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Micronutrient malnutrition, the deficiency of vitamins or minerals, impacts on physical and mental health, in clinical and general populations, across the life course. In older western populations the high prevalence and impact of micronutrient malnutrition is less well recognised. Low- and middle-income countries are experiencing the ‘double burden of disease’ where malnutrition coexists alongside the non-communicable diseases of aging, obesity, type 2 diabetes and cardiovascular disease. Held in December 2020, the Winter Conference of the Nutrition Society was designed to cover new areas of research and concern in micronutrient malnutrition across the life course. Common themes arising from the conference were: 1) The continuing high prevalence of micronutrient malnutrition across the life-course, in diverse populations, in high, middle and low-income countries. 2) That multiple deficiencies of micronutrients frequently exist. 3) The primary cause of deficiency is poor quality diets, of low diversity, low in micronutrient dense foods. 4) Clinical conditions, medications for common non-communicable diseases, and environmental conditions, interact with and exacerbate the effects of poor diet quality. 5) Understanding of the mechanistic effects of micronutrients is still emerging. 6) Micronutrients are necessary for maintaining immune function, which has importance for the COVID-19 epidemic. 7) Better biomarkers are needed detect and understand the effects of deficiency. 7) Dietary recommendations need to be updated regularly. Further research is needed in all these areas. Comprehensive public health and government approaches to ensure access and affordability of good quality foods to populations of all ages, particularly during the ongoing COVID-19 epidemic, are crucial.
Sarcopenia, characterised by loss of skeletal muscle mass and strength with age, is a significant risk factor for loss of mobility and independence. The combination of low muscle mass and high fat mass in sarcopenic obesity is associated with particularly poor outcomes. Micronutrient deficiencies can occur alongside obesity despite total energy surplus, and older individuals may be at greater risk of deficiency. Research suggests vitamin C is important for musculoskeletal health, but the relationship with obesity is underexplored.
This study aimed to investigate associations of plasma vitamin C with obesity status and explore the relationship with the sarcopenic risk factor, low skeletal muscle mass.
EPIC-Norfolk cohort study data were analysed. Bioelectrical impedance analysis-estimated fat free mass (FFM; a proxy for skeletal muscle mass) was adjusted for BMI to give a scaled variable, FFMBMI. A ‘low muscle mass’ category was defined as individuals with the lowest 10% FFMBMI, representing those at high risk of sarcopenia. Plasma vitamin C (ascorbic acid) concentrations were categorised as inadequate (< 50micromol/L) or adequate (≥ 50micromol/L), and obesity status as non-obese (< 30kg/m2) or obese (≥ 30kg/m2).
Individuals were grouped according to vitamin C and obesity status: 1, non-obese and adequate vitamin C; 2, non-obese and inadequate vitamin C; 3, obese and adequate vitamin C; and 4, obese and inadequate vitamin C. Using logistic regression, the odds ratio (OR) of each vitamin/obesity status group was calculated in relation to membership of the ‘low muscle mass’ category. Analyses were sex-stratified and adjusted for age, smoking status, physical activity, social class, menopausal and HRT status in women, statin use, and corticosteroid use.
Data were analysed for 5903 men (mean 62.9 years, SD 9.0) and 7416 women (mean 61.5 years, SD 9.0). Prevalence of vitamin C inadequacy was higher in obese vs non-obese individuals (men 45.8% vs 33.0%; and women 26.0% vs 15.3%). The odds of ‘low muscle mass’ were higher in all vitamin/obesity status groups vs group 1, but the greatest odds were seen for group 4 (combined obesity and inadequate vitamin C) in men (OR 16.5, 95% CI: 12.6–21.6; p < 0.001) and women (OR 30.2, 95% CI: 23.0–39.8; p < 0.001).
In this cohort of older individuals higher prevalence of vitamin C inadequacy is associated with obese individuals. Of importance to musculoskeletal health and our understanding of sarcopenia is the observation that while vitamin C inadequacy and obesity are each independently important, their coexistence is a particularly strong predictor of sarcopenic risk.
Skeletal muscle is integral to the metabolism and utilisation of macronutrients; however, substantial muscle loss and morphological changes occur with ageing. These are associated with loss of muscle function and accelerate rapidly from the age of 60 years, leading to the conditions of sarcopenia and frailty. As the relationship between muscle ageing and macronutrient metabolism and utilisation has seen limited research to date, this review focuses on the interactions between skeletal muscle changes during ageing, metabolism and utilisation of fat, carbohydrates and overall energy expenditure.
Skeletal muscle contributes less to resting energy expenditure during ageing, potentially contributing to onset of obesity from middle age. Age-related changes to skeletal muscle lead to glucose dysregulation, with consequent reduction in glycaemic control, increased insulin resistance and ultimately onset of type-2 diabetes. Recent studies indicate that high total fat and SFA intake are detrimental to skeletal muscle, while higher intakes of PUFA are protective. Age-associated changes in skeletal muscle may also reduce total fatty acid utilisation.
In conclusion, further research is needed to understand the relationships between macronutrient metabolism and utilisation and age-related changes to skeletal muscle. No dietary recommendations exist specifically for skeletal muscle health during ageing, but we advise individuals to follow healthy eating guidelines, by consuming sufficient protein, fruit and vegetables, and limited SFA and to maintain physically active lifestyles. Clinicians responsible for managing type-2 diabetes need to be aware of growing evidence relating age-related skeletal muscle changes to diabetes onset and progression.
Carotenoids are found in abundance in fruit and vegetables, and may be involved in the positive association of these foods with bone health. This study aimed to explore the associations of dietary carotenoid intakes and plasma concentrations with bone density status and osteoporotic fracture risk in a European population. Cross-sectional analyses (n 14 803) of bone density status, using calcaneal broadband ultrasound attenuation (BUA) and longitudinal analyses (n 25 439) of fracture cases were conducted on data from the prospective European Prospective Investigation into Cancer and Nutrition-Norfolk cohort of middle-aged and older men and women. Health and lifestyle questionnaires were completed, and dietary nutrient intakes were derived from 7-d food diaries. Multiple regression demonstrated significant positive trends in BUA for women across quintiles of dietary α-carotene intake (P=0·029), β-carotene intake (P=0·003), β-cryptoxanthin intake (P=0·031), combined lutein and zeaxanthin intake (P=0·010) and lycopene intake (P=0·005). No significant trends across plasma carotenoid concentration quintiles were apparent (n 4570). The Prentice-weighted Cox regression showed no trends in fracture risk across dietary carotenoid intake quintiles (mean follow-up time 12·5 years), except for a lower risk for wrist fracture in women with higher lutein and zeaxanthin intake (P=0·022); nevertheless, inter-quintile differences in fracture risk were found for both sexes. Analysis of plasma carotenoid data (mean follow-up time 11·9 years) showed lower hip fracture risk in men across higher plasma α-carotene (P=0·026) and β-carotene (P=0·027) quintiles. This study provides novel evidence that dietary carotenoid intake is relevant to bone health in men and women, demonstrating that associations with bone density status and fracture risk exist for dietary intake of specific carotenoids and their plasma concentrations.
Age-related skeletal muscle loss, sarcopenia, cachexia and wider malnutrition (under nutrition) are complex in aetiology with interaction of clinical, social and economic factors. Weight loss and loss of skeletal muscle mass in older people are associated with increased morbidity and mortality with implications for increasing health and social care costs. There is insufficient evidence to identify the ideal treatment options. However, preventing weight loss and loss of skeletal muscle in older age will be keys to reducing morbidity and mortality. This will require all those coming into contact with older people to identify and address weight loss early, including through diet, improving physical activity and increasing social interaction. Public health messages on diet should, in the main, continue to focus on older people achieving current UK dietary recommendations for their age as visually depicted in the eatwell plate together with associated messages regarding dietary supplements where appropriate.
Osteoporosis and related fractures are a major global health issue, but there are few preventative strategies. Previously reported associations between higher intakes of fruits and vegetables and skeletal health have been suggested to be partly attributable to vitamin C. To date, there is some evidence for a potential role of vitamin C in osteoporosis and fracture prevention but an overall consensus of published studies has not yet been drawn. The present review aims to provide a summary of the proposed underlying mechanisms of vitamin C on bone and reviews the current evidence in the literature, examining a potential link between vitamin C intake and status with osteoporosis and fractures. The Bradford Hill criteria were used to assess reported associations. Recent animal studies have provided insights into the involvement of vitamin C in osteoclastogenesis and osteoblastogenesis, and its role as a mediator of bone matrix deposition, affecting both the quantity and quality of bone collagen. Observational studies have provided some evidence for this in the general population, showing positive associations between dietary vitamin C intake and supplements and higher bone mineral density or reduced fracture risk. However, previous intervention studies were not sufficiently well designed to evaluate these associations. Epidemiological data are particularly limited for vitamin C status and for fracture risk and good-quality randomised controlled trials are needed to confirm previous epidemiological findings. The present review also highlights that associations between vitamin C and bone health may be non-linear and further research is needed to ascertain optimal intakes for osteoporosis and fracture prevention.
Dietary supplements are commonly consumed but may not be beneficial for everyone. It is known that supplement users have healthy behaviour characteristics but until now concordance between spouses living in the same household has not been investigated and concordance may be an important behavioural determinant.
Prospective cohort study, cross-sectional data analysis.
European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) in the UK, recruitment between 1993 and 1998.
Married (or living as married) participants sharing a household, who attended a health examination and completed a 7 d diet diary were included in the analysis (n 11 060). The age range was 39–79 years.
Nearly 75 % of the households in EPIC-Norfolk were concordant in their supplement use, with 46·7 % not using supplements and 27·0 % using supplements. Concordance increased with age; the percentage of concordant couples varied less by other sociodemographic characteristics. Participants who had a spouse who used a supplement were nearly nine times more likely to use a supplement (unadjusted). Depending on participants’ sex and type of supplement used, odds ratios for ‘supplement use by spouse’ in the prediction of participants’ supplement use varied between 6·2 and 11·7 adjusted for participants’ age, smoking status, BMI, social class, education level and physical activity.
‘Supplement use by spouse’ is an independent and the strongest predictor of participants’ supplement use. This phenomenon can be useful in the design of studies and health interventions; or when assessing risk of excessive intake from dietary supplements.
Age-related muscle loss impacts on whole-body metabolism and leads to frailty and sarcopenia, which are risk factors for fractures and mortality. Although nutrients are integral to muscle metabolism the relationship between nutrition and muscle loss has only been extensively investigated for protein and amino acids. The objective of the present paper is to describe other aspects of nutrition and their association with skeletal muscle mass. Mechanisms for muscle loss relate to imbalance in protein turnover with a number of anabolic pathways of which the mechanistic TOR pathway and the IGF-1–Akt–FoxO pathways are the most characterised. In terms of catabolism the ubiquitin proteasome system, apoptosis, autophagy, inflammation, oxidation and insulin resistance are among the major mechanisms proposed. The limited research associating vitamin D, alcohol, dietary acid–base load, dietary fat and anti-oxidant nutrients with age-related muscle loss is described. Vitamin D may be protective for muscle loss; a more alkalinogenic diet and diets higher in the anti-oxidant nutrients vitamin C and vitamin E may also prevent muscle loss. Although present recommendations for prevention of sarcopenia focus on protein, and to some extent on vitamin D, other aspects of the diet including fruits and vegetables should be considered. Clearly, more research into other aspects of nutrition and their role in prevention of muscle loss is required.
The aim of the present study was to describe the energy, nutrient and crude v. disaggregated food intake measured using 7 d diet diaries (7dDD) for the full baseline Norfolk cohort recruited for the European Prospective Investigation into Cancer (EPIC-Norfolk) study, with emphasis on methodological issues. The first data collection took place between 1993 and 1998 in Norfolk, East Anglia (UK). Of the 30 445 men and women, aged 40–79 years, registered with a general practitioner invited to participate in the study, 25 639 came for a health examination and were asked to complete a 7dDD. Data from diaries with data recorded for at least 1 d were obtained for 99 % members of the cohort; 10 354 (89·8 %) of the men and 12 779 (91·5 %) of the women completed the diet diaries for all 7 d. Mean energy intake (EI) was 9·44 (sd 2·22) MJ/d and 7·15 (sd 1·66) MJ/d, respectively. EI remained approximately stable across the days, but there was apparent under-reporting among the participants, especially among those with BMI >25 kg/m2. Micronutrient density was higher among women than among men. In conclusion, under-reporting is an issue, but not more so than that found in national surveys. How foods were grouped (crude or disaggregated) made a difference to the estimates obtained, and comparison of intakes showed wide limits of agreement. The choice of variables influences estimates obtained from the food group data; while this may not alter the ranking of individuals within studies, this issue may be relevant when comparing absolute food intakes between studies.
To examine the differences in dietary intakes of children consuming school meals and packed lunches, the contribution of lunchtime intake to overall dietary intake, and how lunchtime intake relates to current food-based recommendations for school meals.
Cross-sectional analysis of overall intake of macronutrients and food choice from 4 d food diaries and school lunchtime intake from the two diary days completed while at school.
One thousand six hundred and twenty-six children (aged 9–10 years) attending ninety Norfolk primary schools.
At school, lunchtime school meal eaters consumed more vegetables, sweet snacks, chips, starchy foods and milk, and less squash/cordial, fruit, bread, confectionery and savoury snacks than packed lunch eaters. These differences were also reflected in the overall diet. On average school meal eaters met the School Food Trust (SFT) food-based standards, while food choices among packed lunch eaters were less healthy. The contribution of food consumed at school lunchtime to overall diet varied by food and lunch type, ranging from 0·8 % (milk intake in packed lunches) to 74·4 % (savoury snack intake in packed lunches).
There were significant differences in the foods consumed by school meal and packed lunch eaters, with food choices among school meal eaters generally in line with SFT standards. The food choices made at school lunchtime make a significant contribution to overall diet.
To examine the association between breakfast consumption and physical activity in a well-characterised sample of English children.
Cross-sectional study using food diaries to record breakfast consumption and accelerometry to assess physical activity.
Norfolk county, England.
Children (n 1697) aged 9–10 years from the SPEEDY (Sport, Physical Activity and Eating behaviour: Environmental Determinants in Young people) study.
Boys who consumed a poor-quality breakfast based on dairy product, cereal and fruit intakes spent approximately 7 min more time in moderate-to-vigorous physical activity (MVPA) during weekday afternoons and evenings compared with those who did not consume breakfast (P < 0·05). On weekend days, boys who consumed a poor- or good-quality breakfast spent approximately 6 and 5 min less time respectively being sedentary during the mornings compared with breakfast non-consumers (P < 0·05). Boys who consumed a good-quality breakfast spent almost 3 min more in MVPA during the morning on weekend days compared with non-consumers, and boys who consumed a poor- or good-quality breakfast were 22 % and 16 % more active overall respectively than breakfast non-consumers (P < 0·05). During the rest of the day, boys who consumed a good-quality breakfast spent about 11 min less time being sedentary (P < 0·05) and 7 min more time in MVPA (P < 0·01).
Although some associations between breakfast consumption and physical activity were detected for boys, the present study does not provide strong evidence that failing to consume breakfast, or having a low energy intake at breakfast time, is detrimental to children's physical activity levels.
Supplements are an important source of micronutrient intake, which, unless taken into account, can misclassify individuals with regard to levels of nutrient exposure. A label-based vitamin and mineral supplements (ViMiS) database was developed to contain manufacturers’ information and to enter supplement use by participants in the European Prospective Investigation into Cancer and Nutrition in Norfolk (EPIC-Norfolk). The ViMiS database contains information on all ingredients, broken down into nutrient information in order to be combined with nutrient intake derived from food consumption.
Development of the ViMiS database and cross-sectional analysis of supplement use in a population-based study.
Men and women aged 40–79 years from the general population participating in the EPIC-Norfolk study between 1993 and 1997, with data available from 7 d diet diaries (7dDD).
A subset of 19 330 participants with available 7dDD and known supplement status.
To date, the ViMiS database includes 2066 supplements, which altogether contain 16 586 ingredients, with a median of eleven nutrient/ingredients per supplement. Forty per cent of the cohort took a supplement, of which cod liver oil was the most common (24·5 %).
The ViMiS database provides a flexible tool for estimating total nutrient intake. The high prevalence of supplement use in the general population indicates that supplement use needs to be taken into account when examining the relationship of intake of particular nutrients to health outcomes.
Poor diet in childhood increases risk of obesity but the relationship between access to food and children’s food choice is underexplored. We determined relationships between distance to and density of food outlets on children’s food choice.
Children (n 1721) aged 9–10 years who participated in a cross-sectional study from a sample of state and private schools across urban and rural areas. Food consumption was reported using a short validated FFQ. A Geographic Information System was used to determine proximity to local food outlets. Multivariable regression analyses were performed to determine associations between food consumption and distance to and density of local food outlets.
Boys (n 754) and girls (n 967) aged 9–10 years.
The impact of distance to or density of food outlets on food choice was small after adjustment. Living further away from a supermarket increased portions of fruit (0·11 portions/week per 1 km increase in distance to nearest supermarket, P < 0·05) and vegetables (0·11 portions/week, P < 0·05) consumed. Living closer to convenience stores was also associated with an increased consumption of crisps, chocolate and white bread. Density of supermarkets was associated with both an increase in vegetable intake (0·31 portions/week, P < 0·05) and unhealthy foods.
Distance to and density of food outlets are both associated with children’s food choice, although the impact appears to be small and the relationship is complex. However, the effects of individual foods combined could be important, particularly as even small differences in intake can impact on body weight over time.
Evidence exists that a more acidic diet is detrimental to bone health. Although more precise methods exist for measurement of acid–base balance, urine pH reflects acid–base balance and is readily measurable but has not been related to habitual dietary intake in general populations. The present study investigated the relationship between urine pH and dietary acid–base load (potential renal acid load; PRAL) and its contributory food groups (fruit and vegetables, meats, cereal and dairy foods). There were 22 034 men and women aged 39–78 years living in Norfolk (UK) with casual urine samples and dietary intakes from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Norfolk FFQ. A sub-study (n 363) compared pH in casual samples and 24 h urine and intakes from a 7 d diary and the FFQ. A more alkaline diet (low PRAL), high fruit and vegetable intake and lower consumption of meat was significantly associated with a more alkaline urine pH before and after adjustment for age, BMI, physical activity and smoking habit and also after excluding for urinary protein, glucose, ketones, diagnosed high blood pressure and diuretic medication. In the sub-study the strongest relationship was found between the 24 h urine and the 7 d diary. In conclusion, a more alkaline diet, higher fruit and vegetable and lower meat intake were related to more alkaline urine with a magnitude similar to intervention studies. As urine pH relates to dietary acid–base load its use to monitor change in consumption of fruit and vegetables, in individuals, warrants further investigation.
To compare the average out-of-home (OH) consumption of foods and beverages, as well as energy intake, among populations from 10 European countries and to describe the characteristics of substantial OH eaters, as defined for the purpose of the present study, in comparison to other individuals.
Cross-sectional study. Dietary data were collected through single 24-hour dietary recalls, in which the place of consumption was recorded. For the present study, substantial OH eaters were defined as those who consumed more than 25% of total daily energy intake at locations other than the household premises. Mean dietary intakes and the proportion of substantial OH eaters are presented by food group and country. Logistic regression analyses were used to estimate the odds of being a substantial OH eater in comparison to not being one, using mutually adjusted possible non-dietary determinants.
Ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC).
The subjects were 34 270 individuals, 12 537 men and 21 733 women, aged 35–74 years.
The fraction of energy intake during OH eating was generally higher in northern European countries than in the southern ones. Among the food and beverage groups, those selectively consumed outside the home were coffee/tea/waters and sweets and, to a lesser extent, cereals, meats, added lipids and vegetables. Substantial OH eating was positively associated with energy intake and inversely associated with age and physical activity. Substantial OH eating was less common among the less educated compared with the more educated, and more common during weekdays in central and north Europe and during the weekend in south Europe.
Eating outside the home was associated with sedentary lifestyle and increased energy intake; it was more common among the young and concerned in particular coffee/tea/waters and sweets.
In addition to their possible direct biological effects, plasma carotenoids can be used as biochemical markers of fruit and vegetable consumption for identifying diet–disease associations in epidemiological studies. Few studies have compared levels of these carotenoids between countries in Europe.
Our aim was to assess the variability of plasma carotenoid levels within the cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC).
Plasma levels of six carotenoids – α-carotene, β-carotene, β-cryptoxanthin, lycopene, lutein and zeaxanthin – were measured cross-sectionally in 3043 study subjects from 16 regions in nine European countries. We investigated the relative influence of gender, season, age, body mass index (BMI), alcohol intake and smoking status on plasma levels of the carotenoids.
Mean plasma level of the sum of the six carotenoids varied twofold between regions (1.35μmoll−1 for men in Malmö, Sweden vs. 2.79μmoll−1 for men in Ragusa/Naples, Italy; 1.61μmoll−1 for women in The Netherlands vs. 3.52μmoll−1 in Ragusa/Naples, Italy). Mean levels of individual carotenoids varied up to fourfold (α-carotene: 0.06μmoll−1 for men in Murcia, Spain vs. 0.25μmoll−1 for vegetarian men living in the UK). In multivariate regression analyses, region was the most important predictor of total plasma carotenoid level (partial R2=27.3%), followed by BMI (partial R2=5.2%), gender (partial R2=2.7%) and smoking status (partial R2=2.8%). Females had higher total carotenoid levels than males across Europe.
Plasma levels of carotenoids vary substantially between 16 different regions in Italy, Greece, Spain, France, Germany, the UK, Sweden, Denmark and The Netherlands. Compared with region of residence, the other demographic and lifestyle factors and laboratory measurements have limited predictive value for plasma carotenoid levels in Europe.
To describe methods and dietary habits of a large population cohort.
Prospective assessment of diet using diet diaries and food-frequency questionnaires, and biomarkers of diet in 24-h urine collections and blood samples.
Free living individuals aged 45 to 75 years living in Norfolk, UK.
Food and nutrient intake from a food-frequency questionnaire on 23 003 men and women, and from a 7-day diet diary from 2117 men and women. Nitrogen, sodium and potassium excretion was obtained from single 24-h urine samples from 300 individuals in the EPIC cohort. Plasma vitamin C was measured for 20 846 men and women.
The food-frequency questionnaire (FFQ) and the food diary were able to determine differences in foods and nutrients between the sexes and were reliable as judged by repeated administrations of each method. Plasma vitamin C was significantly higher in women than men. There were significant (P<0.001) differences in mean intake of all nutrients measured by the two different methods in women but less so in men. The questionnaire overestimated dairy products and vegetables in both men and women when compared with intakes derived from the diary, but underestimated cereal and meat intake in men. There were some consistent trends with age in food and nutrient intakes assessed by both methods, particularly in men. Correlation coefficients between dietary intake assessed from the diary and excretion of nitrogen and potassium in a single 24-h urine sample ranged from 0.36 to 0.47. Those comparing urine excretion and intake assessed from the FFQ were 0.09 to 0.26. The correlations between plasma vitamin C and dietary intake from the first FFQ, 24-h recall or diary were 0.28, 0.35 and 0.40.
EPIC Norfolk is one of the largest epidemiological studies of nutrition in the UK and the largest on which plasma vitamin C has been obtained. Methods for obtaining food and nutrient intake are described in detail. The results shown here for food and nutrient intakes can be compared with results from other population studies utilising different methods of assessing dietary intake. The utility of different methods used in different settings within the main EPIC cohort is described. The FFQ is to be used particularly in pooled analyses of risk from diet in relation to cancer incidence within the larger European EPIC study, where measurement error is more likely to be overcome by large dietary heterogeneity on an international basis. Findings in the UK, where dietary variation between individuals is smaller and hence the need to use a more accurate individual method greater, will be derived from the 7-day diary information on a nested case–control basis. 24-h recalls can be used in the event that diary information should not be forthcoming from some eventual cases. Combinations of results utilising all dietary methods and biomarkers may also be possible.