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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.
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.
To investigate familial influences on the full range of variability in attention and activity across adolescence, we collected maternal ratings of 339 twin pairs at ages 12, 14, and 16, and estimated the transmitted and new familial influences on attention and activity as measured by the Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale. Familial influences were substantial for both traits across adolescence: genetic influences accounted for 54%–73% (attention) and 31%–73% (activity) of the total variance, and shared environmental influences accounted for 0%–22% of the attention variance and 13%–57% of the activity variance. The longitudinal stability of individual differences in attention and activity was largely accounted for by familial influences transmitted from previous ages. Innovations over adolescence were also partially attributable to familial influences. Studying the full range of variability in attention and activity may facilitate our understanding of attention-deficit/hyperactivity disorder's etiology and intervention.
The objective of the present study was to investigate associations between sugar intake and overweight using dietary biomarkers in the Norfolk cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk).
Prospective cohort study.
EPIC-Norfolk in the UK, recruitment between 1993 and 1997.
Men and women (n 1734) aged 39–77 years. Sucrose intake was assessed using 7 d diet diaries. Baseline spot urine samples were analysed for sucrose by GC-MS. Sucrose concentration adjusted by specific gravity was used as a biomarker for intake. Regression analyses were used to investigate associations between sucrose intake and risk of BMI>25·0 kg/m2 after three years of follow-up.
After three years of follow-up, mean BMI was 26·8 kg/m2. Self-reported sucrose intake was significantly positively associated with the biomarker. Associations between the biomarker and BMI were positive (β=0·25; 95 % CI 0·08, 0·43), while they were inverse when using self-reported dietary data (β=−1·40; 95 % CI −1·81, −0·99). The age- and sex-adjusted OR for BMI>25·0 kg/m2 in participants in the fifth v. first quintile was 1·54 (95 % CI 1·12, 2·12; Ptrend=0·003) when using biomarker and 0·56 (95 % CI 0·40, 0·77; Ptrend<0·001) with self-reported dietary data.
Our results suggest that sucrose measured by objective biomarker but not self-reported sucrose intake is positively associated with BMI. Future studies should consider the use of objective biomarkers of sucrose intake.
Health-beneficial effects of adhering to a healthy Nordic diet index have been suggested. However, it has not been examined to what extent the included dietary components are exclusively related to the Nordic countries or if they are part of other European diets as well, suggesting a broader preventive potential. The present study describes the intake of seven a priori defined healthy food items (apples/pears, berries, cabbages, dark bread, shellfish, fish and root vegetables) across ten countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) and examines their consumption across Europe.
Cross-sectional study. A 24 h dietary recall was administered through a software program containing country-specific recipes. Sex-specific mean food intake was calculated for each centre/country, as well as percentage of overall food groups consumed as healthy Nordic food items. All analyses were weighted by day and season of data collection.
Multi-centre, European study.
Persons (n 36 970) aged 35–74 years, constituting a random sample of 519 978 EPIC participants.
The highest intakes of the included diet components were: cabbages and berries in Central Europe; apples/pears in Southern Europe; dark bread in Norway, Denmark and Greece; fish in Southern and Northern countries; shellfish in Spain; and root vegetables in Northern and Central Europe. Large inter-centre variation, however, existed in some countries.
Dark bread, root vegetables and fish are strongly related to a Nordic dietary tradition. Apples/pears, berries, cabbages, fish, shellfish and root vegetables are broadly consumed in Europe, and may thus be included in regional public health campaigns.
Dietary interventions with flavan-3-ols have shown beneficial effects on vascular function. The translation of these findings into the context of the health of the general public requires detailed information on habitual dietary intake. However, only limited data are currently available for European populations. Therefore, in the present study, we assessed the habitual intake of flavan-3-ol monomers, proanthocyanidins (PA) and theaflavins in the European Union (EU) and determined their main food sources using the EFSA (European Food Safety Authority) Comprehensive European Food Consumption Database. Data for adults aged 18–64 years were available from fourteen European countries, and intake was determined using the FLAVIOLA Flavanol Food Composition Database, developed for the present study and based on the latest US Department of Agriculture and Phenol-Explorer databases. The mean habitual intake of flavan-3-ol monomers, theaflavins and PA ranged from 181 mg/d (Czech Republic) to 793 mg/d (Ireland). The highest intakes of flavan-3-ol monomers and theaflavins were observed in Ireland (191/505 mg/d) and the lowest intakes in Spain (24/9 mg/d). In contrast, the daily intake of PA was highest in Spain (175 mg/d) and lowest in The Netherlands (96 mg/d). Main sources were tea (62 %), pome fruits (11 %), berries (3 %) and cocoa products (3 %). Tea was the major single contributor to monomer intake (75 %), followed by pome fruits (6 %). Pome fruits were also the main source of PA (28 %). The present study provides important data on the population-based intake of flavanols in the EU and demonstrates that dietary intake amounts for flavan-3-ol monomers, PA and theaflavins vary significantly across European countries. The average habitual intake of flavan-3-ols is considerably below the amounts used in most dietary intervention studies.
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.
A greater adherence to the traditional Mediterranean (MED) diet is associated with a reduced risk of developing chronic diseases. This dietary pattern is based on higher consumption of plant products that are rich in flavonoids. We compared the total flavonoid dietary intakes, their food sources and various lifestyle factors between MED and non-MED countries participating in the EPIC study. Flavonoid intakes and their food sources for 35 628 subjects, aged 35–74 years and recruited between 1992 and 2000, in twenty-six study centres were estimated using standardised 24 h dietary recall software (EPIC-Soft®). An ad hoc food composition database on flavonoids was compiled using analytical data from the United States Department of Agriculture and Phenol-Explorer databases. Moreover, it was expanded to include using recipes, estimations of missing values and flavonoid retention factors. No significant differences in total flavonoid mean intake between non-MED countries (373·7 mg/d) and MED countries (370·2 mg/d) were observed. In the non-MED region, the main contributors were proanthocyanidins (48·2 %) and flavan-3-ol monomers (24·9 %) and the principal food sources were tea (25·7 %) and fruits (32·8 %). In the MED region, proanthocyanidins (59·0 %) were by far the most abundant contributor and fruits (55·1 %), wines (16·7 %) and tea (6·8 %) were the main food sources. The present study shows similar results for total dietary flavonoid intakes, but significant differences in flavonoid class intakes, food sources and some characteristics between MED and non-MED countries. These differences should be considered in studies about the relationships between flavonoid intake and chronic diseases.
The role of dietary phyto-oestrogens in health has been of continued interest and debate, but data available on the distribution of intake in the Australian diet are scarce. Therefore, we aimed to estimate phyto-oestrogen consumption in Australian women, describe the pattern of intake and identify correlates of high phyto-oestrogen intake. Study participants were 2078 control women (18–79 years) from two population-based case–control studies on gynaecological cancers (2002–2007). Dietary information was obtained using a 135-item FFQ, and the intakes of isoflavones, lignans, enterolignans and coumestans, including their individual components, were estimated using a database of phyto-oestrogen content in food developed in the UK. Median total intake (energy-adjusted) of phyto-oestrogens was 1·29 mg/d, including 611 µg/d isoflavones, 639 µg/d lignans, 21 µg/d enterolignans and 8 µg/d coumestrol. Both isoflavone and lignan intakes were strongly skewed towards higher values and positively correlated with age. Women consumed on average two servings of soyabean foods/week. Compared to lower phyto-oestrogen consumers (≤1·29 mg/d, median split), higher phyto-oestrogen consumers (>1·29 mg/d) were slightly older, less likely to be smokers, had a higher educational and physical activity level, lower BMI, lower intake of dietary fat, and higher intake of fibre, selected micronutrients and soyabean foods (all P < 0·03). The daily intake of phyto-oestrogens in Australian women with predominantly Caucasian ethnicity is approximately 1 mg; this is similar to other Western populations, but considerably lower than that among Asian women. However, those with a relatively high phyto-oestrogen diet seem to have a healthier lifestyle and a more favourable dietary profile compared to others.
A diet rich in phyto-oestrogens has been suggested to protect against a variety of common diseases but UK intake data on phyto-oestrogens or their food sources are sparse. The present study estimates the average intakes of isoflavones, lignans, enterolignans and coumestrol from 7 d food diaries and provides data on total isoflavone, lignan and phyto-oestrogen consumption by food group.
Development of a food composition database for twelve phyto-oestrogens and analysis of soya food and phyto-oestrogen consumption in a population-based study.
Men and women, aged 40–79 years, from the general population participating in the Norfolk arm of the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk) between 1993 and 1997, with nutrient and food data from 7 d food diaries.
A subset of 20 437 participants.
The median daily phyto-oestrogen intake for all men was 1199 μg (interquartile range 934–1537 μg; mean 1504 μg, sd 1502 μg) and 888 μg for all women (interquartile range 710–1135 μg; mean 1205 μg, sd 1701 μg). In soya consumers, median daily intakes were higher: 2861 μg in men (interquartile range 1304–7269 μg; mean 5051 μg, sd 5031 μg) and 3142 μg in women (interquartile range 1089–7327 μg; mean 5396 μg, sd 6092 μg). In both men and women, bread made the greatest contribution to phyto-oestrogen intake – 40·8 % and 35·6 %, respectively. In soya consumers, vegetable dishes and soya/goat's/sheep's milks were the main contributors – 45·7 % and 21·3 % in men and 38·4 % and 33·7 % in women, respectively.
The ability to estimate phyto-oestrogen intake in Western populations more accurately will aid investigations into their suggested effects on health.
Phyto-oestrogens have been associated with a decreased risk for osteoporosis, but results from intervention and observational studies in Western countries have been inconsistent. In the present study, we investigated the association between habitual phyto-oestrogen intake and broadband ultrasound attenuation (BUA) of the calcanaeum as a marker of bone density. We collected 7 d records of diet, medical history and demographic and anthropometric data from participants (aged 45–75 years) in the European Prospective Investigation into Cancer-Norfolk study. Phyto-oestrogen (biochanin A, daidzein, formononetin; genistein, glycitein; matairesinol; secoisolariciresinol; enterolactone; equol) intake was determined using a newly developed food composition database. Bone density was assessed using BUA of the calcanaeum. Associations between bone density and phyto-oestrogen intake were investigated in 2580 postmenopausal women who were not on hormone replacement therapy and 4973 men. Median intake of total phyto-oestrogens was 876 (interquartile range 412) μg/d in postmenopausal women and 1212 (interquartile range 604) μg/d in men. The non-soya isoflavones formononetin and biochanin A were marginally significant or significantly associated with BUA in postmenopausal women (β = 1·2; P < 0·1) and men (β = 1·2; P < 0·05), respectively; enterolignans and equol were positively associated with bone density in postmenopausal women, but this association became non-significant when dietary Ca was added to the model. In the lowest quintile of Ca intake, soya isoflavones were positively associated with bone density in postmenopausal women (β = 1·4; P < 0·1). The present results therefore suggest that non-soya isoflavones are associated with bone density independent of Ca, whereas the association with soya or soya isoflavones is affected by dietary Ca.
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.
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 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.
The aim of this study was to identify the level of isoflavone intake (total isoflavones, daidzein and genistein) in four European countries: Ireland, Italy, The Netherlands and the UK. For this purpose national food composition databases of isoflavone content were created in a comparable way, using the Vegetal Estrogens in Nutrition and the Skeleton (VENUS) analytical data base as a common basis, and appropriate food consumption data were selected. The isoflavone intake in Ireland, Italy, The Netherlands and the UK is on average less than 1 mg/d. Small groups of consumers of soya foods could be identified in Ireland, The Netherlands and the UK. The estimated intake levels are low compared with those found in typical Asian diets (∼20–100 mg/d) and also low compared with levels where physiological effects are expected (60–100 mg/d). The results (including a subgroup analysis of soya product consumers) showed that such levels are difficult to achieve with the European diets studied here.
The objective of the Vegetal Estrogens in Nutrition and the Skeleton (VENUS) project was to evaluate existing data on dietary exposure to compounds with oestrogenic and anti-oestrogenic effects present in plant foods as constituents or contaminants, and to identify and disseminate in vitro and in vivo methodologies to analyse the effects of such compounds on bone. To permit the assessment of exposure to isoflavones in European populations (Italy, the UK, Ireland, The Netherlands), the VENUS database of phyto-oestrogen levels in foods was established. Data on the isoflavone (genistein and daidzein) content of 791 foods, including almost 300 foods commonly consumed in Europe, were collected. Levels of coumestrol, formononetin and biochanin A in a limited number of foods were also included. Lignan levels (secoisolariciresinol and matairesinol) in 158 foods were incorporated into the database, which also contains information on the references sourced for the compositional data, on the analytical methods used by each author and on the number of foods analysed in each reference. The VENUS database was constructed in Microsoft® Access 2000, which is widely available as part of Microsoft® Office Professional. This paper outlines the procedures used for the selection and evaluation of existing literature data for incorporation into the database. In addition, the design of the database is described, along with the data entry and quality control procedures used in its construction. Limitations of the data are discussed and guidelines for its use are provided.
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