish and fresh catfish; for n–6 these were eggs and cow's milk. The use of this FFQ in these pregnant Mexican women provided estimates of average long-term intakes of PUFAs and correlated reasonably well with their erythrocyte cell membrane phospholipid status. However, we need to consider that, during pregnancy, there is a faster turnover of PUFAs from fat storage that may modify the profile of erythrocyte PUFAs and lower the correlation between dietary intake and erythrocyte PUFAs.

To examine folic acid and vitamin B12 status in a group of 1000 persons sampled from the community of Umeå, Sweden, and aged 35, 40, 45, 50, 55, 60, 65, 70, 75 or 80 years. Reference data for folate and age-stratified reference data for vitamin B12 are presented, together with an examination of potential confounders.

All subjects participated in extensive health examinations and interviews, and laboratory blood testing was performed.

A series of exclusion criteria were applied, and data from 961 subjects were analysed. Vitamin B12 levels were found to decrease with increasing age, whereas folate levels remained constant across the age span studied. None of the vitamins was found to vary with sex, education, smoking or alcohol consumption, body mass index, prescription-free vitamin supplements, level of haemoglobin, or mean cell volume of erythrocytes. Further, none of these factors was associated with the age-related decrease of vitamin B12 level.

The offered reference ranges should be used only in order to rule out deficiency. For B12 levels, the age of the subject should be considered such that, for elderly people in particular, values above the medians should be considered as indicative of normal vitamin status.

Increasing recognition of the potential importance of phytochemicals in the aetiology of cancer and heart diseases has highlighted the need for methods to measure individual phytochemical consumption that are sufficiently simple to be used in large epidemiological studies and whose reproducibility and accuracy have been quantified. D-Limonene is a natural component of a variety of foods and beverages and is found mainly in citrus fruits. However, D-limonene is not assessed by any nationally available analysis database.

We designed our study to assess the D-limonene content of different citrus juices and beverages and to develop a dietary assessment instrument to measure consumption of citrus foods (fruit, juice and peel) and D-limonene intake and test it for reliability.

A total of 120 citrus juice samples were analysed and used to develop the preliminary D-limonene database. A self-administered citrus food-frequency questionnaire was developed and administered twice to participants, separated by a 2-month interval. The questionnaire was tested for reproducibility of estimates of citrus food consumption and D-limonene intake among 120 participants.

Correlation coefficients between the two administrations of the questionnaire ranged from 0.50 for citrus peel use to 0.82 for orange juice. Mean intakes (range) of D-limonene from citrus juices among consumers were 13.0 (0.24–141.9) mg day−1 and 13.2 (0.07–83.9) mg day−1 (r = 0.60, P < 0.001).

The citrus frequency questionnaire developed in this study provided highly reproducible estimates of citrus foods, citrus peel and D-limonene intakes. This instrument may be a useful tool in studies of the associations between citrus peel use, D-limonene intake and risk for chronic disease.

To review the available data on risk factors for cardiovascular disease (CVD), the influence of urbanisation of Africans on these risk factors, and to examine why stroke emerges as a higher risk than ischaemic heart disease (IHD) in the health transition of black South Africans.

A review of published data on mortality from and risk factors of CVD in South Africans.

South Africa.

South African population groups and communities.

The available data on the contribution of stroke and IHD to CVD mortality in South Africa are briefly reviewed, followed by a comparison of published data on the prevalence and/or levels of CVD risk factors in the different South African population groups. The impact of urbanisation of black South Africans on these risk factors is assessed by comparing rural and urban Africans who participated in the Transition and Health during Urbanisation of South Africans (THUSA) study.

Results and conclusions: The mortality rates from CVD confirmed that stroke is a major public health problem amongst black South Africans, possibly because of an increase in hypertension, obesity, smoking habit and hyperfibrinogenaemia during various stages of urbanisation. The available data further suggest that black South Africans may be protected against IHD because of favourable serum lipid profiles (low cholesterol and high ratios of high-density lipoprotein cholesterol) and low homocysteine values. However, increases in total fat and animal protein intake of affluent black South Africans, who can afford Western diets, are associated with increases in body mass indices of men and women and in total serum cholesterol. These exposures may increase IHD risk in the future.

To understand methodological concerns related to dietary intake collection in transitional societies.

Three days of household weighing and measurement of all food used and repeated 24-hour recalls.

Eight Chinese provinces.

Five thousand nine hundred and fifty-two and 5152 adults aged 20–45 years in 1989 and 1997, respectively.

Great variance exists in the types and quantity of animal products used in common recipes. For example, the proportion of pork from lean cuts in ‘stir-fried fresh pepper and pork’ varies between 14 and 24% in urban and rural areas and the total pork content for 100 g (dish) varies by 15 to 19 g between rural and urban areas in each of eight provinces. Another challenge relates to the variation in the edible vegetable oil content added during food preparation. Reliance on standard recipes for each fried dish would miss the variations in oil use over time, space and socio-economic status.

Dietary change is rapid in transitional countries. Reliance on recipes standardised for animal food and edible oil contents will lead to very large systematic errors in the measurement of energy, fat and protein intakes.