EUCCONET workshop, Bristol 2011Michelle A. Mendez

EARNEST Project Working Group on Comparative Analyses of Diet in Pregnancy

Dietary intakes during pregnancy across EuropeA collaborative multi-country analysis

Background Maternal diet may influence both maternal and

child health even without marked deficiencies e.g. possible effects on child neurodevelopment,

asthma, allergy, bone mineralization

Relatively little is known about prevailing patterns of intake across different countries and strata

Objectives Take advantage of existing data by developing methods

to standardize food group intakes in studies including >200,000 women from across Europe Dietary data collection costly, time-consuming, food-culture specific

Specific aims: Assess the feasibility of adequate standardization

Estimates comparable to previous studies? Conduct a comparative analysis of maternal diet disparities

Smoking, weight status, age, education groups Facilitate future pooled analyses on maternal diet and health

Methods Post hoc standardization methods were developed

Candidate food groups selected Meats, seafood, fruits & vegetables

Major contributors to key nutrients: bioavailable iron, docosahexanoic acid, folate

Standardized food group definitions derived Detailed description of items to include in each group/subgroup

Iterative process: initial definitions developed based on English-language translations of core partner FFQs

Within-country disparities in intake Maternal characteristics associated with diet

1. Standardized definitions: Meats

1. Meats (excluding poultry/game birds)

Total fresh, processed, organ & other meats (sum of subgroups)

(a) Fresh red meats Include game meats & mixed dish content; exclude poultry, other white meats, & organ meats (reported separately)

(b) Processed meats Include sausages, ham, tinned meats & similar items, incl. content of mixed dishes

(c) Organ meats Liver & other organs incl. content of mixed dishes

(d) Other red meats Other meats not included above

2. Poultry & game birds Total poultry & game birds, including mixed dish content

Standardized food groups/subgroups Fruits and vegetables: including/excluding juices

Whole fruit; fruit juices Raw and cooked vegetables

Meats Red and processed meats; organ meats Poultry/white meat

Seafood (fresh and frozen/tinned) Lean fish Fatty fish (large and small species) Shellfish

2. Potential participants invited to collaborate Collaborators compiled own intake data,

interpreting their local food culture Detailed list of items included in each food group

provided for review e.g. omission of sausages and other processed meats in one

country underestimated total meat intakes

Summary data to be provided: %iles 5, 25, 50, 75, 95; mean±sd

Extremes often most relevant for health; distributions skewed

3. Workshop to review preliminary data Standardized presentation format to ensure

relevant issues discussed by each collaborator, including (i) dietary assessment methods and timing (ii) food item classification (iii) mean intakes overall, across selected strata

Inconsistencies in classification identified, e.g. Meat/vegetable portions of mixed dishes not consistent Varying ability to disaggregate subgroups

Red/processed meats not readily separable due to differences in use of additives/fillers in items such as hamburgers

e.g. processed = 51% of total in Scotland vs. 18% Portugal

4. Compilation and evaluation of intake disparities using revised food groups

Comparisons with other studies to evaluate country intake disparities EPIC multi-country study

Health implications of disparities depend on intake levels

Within-country intake disparities (i) smoking, (ii) age, (iii) education, (iv) obesity

Relevant for targetting nutrition policies/programs Confounding patterns? Insightful for joint analyses of health

outcomes

Results

Participating studies Northern Europe (n=5)

Denmark – Danish National Birth Cohort (DNBC)

England – Avon Longitudinal Study (ALSPAC)

Norway – Mother & Child Study (MoBa)

Scotland – SEATON cohort Sweden – ABIS study

Southern Europe (n=4) Greece – Rhea study Italy – GEPSII study Portugal- Generation XXI Spain – INMA cohorts

Western Europe (n=3) France – EDEN cohort Germany – LISA cohort Netherlands – Generation R

Central/Eastern Europe (n=3) Poland - Lublin study Poland - Krakow study Austria - Vienna study

Varied design, sample sizeN Enrollment

PeriodDietary

Assessment

Northern

Denmark: DNBC 70,133 1996-2002 FFQ 360 items

England: ALSPAC 11,877 1991-2002 FFQ 50 items

Norway: MoBa 54,350 1998-2008 FFQ 255 items

Scotland: SEATON 1,710 1997-1999 FFQ 150 items

Sweden: ABIS 15,659 1997-1999 FFQ 22 items†

Western

France: EDEN 1,610 2003-2005 FFQ 137 items

Germany: LISA 3,039 1998-1999 FFQ 50 items

Netherlands: Gen R 1,203 2002-2006 FFQ 293 items

† Selected components of diet only.

Small influence of trimester of collection on overall energy intakes

3rd vs 1st trimester: modest diff in kcals

Mendez et al, 2011

2 3 1 3 1 233 12

Fruits & vegetables

Gradient in reported intake levels consistent with expectations

Fruits & vegetables (g/day)

Levels of fruit intakesimilar in EARNEST vs. EPIC

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k

Eng

land

Nor

way

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man

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Net

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Gre

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Spa

in

EARNESTEPIC

High (>300g/d)

Med (>250-300g/d)

Low (≤250g/d)

Mendez et al, AJCN 2011

Fruits & vegetables: (i) Smokers reported substantially lower intakes in most regions

Fruits & vegetables (g/day): 50g+ less among smokers in 8 of 11 studies

50

250

450

650

850

1050

Non

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Med

ian

(25t

h/75

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Northern Western Southern Eastern

= disparity >100g (1 serving daily)

Fruits & vegetables: (ii) Younger women often reported substantially lower intakes

Fruits & vegetables (g/day): 50g+ lower in younger women, 9 of 13 studies

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= disparity >100g (1 serving daily)

Fruits & vegetables: (iii) More educated mothers had higher intakes in most regions

Median intakes: 207–485 g/day

Fruits & vegetables (g/day): 50g+ higher in more educated mothers

50

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Fruit & vegetable intakes in the Mediterranean higher and not related to education

Median intakes: 565–600 g/day

Mediterranean/Southern

F&V: (iv) Overweight women had somewhat lower intakes, exceptions largely Mediterranean

Overweight/obese=based on pre-pregnancy BMI

Fruits & vegetables (g/day): 40g+ lower among overweight or obese women except in the Mediterranean

50

250

450

650

850

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Denmark England Norw ay Scotland France Germany Netherld Italy Greece Portugal Spain Poland-L Poland-K

Northern Western Southern Eastern

Red/processed meats

Similar levels of red/processed meat intake in EARNEST vs. EPIC

Den

mar

k

Eng

land

Nor

way

Sw

eden

Fra

nce

Net

herla

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Ital

y

Gre

ece

Spa

inEARNESTEPIC

High (>70g/d)

Med (50-70g/d)

Low (≤70g/d)

Mendez et al, 2011

Red/processed meats: (i) Smokers consistently reported higher intakes

Red/processed meats (g/day): 10g+ higher among smokers in 4 of 11 countries

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100120140160180

Non

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Med

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Northern Western Southern Eastern

=disparity ≈10-15 g/day, 1 serving/wk

Other red/processed meat intake disparities

Younger women often reported higher intakes

More educated women consistently reported lower intakes

Overweight or obese women typically reported somewhat higher intakes

Seafood intakes

Markedly higher in Spain and Portugal Median intakes ≈ 65g/day, vs. 0–40g/d

Substantial proportion exceed 3-4 servings/week

Consistent with expectations, e.g. similar to EPIC

Intakes were related to maternal characteristics Lower levels among smokers, younger, less educated

and more obese women

Conclusions

Feasible to harmonize food group intakes post hoc

Widespread disparities in intakes of fruits & vegetables, but also of red & processed meats and seafood

Disparities were associated with characteristics predictive of poorer pregnancy outcomes Smoking in pregnancy, younger age, less education Pre-pregnancy overweight and obesity: smaller disparities

Standardization challenges: food groups

Group definitions not always straightforward Fruit including juices? Cooked vs. raw weight for vegetables? Cereal products in servings vs. grams (bread vs

pasta/rice cultures)? Dairy products including cheeses, desserts?

Absolute vs. energy-adjusted? Implausible reporters?

Harmonization challenges: nutrients Will FFQ food items yield sufficiently precise rankings?

e.g. seafood details may reduce misclassification of DHA intakes in some FFQs compared to others

Fortification, supplement use, food varieties New food products as well as shifting content existing products

Food folate or dietary folate equivalents including folic acid?

Incomplete or inconsistent food composition data Definitions of available nutrients

Fiber: non-starch polysaccharides or also lignin, resistant starch? Details on specific fatty acids often lacking

Future directions

Feasible to standardize/harmonize intakes though care is needed Nutrients likely more time-consuming

EPIC food table compilations for several European countries an important resource soon to be available

Collaborative analyses of health effects Sensitivity analyses to assess impact of variable FFQs