To explore the use of epidemiological modelling for the estimation of health effects of behaviour change interventions, using the example of computer-tailored nutrition education aimed at fruit and vegetable consumption in The Netherlands.

The effects of the intervention on changes in consumption were obtained from an earlier evaluation study. The effect on health outcomes was estimated using an epidemiological multi-state life table model. Input data for the model consisted of relative risk estimates for cardiovascular disease and cancers, data on disease occurrence and mortality, and survey data on the consumption of fruits and vegetables.

If the computer-tailored nutrition education reached the entire adult population and the effects were sustained, it could result in a mortality decrease of 0.4 to 0.7% and save 72 to 115 life-years per 100 000 persons aged 25 years or older. Healthy life expectancy is estimated to increase by 32.7 days for men and 25.3 days for women. The true effect is likely to lie between this theoretical maximum and zero effect, depending mostly on durability of behaviour change and reach of the intervention.

Epidemiological models can be used to estimate the health impact of health promotion interventions.

To study risk factors for overweight among Brazilian adolescents of low-income families.

Case–control study of obese and non-obese adolescents.

Anthropometric survey including 1420 students (aged 14–19 years) attending a public high school in São Paulo, Brazil.

Selection of 83 overweight (body mass index (BMI) >85th percentile) and 89 non-overweight (BMI >5th percentile and <85th percentile) subjects, frequency-matched by age, gender, pubertal development and socio-economic status. Among the nutritional, familial and behavioural data available, five covariates (parents' obesity, adolescents' past obesity, to have a best friend, dietary restriction and habit of napping) were included in the fitted hierarchical conditional logistic regression models.

Parents or guardians and adolescents were weighed, measured and answered a pre-tested questionnaire applied by trained nutritionists and paediatricians.

The prevalence of overweight was 15.2%. As previous risks, obese parents and obesity during infancy presented odds ratios (OR) and 95% confidence intervals (CI) of 2.23 (1.15–4.35) and 3.60 (1.47–8.80), respectively. As concurrent factors, the habit of napping, to have a best friend and reported dietary restriction presented OR (95% CI) of 3.43 (1.32–8.92), 5.15 (1.76–15.07) and 7.26 (2.95–17.88), respectively. Dietary patterns, frequency of obesogenic foods and other physical activity indicators presented no statistical significance.

In case–control studies, OR may overestimate the true risks. Parents' obesity and previous childhood obesity were identified as risk factors; therefore these factors should be the target for preventive programmes and policies in order to prevent the burden of obesity in the near future.

To compare the anthropometric, alimentary, nutritional and lipid profiles and global diet quality of Spanish children according to saturated fat intake.

This was a cross-sectional study. Food data were collected using a food-frequency questionnaire.

The sample included 1112 children of both sexes, aged between 6 and 7 years, selected by means of random cluster sampling in schools. The plasma lipid profile included measurements of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, apolipoprotein A1 (apoA1) and apolipoprotein B (apoB). Global diet quality was evaluated by the Dietary Variety Index (DVI) and the Healthy Eating Index (HEI).

Energy intake, DVI and HEI of children from the lower quartile of saturated fat intake (LL) were higher (P < 001) than in the remaining children (UL). However, there were no significant differences in average height or weight between groups. The UL children had lower intakes of meat, fish, vegetables, fruits and olive oil and a higher intake of dairy products (P < 0.001). The intakes of fibre, vitamins C, D, B6, E and folic acid were higher in the LL children, who had lower intakes of vitamin A and calcium. The ratios LDL-C/HDL-C and apoB/apoA1 were lower (P = 0.04) in the LL children (1.87 and 0.52, respectively) than in the UL children (2.02 and 0.54, respectively).

The growth rate of children does not seem to be affected by the level of saturated fat intake. Furthermore, at the levels of intake observed in this study, diets with less saturated fat are associated with better alimentary, nutritional and plasma lipid profiles.

To analyse the socio-economic factors related to breakfast eating, the association between breakfast eating and overweight, and to gain a more thorough understanding of the relationship between these two elements in a population-based cohort of 4.5-year-old children. We hypothesised that a relationship could be observed between breakfast skipping and overweight independently of socio-economic factors such as ethnicity, maternal education, single parenting and family income.

A population-based study whereby standardised nutritional interviews were conducted with each child's parent. The children's height and weight were taken by a trained nutritionist and parents were asked about their child's breakfast eating.

The analyses were performed using data from the Québec Longitudinal Study of Child Development (1998–2002), conducted by Santé Québec (Canada).

Subjects were 1549 children between the ages of 44 and 56 months, with a mean age of 49 months.

Almost a tenth (9.8%) of the children did not eat breakfast every day. A greater proportion of children with immigrant mothers (19.4% vs. 8.3% from non-immigrant mothers), with mothers with no high school diploma (17.5% vs. <10% for higher educated mothers) and from low-income families (15% for income of $39 999 or less vs. 5–10% for better income) did not eat breakfast every day. Not eating breakfast every day nearly doubled the odds (odds ratio = 1.9, 95% confidence interval 1.2–3.2) of being overweight at 4.5 years when mother's immigrant status, household income and number of overweight/obese parents were part of the analysis.

Although our results require replication before public policy changes can be advocated, encouraging breakfast consumption among pre-school children is probably warranted and targeting families of low socio-economic status could potentially help in the prevention of childhood obesity.

To assess the prevalence of anaemia in rural Vietnam and to determine its risk factors.

A cross-sectional survey.

Vietnam, Nghe An Province.

The total number of participants was 439. Of these participants, one was excluded from the study due to a mental disorder. Forty-seven did not participate in the test for parasites and 68 did not complete at least one of the questions.

The prevalence of anaemia (haemoglobin (Hb) < 11.0 g dl−1) was 43.2% and of severe anaemia (Hb < 8.0 g dl−1) was 0.5%. Taking iron tablets, the consumption of eggs and the preference for Western medicine significantly and positively correlated with Hb concentration in the pregnant women in a multiple regression analysis. Pregnancy duration and hookworm infestation significantly and negatively correlated with Hb concentration in the pregnant women.

The prevalence of anaemia in rural Vietnam has remained as high as that found in the national anaemia survey in 2000. The results of the present study could aid in the development of an iron-deficiency anaemia programme among pregnant women in rural Vietnam that emphasises iron supplementation, parasite control and improved diet, including the consumption of eggs. The programme's focus should be on women who prefer traditional medicine to Western medicine.

There is increasing evidence for a significant effect of processed meat (PM) intake on cancer risk. However, refined knowledge on how components of this heterogeneous food group are associated with cancer risk is still missing. Here, actual data on the intake of PM subcategories is given; within a food-based approach we considered preservation methods, cooking methods and nutrient content for stratification, in order to address most of the aetiologically relevant hypotheses.

Standardised computerised 24-hour diet recall interviews were collected within the framework of the European Prospective Investigation into Cancer and Nutrition (EPIC), a prospective cohort study in 27 centres across 10 European countries.

Subjects were 22 924 women and 13 031 men aged 35–74 years.

Except for the so-called ‘health-conscious’ cohort in the UK, energy-adjusted total PM intake ranged between 11.1 and 47.9 g day−1 in women and 18.8 and 88.5 g day−1 in men. Ham, salami-type sausages and heated sausages contributed most to the overall PM intake. The intake of cured (addition of nitrate/nitrite) PM was highest in the German, Dutch and northern European EPIC centres, with up to 68.8 g day−1 in men. The same was true for smoked PM (up to 51.8 g day−1). However, due to the different manufacturing practice, the highest average intake of NaNO2 through PM consumption was found for the Spanish centres (5.4 mg day−1 in men) as compared with German and British centres. Spanish centres also showed the highest intake of NaCl-rich types of PM; most cholesterol- and iron-rich PM was consumed in central and northern European centres. Possibly hazardous cooking methods were more often used for PM preparation in central and northern European centres.

We applied a food-based categorisation of PM that addresses aetiologically relevant mechanisms for cancer development and found distinct differences in dietary intake of these categories of PM across European cohorts. This predisposes EPIC to further investigate the role of PM in cancer aetiology.

To assess the relationship between intake of dietary folate equivalents and risk of myocardial infarction in a German cohort.

Intake of dietary folate equivalents was assessed by a validated food-frequency questionnaire. Cox proportional hazard models were used to evaluate the association between intake of dietary folate equivalents and risk of myocardial infarction.

The European Prospective Investigation into Cancer and Nutrition (EPIC)–Potsdam cohort, Germany.

Subjects were 22 245 apparently healthy non-users of vitamin supplements aged 35–64 years.

During 4.6 years of follow-up, 129 incident cases of myocardial infarction were identified. Compared with intake below the median (103 μg), higher intake of dietary folate equivalents was associated with a multivariate-adjusted hazard ratio (HR) of 0.57 (95% confidence interval (CI) 0.36–0.91). The inverse association of folate intake and myocardial infarction risk was stronger in participants with an ethanol intake equal to or above the sex-specific median (HR = 0.37, 95% CI 0.18–0.79) and attenuated in those with a low ethanol intake (HR = 0.67, 95% CI 0.37–1.22).

An increased intake of dietary folate equivalents was observed to be associated with decreased risk of myocardial infarction in a German study population, pointing towards the importance of folate intake with respect to primary prevention of myocardial infarction.

Antioxidant nutrients like carotenoids, tocopherols and vitamin C have been suggested to protect against allergic rhinitis and allergic sensitisation but scientific evidence is scarce. The aims of the study were to measure the plasma concentration of six carotenoids, α- and γ-tocopherol and vitamin C as biomarkers of the intake, absorption and subsequent metabolism of these nutrients, and to assess their association with allergic rhinitis and sensitisation.

Data from a cross-sectional study on representative dietary and lifestyle habits of the population of Bavaria, Germany, were analysed. The plasma levels of six carotenoids (α-carotene, β-carotene, lycopene, lutein/zeaxanthin, canthaxanthin and cryptoxanthin) as well as of α-tocopherol, γ-tocopherol and vitamin C were measured in 547 adults aged between 19 and 81 years. Participants with specific serum immunoglobulin E ≥700 U l−1 were categorised as sensitised. The association of plasma antioxidant levels, allergic rhinitis and allergic sensitisation was assessed by means of unconditional logistic regression models.

We observed a negative association between plasma total carotenoids and the prevalence of allergic rhinitis, with odds ratio (95% confidence interval) of 1.13 (0.54–2.39) for the second, 0.72 (0.33–1.58) for the third and 0.44 (0.19–1.03) for the fourth quartile of total carotenoids concentration (P for trend = 0.0332); results for lycopene failed to reach statistical significance (P = 0.0608). Other single carotenoids, tocopherols and vitamin C were unrelated to allergic rhinitis. Allergic sensitisation was negatively associated with plasma γ-tocopherol, with odds ratio (95% confidence interval) of 0.92 (0.51–1.65) for the second, 1.00 (0.56–1.80) for the third and 0.45 (0.23–0.88) for the fourth quartile of plasma γ-tocopherol concentration (P for trend = 0.0410). No other antioxidant was significantly related to allergic sensitisation.

High plasma carotenoid concentrations reflecting a diet high in various fruits and vegetables might have a protective effect on allergic rhinitis in adulthood.

The relation between several measures of body iron and atherosclerotic disease, particularly acute myocardial infarction (AMI), is debated. This is of specific interest since iron is frequently included in supplementation and fortification of foods. We assessed the relation between dietary iron intake and the risk of non-fatal AMI.

Case–control study. The information was collected by interviewers using a food-frequency questionnaire tested for validity and reproducibility. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were obtained by multiple unconditional logistic regression models, including terms for energy and alcohol intakea, as well as for sociodemographic factors, tobacco and other major recognised risk factors for AMI.

Milan, Italy, between 1995 and 1999.

Cases were 507 patients, below age 79 years, with a first episode of non-fatal AMI, and controls were 478 patients admitted to hospital for a wide spectrum of acute conditions unrelated to known or potential AMI risk factors.

Compared with patients in the lowest tertile of total iron intake, the OR was 0.48 (95% CI 0.29–0.82) for those in the highest tertile. The corresponding value for haem iron was 0.71 (95% CI 0.48–1.06), for non-haem, non-alcohol iron was 0.80 (95% CI 0.51–1.24) and for iron derived from alcoholic beverages was 0.60 (95% CI 0.40–0.90). Sex-specific OR for total iron intake were not heterogeneous.

In this Italian population dietary iron intake was inversely related to AMI risk. This inverse association may depend on other nutrients present in the major sources of iron in the Italian diet.

To understand the role of women's input into household decisions as a possible factor contributing to women's undernutrition in settings where HIV/AIDS and drought have constrained household resources.

Three cross-sectional surveys of non-pregnant women in partnerships without a birth in the last 3 months were analysed. Factors associated with chronic energy deficiency (CED), defined as body mass index of < 18.5 kg m−2, were assessed among 1920 women in Zimbabwe, 2870 women in Zambia and 6219 women in Malawi.

Prevalence of CED was 4.2% in Zimbabwe, 13.5% in Zambia and 6.7% in Malawi. In Malawi, women with less input into decisions were more likely to have CED. After multivariable adjustment, each additional decision made by the partner increased the odds of CED in Malawi by 1.08 (95% confidence interval (CI) 1.02–1.15); each additional decision made by the woman decreased the odds of CED by 0.90 (95% CI 0.88–0.97). Malawian women with all the final say or with partners with no final say had significantly more CED than expected (odds ratio (OR) = 2.88, 95% CI 1.42–5.83 and OR = 1.64, 95% CI 1.06–2.52, respectively), and removing these points increased the magnitude and significance of the linear trends. In Zambia, the relationship was found for urban women only and no associations were found in Zimbabwe.

Input into household decisions may be a key factor in the cycle of drought and CED. Women with both low input and CED may lose productive capacity, putting them at greater risk of food insecurity and potentially HIV/AIDS in high prevalence settings.

To determine whether the literature filtering process, a vital initial component of a systematic literature review, could be successfully completed by nutrition professionals or non-professionals.

Using a diet–disease relationship as the guideline topic, inter-rater agreement for the title and abstract filtering processes between and among professionals and non-professionals was assessed and compared with an expert reference standard. Predetermined eligibility criteria were applied by all raters to 185 titles and 90 abstracts. Filtering decisions were initially made independently and then revised after a within-pair consensus meeting.

The raters were six dietitians (RD) and six nutrition graduate students (Grad). To assess inter-rater agreement (reliability), each group was divided into three pairs.

Weighted and unweighted kappa statistics and percentage agreement were calculated to determine the inter-rater agreement within pairs. Sensitivity and specificity estimates were determined by comparing responses with those of an expert reference standard. Overall, Grad pairs demonstrated greater inter-rater agreement than RD pairs for title filtering (P < 0.05); no differences were observed for abstract filtering. Compared with the expert reference standard, every rater and pair had false-negative responses for both title and abstract filtering.

After consensus meetings, both RDs and Grads were comparable in their agreement on title and abstract filtering, although important differences remained compared with the expert reference standard. This study provides preliminary findings on the value of utilising a non-expert pair in developing guidelines, and suggests that the literature filtering process is complex and quite subjective.

To develop a concise, simple tool for use by non-specialists to assess diet in children aged 3–7 years attending primary schools.

A 24-hour food tick list covering all aspects of the diet and with a focus on fruit and vegetable consumption was developed. This was compared against a 24-hour semi-weighed food diary obtained for the same day as the tick list.

Six primary schools with a range of socio-economic and ethnic backgrounds from a large city in the north of England (Leeds).

One hundred and eighty children returned completed packs of information; a response rate of 77% of those who were willing to take part, 48% of those approached.

On average, 2.4 items of fruit including juice (2.1 items as 5-a-day count) were eaten and 1.6 items of vegetables (excluding potato). Twenty-seven per cent and 36% of boys and 23% and 24% of girls reported not eating any fruit or vegetables, respectively, on the recording day. Correlations comparing the diary and tick list were high for both foods (range r = 0.44 to 0.89) and nutrients (range r = 0.41 to 0.68). The level of misclassification was much less than would be expected by chance. Parent and teacher evaluation of the tick list was very positive. Parents felt the tick list was easy and quick to complete.

The Child and Diet Evaluation Tool (CADET) tick list has been used successfully for rapid collection of food and nutrient information from children aged 3–7 years from diverse social and ethnic backgrounds. The tool has performed better than many food-frequency questionnaires in comparison to a food diary.

In order to obtain a measure of nutrient intake, a measure or estimate of the amount of food consumed is required. Weighing foods imposes a large burden on subjects, often resulting in underreporting. Tools are available to assist subjects in providing an estimate of portion size and these include food photographs. The application of these tools in improving portion size estimation by children has not been investigated systematically.

To assess the accuracy with which children are able to estimate food portion sizes using food photographs designed for use with adults, and to determine whether the accuracy of estimates is improved when age-appropriate portion size photographs are provided.

Original data from three separate studies, on the accuracy of portion size estimates by adults using food photographs, by children using adult photographs and by children using age-appropriate photographs, are analysed and compared.

One hundred and thirty-five adults aged 18 to 90 years and 210 children aged 4 to 11 years.

Children's estimates of portion sizes using age-appropriate food photographs were significantly more accurate (an underestimate of 1% on average) than estimates using photographs designed for use with adults (an overestimate of 45% on average). Accuracy of children's estimates of portion size using age-appropriate photographs was not significantly different from that of adults. Children overestimated a food's weight by 18% on average and adults underestimated by 5%.

Providing children with food photographs depicting age-appropriate portion sizes greatly increases the accuracy of portion size estimates compared with estimates using photographs designed for use with adults.

As a part of an ongoing project to develop a nutritional screening tool, we evaluated the performance of a semi-quantitative food-frequency questionnaire (FFQ) in terms of validity in a Sheffield Caucasian pregnant population using two different statistical approaches – the correlation coefficient and the limits of agreement (LOA). The FFQ was designed specifically for pregnant women and previously used in a large-scale study.

A validation study.

A community-based field study of a general population of pregnant women booked for their first antenatal appointment at the Jessop Wing, Royal Hallamshire Hospital, Sheffield, UK.

One hundred and twenty-three women of different socio-economic status, aged between 17 and 43 years, provided complete dietary data.

The validity of the FFQ was tested against a series of two 24-hour recalls. As expected, the intakes of all examined nutrients, except for iodine, carotene, vitamin E, biotin, vitamin C and alcohol, were higher when determined by the FFQ than when determined by 24-hour recall. Pearson's correlation coefficient between the two methods ranged from 0.19 (added sugar, zinc) to 0.47 (Englyst fibre). The LOA were broader for some of the nutrients, e.g. protein, Southgate fibre and alcohol, and an increasing lack of agreement between the two methods was identified with higher dietary intakes.

The FFQ gave useful estimates of the nutrient intakes of Caucasian pregnant women and appears to be a valid tool for categorising pregnant women according to dietary intake. The FFQ performed well for most nutrients and had acceptable agreement with the 24-hour recall.

The National Diet and Nutrition Surveys (NDNS) are a series of government-funded surveys of food intake, nutrient intake and nutritional status of individuals, undertaken to support nutritional policy and risk assessment. This paper summarises a review that considered the extent to which NDNS met the needs of users and suggested options for the future. The Food Standards Agency has since progressed favoured options. This paper aims to help others wishing to obtain this type of information within their own populations.

A detailed questionnaire was used to probe use of data and gather opinions from users, producers and managers of the NDNS. It asked about general information needs from NDNS and changes that might be made. This was followed by a two-day workshop which included discussion of the main issues and the generation of 19 possible future options for consideration by the Agency.

Options to improve effectiveness included methods to prioritise breadth and depth of coverage and possible ways of improving response and compliance. Strategies to make surveys more efficient and timely, such as adopting a rolling programme, disaggregating survey components, integrating with other studies and improving data access, were also suggested. A rolling programme, in which data are collected continuously, was the favoured option to address some of the concerns and a strategy is now in place to achieve this.

There is widespread support for the NDNS from its users. There is no alternative source for such high-quality data on food and nutrient consumption and nutritional status and physical measurements in the same individuals. Useful information, such as the potential value of using a rolling programme from the outset, can be gained from this British experience by others wishing to measure food and nutrient intakes and status in their own populations.