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The volume of cold tap water consumed is an essential element in quantitative microbial risk assessment. This paper presents a review of tap water consumption studies. Study designs were evaluated and statistical distributions were fitted to water consumption data from The Netherlands, Great Britain, Germany and Australia. We conclude that the diary is to be preferred for collecting water consumption data. If a diary is not feasible, a 24 h recall would be the best alternative, preferably repeated at least once. From the studies evaluated, the mean daily consumption varies from 0.10 L to 1.55 L. No conclusions could be drawn regarding the effects of season, age and gender on tap water consumption. Physical activity, yearly income and perceived health status were reported to influence water consumption. Comparison of the different statistical probability distribution functions of the datasets demonstrated that the Poisson distribution performed better than the lognormal distribution as suggested by Roseberry and Burmaster. For quantitative microbiological risk assessment (QMRA) it is recommended to use country-specific consumption data and statistical distributions, if available. If no country specific data are available we recommend to use the Australian distribution data from the Melbourne diary study (Poisson, lambda=3.49 glasses/d) as a conservative estimate.

Background: Treatment of persons at high risk for coronary heart disease (CHD) should include nutritional counselling, but little is known about the effects of different types of education., Methods: In a quasi-experimental study design the effects of a nutritional education programme (1st year: three group sessions by a dietitian; 2nd year: one group session; 3rd year: additional focus on saturated fat; reinforcement by written nutritional messages annually) (intervention group; n=103) are compared with the effects of a posted leaflet containing standard dietary guidelines (control group; n=163). Participants had hypercholesterolemia (6-8 mmol/l) and at least two other CHD risk factors., Results: After 3 years, no significant differences existed in established CHD risk factors between intervention and control groups (adjusted mean net differences: total cholesterol (0 mmol/l), diastolic blood pressure (-1.1 mm Hg; NS), and body weight (+0.3 kg, NS)). Regarding dietary intake, the intervention group had a lower intake of total (net difference -2.0% of energy, SEM 0.9) and saturated fat (-1.2% of energy, SEM 0.4) and a higher fish (+11 g/day, SEM 4) and vegetables consumption (+21 g/day, SEM 10) during the study period (p<0.05 for all)., Conclusion: A nutritional education programme with group sessions changed dietary intake more effectively than a posted leaflet, but no additional positive effects were observed on established CHD risk factors after three years of follow-up.

Probabilistic modelling can be used to get an insight into the variability and uncertainty of the nutrient intake in a population. When a probabilistic model is used, it is important that it is validated. Furthermore, a sensitivity analysis of the model output can give an insight into the most important input variables of the model and can be used as an aid to describe the reliability of the model. In this study, four models to estimate vitamin B(6) intake among males and females were validated using the method of Kaaks et al. This method compares the relationship between three different kind of measurements with the unknown 'true' intake. In each of these four models, only one input variable (concentration or bioavailability) was changed compared with a reference model. A sensitivity analysis was also performed. The results of the validation showed that for males, a model using a fixed bioavailability factor at the food group level was valid, while for females a model using either a fixed value or a distribution for the bioavailability factor was valid. Use of a distribution for the concentration of vitamin B(6) in supplements was not valid. The results of the sensitivity analysis showed that the concentration of vitamin B(6) in food and supplements was the key contributor to variability and uncertainty in the model estimates of vitamin B(6) intake, in both males and females. All results indicated that when taking variability and uncertainty into account by using probabilistic modelling, the effect on the nutrient intake for nutrients that are present in many common eaten foods, is small. For these broadly available nutrients, fixed concentrations and bioavailability factors give a good estimate of the nutrient intake in a population. When using probabilistic modelling, it is very important to collect more actual information about the concentration.

Objective: To study differences in dietary intake between adults with different socioeconomic status (SES) and trends over time., Design: Cross-sectional study based on data of three Dutch National Food Consumption Surveys (DNFCS-1 1987/88; DNFCS-2 1992; DNFCS-3 1997/98), obtained from a panel by a stratified probability sample of the non-institutionalized Dutch population., Subjects: A total of 6008 men and 6957 women aged 19 y and over., Methods: Dietary intake was assessed with a 2 day dietary record. Background information was obtained by structured questionnaire. Sociodemographic variables were available from panel information. SES, based on educational level, occupation and occupational position was categorized into (very) low, middle and high. Analysis of variance with age as covariable was used to explore the effects of SES on dietary intake and anthropometry. Statistical tests for trend were carried out with models in which week-weekend-day effects and an interaction term of time with SES were also included., Results: The prevalence of obesity and skipping of breakfast was higher among people with a low SES. In all three surveys, subjects in the (very) low SES group reported having a higher consumption of potatoes, meat and meat products, visible fats, coffee and soft drinks (men only). Subjects with a high SES reported consuming more vegetables, cheese and alcohol. As regards nutrients, in all surveys a higher SES was associated with higher intake of vegetable protein, dietary fibre and most micronutrients. A higher SES was also associated with a lower fat intake but the differences between social classes were rather small and not consistent when the contribution of alcohol to energy intake was taken into account., Conclusion: In general, dietary intake among subjects in higher SES groups tended to be closer to the recommendations of the Netherlands Food and Nutrition Council and this phenomenon was quite stable over a period of 10 y.

Objective: The aim of the EFCOSUM project was to develop a method to estimate both acute and usual consumption levels in European countries and for the sake of comparison, a common basic method for dietary assessment was needed. The method should allow a reliable comparison of the intake of relevant dietary indicators among large population groups., Design and Results: The selection of methodology was based on the available literature and the expertise of the participants. To guide the selection process, decision trees containing all relevant moments of choice, alternatives and criteria for the selection of a method for food consumption measurement were developed. Considering that insight into average food and nutrient intake and their distribution in well-defined groups of individuals was important, it was decided that for the monitoring of the selected dietary indicators food consumption data should be collected at an individual level. Different methods were reviewed (24 h recall, dietary record, food frequency questionnaire, dietary history method)., Conclusions: Since the 24 h recall method is applicable in large European populations of different ethnicity, has a relatively low respondent and interviewer burden, is open-ended and is cost-effective, this method can be considered as the best method for EFCOSUM to get population mean intakes and distributions for subjects aged 10 y and over in different European countries. Usual intake should be estimated by statistical modelling techniques, using two non-consecutive 24 h recalls and a food list to assess the proportion non-users for infrequently consumed foods.

Objective: To establish a method for food consumption data collection in ethnic groups in the Netherlands., Methods: Two pilot studies have been carried out, one among Moroccan women and one among Surinam men. First, focus group discussions were held to obtain background information from members of the target population. For food consumption assessment 2 X 24-h recall was chosen. Furthermore, background information on age, place of birth, frequency of visits to Morocco or Surinam, Dutch language skills, meal pattern, food purchases and antropometric measurements were taken., Results: It was found that the diets of both Moroccan women and Surinam men tended to approach the recommended daily intake of macronutrients more than the average intake of a Dutch person. However, reported energy and micronutrient intake on the second day of the dietary recall was lower than on the first recall day., Conclusion: The 24-h recall is a suitable method for food consumption measurements among Moroccan and Surinam people. On the other hand, the interviewer must be aware of potential under-reporting, especially during the second recall.

Objective: A consideration of eating patterns in the general population is necessary when deriving food-based dietary guidelines (FBDG) as promoting the intake of one food may indirectly result in the increased consumption of another, which may not always be desirable. A number of issues that influence meal patterns such as temporal distribution of food intake (using data from the Netherlands), converging and diverging foods (using data from Ireland) and meals eaten inside and outside of the home (using data from the UK) are examined and discussed in the context of developing FBDG., Setting: Food intake databases from three EU countries: The Netherlands, Ireland and the UK., Results: The hot meal (dinner) was found to be the main contributor to the intake of energy and macro-nutrients in the Dutch population. It was also the main contributor to the intake of all micro-nutrients with the exception of calcium where the bread meal contributed a similar proportion as the hot meal to the intake of this micronutrient. Furthermore, fruit intake showed a very different temporal distribution to vegetable intake. Exploring the convergence of certain foods in the Irish population also revealed differences between fruit and vegetables. A low correlation was shown for consumers of fruit and vegetables indicating that being a high fruit consumer did not suggest being also a high vegetable consumer. An examination of where meals were consumed among British adults showed that 71% of all meals were consumed inside the home while 29% were consumed outside. 27% of food energy and 45% of alcohol energy was consumed out of home by the total population. In addition, those eating less of their foods out of home obtained a lower proportion of their food energy from fat and protein and a higher proportion from carbohydrate. A different demographic profile was associated with eating out compared to eating in, comprising more males and younger individuals., Conclusions: Information on patterns of food intake and food habits, specifically temporal distribution, the convergence and divergence of foods and foods consumed inside and outside of the home, give a culturally specific picture of food consumption practices within a population. This should enable the development of more culturally acceptable and realistic FBDG.

Objective: To show the effects of statistical approaches of data analysis to be used in the development of Food-Based Dietary Guidelines (FBDG)., Setting: Databases from dietary surveys in 6 European countries., Results: Quantile analysis based on iron intake among adult women resulted in differences among European countries regarding (macro) nutrient intake and consumption of food groups. However, in all countries women in the highest quartile had a higher intake of energy and dietary fibre and a higher intake of most food groups. In developing FBDG adjustment of energy intake is recommended. Discriminant analyses showed that among Dutch women potatoes, red meat, sausages, offal, savoury snacks, eggs and total vegetables were found to be the most predictive for differences in iron intake. Relatively high correlations were observed for iron and dietary fibre and iron and (some) B-vitamins. Examples from cluster and factor analysis showed that this type of analysis considers the complexity of the dietary pattern and could also be a helpful instrument in the development of FBDG., Conclusions: The use of a nutrient distribution can be used as a minimum approach in developing FBDG. More advanced methods can also be used in addition to set priorities for FBDG and to analyse complete dietary patterns.

Objective: this paper aims to give a broad overview of published data on nutrition and health among migrants in the Netherlands, as well as data on determinants of health., Results and Conclusions: Depending on the definition, 9 to 17% of the population belongs to the group 'migrants' and this proportion is expected to grow in the coming years. Roughly 2/3 of migrants are of the first generation and on average, they are younger than the Dutch population. Relatively few data concerning the health status of migrants are available. The diet of migrants showed both positive (macronutrients) and negative (micronutrients) differences with the general Dutch diet. The risk of overweight was high among both children and adult women, and the data suggest a higher risk for Turkish and Moroccan groups than for Dutch groups. The importance of health determinants, such as smoking, alcohol use and physical and social environment, was different for migrants than for the Dutch population; however, there were also differences between ethnic groups. The limited data on morbidity for migrants suggest higher risks than for the indigenous population. The same holds for mortality data, especially for the younger age groups. In general, the data that are available suggest that the health status of migrants was less favourable than that of the indigenous population. However, there were also differences between the various groups of migrants. The lower socio-economic position of migrant groups partly explained the differences in health status. Nevertheless, a study among Turkish people indicated that their health status was lower than that of Dutch people of comparable socioeconomic status.

Objective: To investigate the impact of intensive group education on the Mediterranean diet on dietary intake and serum total cholesterol after 16 and 52 weeks, compared to a posted leaflet with the Dutch nutritional guidelines, in the context of primary prevention of cardiovascular disease (CVD)., Design: Controlled comparison study of an intervention group given intensive group education about the Mediterranean diet and a control group of hypercholesterolaemic persons given usual care by general practitioners (GPs)., Setting: A socioeconomically deprived area in the Netherlands with an elevated coronary heart disease (CHD) mortality ratio., Subjects: Two hundred and sixty-six hypercholesterolaemic persons with at least two other CVD risk factors., Results: After 52 weeks, the intervention group decreased total and saturated fat intake more than the control group (net differences were 1.8 en% (95%CI 0.2-3.4) and 1.1 en% (95%CI 0. 4-1.9), respectively). According to the Mediterranean diet guidelines the intake of fish, fruit, poultry and bread increased in the intervention group, more than in the control group. Within the intervention group, intake of fish (+100%), poultry (+28%) and bread (+6%) was significantly increased after 1 year (P < 0.05). The intensive programme on dietary education did not significantly lower serum cholesterol level more (-3%) than the posted leaflet (-2%) (net difference 0.06 mmol l-1, 95%CI -0.10 to 0.22). Initially, the body mass index (BMI) decreased more in the intervention group, but after 1 year the intervention and control group gained weight equally (+1%)., Conclusions: Despite beneficial changes in dietary habits in the intervention group compared with the control group, after 1 year BMI increased and total fat and saturated fat intake were still too high.

Food chemical risk management needs, among other things, assessment of exposure. For dietary intake food consumption surveys are the data source to be used. One complicating factor in the usage of these data is the dependence of dietary intake estimates on the time frame of assessment. Central to this time dependence is the within-subject variation regarding the usage of food products and, as a consequence, the intake of chemicals. Within-subject variation is mostly as large as or larger than between-subject variation. Expressed per kilogram body weight, average (total) variation in intake variables depends on the age group, with variation usually being greater at younger age, most likely as a result of the higher intake levels at that age. Combination of age groups results in an increase in between-subject variation, and correction based on the figures for the total population will be too small. Ideally, exposure data for all days of one's life should be available to assess lifetime exposure. Since information on all these days is not an attainable and practical option, and not an option to strive for either, the most recent available data should be used that can be extended with simulation studies to anticipate future developments. The present food consumption surveys available in European countries are based on data that vary from 1 day (24-h recall and dietary record) to habitual intake (dietary history and food frequency). The data of a survey based on 1 day refer to 0.004% of an average lifetime of 70 years. Based on the demographic picture of the population, a reasonable approximation of lifetime intake can be obtained. The proportion of users and the consumption level among users depend on the time frame of assessment, especially for irregularly consumed products. Usage of the concept of "users only" overestimates lifetime exposure of the population, the extent of overestimation depending on the duration of the survey. The likelihood that all consumers have been exposed to a chemical once during a lifetime period is realistic in the sense of the best approximation of reality. As a result of this assumption all exposure assessments will have a similar point of departure and the dependence of the results on the food consumption method will be reduced.

Recently, the concept of food-based dietary guidelines has been introduced by WHO and FAO. For this concept, several assumptions were necessary. The validity and potential consequences of some of these assumptions are discussed in this paper on the basis of the Dutch National Food Consumption Surveys. The topics were interrelationships among dietary characteristics, nutrient density, diets in accordance with the guidelines, and food variety. To obtain insight into overall diet quality, a dietary quality index based on nutrients and a food-based quality index based on food groups were created and tested. As expected the results showed that a higher dietary quality index was associated with an improved intake of the nutrients included in the index, in particular a lower intake of total fat and cholesterol. This was related to a lower consumption of cheese, fats and oils, meat and meat products, and a higher consumption of fruit and vegetables. The information obtained with a dietary quality index can be used to assess the feasibility of a particular goal in combination with other relevant goals and to obtain clues or confirmation for recommendations regarding food consumption. The food-based quality index created showed that a combination of several food-based goals (formulated in quantitative terms) was associated with an increase in food consumption, without a clear relevance for the dietary quality. Therefore, the formulation of food-based guidelines should be based on explicitly stated dietary goals. The findings regarding nutrient density were in the direction of what was assumed, namely a positive association between density and absolute intake, although the expected effects were not completely found. The results regarding the association between variety and dietary intake were characterized mainly by differences in quantity rather than dietary quality. The data indicate that energy intake may be an important pitfall in implementing food-based dietary guidelines, that 'eat a variety of food' can be an empty slogan and that nutrient density is positively related to the absolute intake of specific micronutrients. Further, the 'absence' of interrelationships among risk nutrients indicates that a selection process has to be applied.

Dietary intake characteristics were studied among 3833 adults of the second Dutch National Food Consumption Survey held in 1992. The subjects were classified into three groups based on their intake of total fat (% energy), saturated fatty acids (% energy), dietary fibre (g/MJ), and fruit and vegetables (g/d). All the classifications resulted in differences in energy intake. Except for dietary fibre, the mean energy intake was higher in the higher-intake tertiles. For the classification based on total fat, saturated fatty acids and dietary fibre the more prudent diets were accompanied with a lower energy-intake. As to the consumption of food groups, differences existed in both the proportion of consumers and in the mean consumption among users. It is concluded that the trends observed are probably more important than the actual figures.

Objective: To assess the intake of trans fatty acids (TFA) and other fatty acids in 14 Western European countries., Design and Subjects: A maximum of 100 foods per country were sampled and centrally analysed. Each country calculated the intake of individual trans and other fatty acids, clusters of fatty acids and total fat in adults and/or the total population using the best available national food consumption data set., Results: A wide variation was observed in the intake of total fat and (clusters) of fatty acids in absolute amounts. The variation in proportion of energy derived from total fat and from clusters of fatty acids was less. Only in Finland, Italy, Norway and Portugal total fat did provide on average less than 35% of energy intake. Saturated fatty acids (SFA) provided on average between 10% and 19% of total energy intake, with the lowest contribution in most Mediterranean countries. TFA intake ranged from 0.5% (Greece, Italy) to 2.1% (Iceland) of energy intake among men and from 0.8% (Greece) to 1.9% among women (Iceland) (1.2-6.7 g/d and 1.7-4.1 g/d, respectively). The TFA intake was lowest in Mediterranean countries (0.5-0.8 en%) but was also below 1% of energy in Finland and Germany. Moderate intakes were seen in Belgium, The Netherlands, Norway and UK and highest intake in Iceland. Trans isomers of C18:1 were the most TFA in the diet. Monounsaturated fatty acids contributed 9-12% of mean daily energy intake (except for Greece, nearly 18%) and polyunsaturated fatty acids 3-7%., Conclusion: The current intake of TFA in most Western European countries does not appear to be a reason for major concern. In several countries a considerable proportion of energy was derived from SFA. It would therefore be prudent to reduce intake of all cholesterol-raising fatty acids, TFA included.

This study presents data on dietary intake of specific carotenoids in the Netherlands, based on a recently developed food composition database for carotenoids. Regularly eaten vegetables, the main dietary source of carotenoids, were sampled comprehensively and analysed with modern analytic methods. The database was complemented with data from recent literature and information from food manufacturers. In addition, data on intake of vitamin A are presented, which are based on the most recent update of the Dutch Food Composition Table. Intake of vitamin A was calculated for adult participants of the second Dutch National Food Consumption Survey in 1992, whereas intake of carotenoids was calculated for participants of the Dutch Cohort Study on diet and cancer, aged 55 to 69 in 1986. Mean intake of vitamin A amounted to 1.1 and 0.9 mg RE/day for men and women, respectively; the contributions of meat, fats and oils, vegetables and dairy products to total intake were 35%, 24%, 16%, and 16%, respectively. Mean intake of alpha-carotene, beta-carotene and lutein plus zeaxanthin was 0.7, 3.0, and 2.5 mg/day respectively for both men and women, while mean intake of lycopene was 1.0 mg/day for men and 1.3 mg/day for women. The most important foods contributing to intake of beta-carotene and lutein plus zeaxanthin were carrots (beta-carotene only), spinach, endive and kale.

Objective: To assess the prevalence of low and marginal iodine intake and urinary iodine excretion among adults in the Netherlands and to investigate determinants of urinary iodine excretion., Design and Subjects: The study population consisted of 444 people aged 20-79 y, balanced for sex and 10 y age classes with an over-representation of people with a low habitual intake of vitamin B6. Food consumption was measured by three day food records and 24 h urine was sampled twice., Results and Conclusions: On average, iodine intake (mean of three days) in men was in the recommended range of 150-300 microg/d, but average intake in women was not. Mean 24 h urinary excretion values confirmed this observation. Estimation of the prevalence of low iodine excretion depended on the parameter chosen (absolute per 24 h, per kg body weight per 24 h, as concentration or per creatinin). The prevalence of low iodine supply, based on intake <100 microg/d (mean of three days) and intake or excretion parameters per creatinin excretion or per kg body weight, varied from 4-14% among adult women and from 5-17% among adult men. The prevalence of marginal iodine intake (<50 microg/d) and excretion was less than 5% in all adult age-sex groups. Urinary iodine excretion was most strongly associated with intake of iodine as such or as bread in combination with urinary excretion of sodium or potassium, confirming the importance of iodized salt (in bread) for iodine status. Age and total energy intake had a relatively minor impact on urinary iodine excretion.

Objective: To assess the adequacy of the iodine supply in the Netherlands and to study possible ways of increasing the iodine intake. DESIGN, SETTINGS AND SUBJECTS: Goitre and nutrition surveillance studies (intake and urinary excretion of iodine) among population groups (age: 12-85 y, n=57-1704) in the Netherlands in the period 1981-1993. Simulation studies, based on the Dutch Nutrition Food Consumption Surveys (n=6000), calculating iodine intake among population groups after fictively iodizing different food groups., Results: Mean intake of iodine, measured with different food consumption methods in the period 1984-1993, met the recommended amount of 150-300 microg per day in males, but not in females. Median urinary iodine excretion levels were in the range for mild Iodine Deficiency Disorders in both sexes. According to dietary methods reflecting habitual intake and urinary iodine excretion per kg body weight or per mmol creatinin the prevalence of low iodine supply among adults is between 4 and 20% for women and between 5 and 15% for men. Iodization of different products would increase mean iodine intakes by up to 45% and would give a reduction of roughly 65% in the prevalence of low iodine intakes., Conclusion: The present goitre prophylaxis in the Netherlands is not optimally effective. The iodine supply is below cut-off points in 4-20% of the adult population. It is possible to decrease the prevalence of low iodine intakes without a clear risk of exceeding the maximum acceptable daily iodine intake by increasing the iodine content of baker's salt and/or by adding iodine to other foods.

Objective: To assess the distribution of dietary vitamin A intake among Dutch women aged 16-50 and among pregnant women, and to evaluate the effect of the use of a vitamin A (1200 RE) containing multivitamin supplement in terms of nutritional and teratogenic risk., Study Design: Data from the 2nd Dutch national food consumption survey (1992) were used for calculation of the vitamin A intake among 1725 16-50 year old women and 58 pregnant women. Calculations were performed with and without simulation of the use of a supplement containing 1200 RE vitamin A., Results: Average vitamin A intake, based on a two-day dietary record method, compared quite well with recommended intake levels: 850 RE for the 16-50 year old non-pregnant (NP) women (RDA: 800 RE), and 990 RE for the pregnant (P) women (RDA: 1000 RE), respectively. The use of liver on one of the days under survey resulted in high intakes: 60% of the women in this subgroup exceeded the 'safe upper intake limit' of 3000 RE, while in 23% of the cases intakes were > 7500 RE. Those not consuming liver or liver products on the days under survey had relatively low average intakes [NP (n = 1472): 540 RE; P (n = 46): 720 RE]; about 70% of the non-liver users had intakes below the RDA. Including the daily use of a vitamin A containing multivitamin supplement with 1200 RE resulted in intakes > RDA, while only in 2% (NP), respectively 3% (P) of the cases the 'total' intake exceeded the 3000 RE level, but remained in all cases below 7500 RE/day. serving per day., Conclusion: The use of a vitamin A containing (maximum 1200 RE) multivitamin supplement can contribute to a controlled and adequate vitamin A intake and be considered as safe for pregnant women or women who wish to become pregnant, if the consumption of liver is completely avoided and the consumption of liver products is limited to maximum one.

To estimate the effect of possible goitre prophylactic measures on the intake of iodine among population groups, simulation studies, based on the first Dutch National Food Consumption Survey, were carried out. Iodine intake figures and prevalence of low intakes were calculated after fictively iodizing either bread, a combination of industrial products, milk and dairy products (without cheese) or margarine and shortenings. In addition, the effect of iodizing both bread and cheese or bread + biscuits + rusks was calculated. The simulated iodization of different products increased mean calculated iodine intakes by up to 45% and gave a reduction of 60-90% in the prevalence of iodine intakes below 100 micrograms/day. The maximum acceptable intake of 1 mg iodine per day was never reached by any subject (average of 2 days). It is concluded that it is possible to increase substantially the mean iodine intake of the Dutch population and to decrease the prevalence of low iodine intakes without a clear risk of exceeding the maximum acceptable daily oral iodine intake.

Objective: Clustering of low vitamin intake may entail a greater functional and/or health risk than the summation of separate low intakes may suggest. Therefore, the prevalence of combined low thiamin, riboflavin, vitamin B6 and vitamin C intake in various adult sex-age groups in The Netherlands was estimated., Methods: Nutritional risks were evaluated by comparing the calculated intakes with the recommendations for each vitamin. For this purpose the data of a subsample of 3353 adults of a nationwide food consumption survey were used, which had been collected in 1987-88 within the framework of the Dutch Nutrition Surveillance System. Food consumption data were obtained through 2-day dietary records. Respondents were segmented into tertiles based on their vitamin intake per 1000 kcal (4.2 MJ) to adjust for energy intake., Results: As compared with the RDAs, mean overall intake was lowest for vitamin B6. Based on tertile analyses, the risk for inadequate intake was relatively high for vitamin C, small for riboflavin and intermediate for thiamin and vitamin B6. Low vitamin densities clustered somewhat since the prevalence of combined low intakes for all four vitamins was higher than expected from probability calculations. This interdependence was mainly the result of a higher consumption of alcoholic beverages and of other food products with a low vitamin density., Conclusion: In affluent societies nutritional risk assessment should not be based solely on single vitamins but should also be oriented at combined low intake levels.

The interrelationships between alcohol consumption, energy and food intake and smoking habits were studied in 1145 men and 1171 women, aged 22-49 years, in the Dutch National Food Consumption Survey, in which a 48-h dietary record method was used. The aim of the study was to investigate the effects of alcohol consumption on dietary habits and smoking. A strong relationship between alcohol consumption and energy intake was found. The energy derived from alcohol was not compensated for by lower intake of other nutrients. There was no increase in Quetelet's index with increasing alcohol consumption, except for non-smoking men who were heavy drinking on midweek days. Possible explanations for this apparent lack of an overall effect of alcohol calories are discussed. Alcohol consumption was much higher on weekend days than on midweek days. No differences in nutrient intake were found between non-drinkers, moderate drinkers and heavy drinkers on midweek days. On weekend days, however, there was a slightly higher total fat and saturated fat intake in moderately drinking men. For women cholesterol intake was found to be higher in moderate and heavy drinkers. Finally, a strong positive relationship between alcohol consumption and smoking was observed. It is concluded that the observations with respect to energy and nutrient intake and smoking habits are not indicative of a healthier lifestyle in moderate alcohol users between 22 and 49 years of age. Consequently, the more favourable prognosis of moderate drinkers cannot be ascribed to a more healthy lifestyle.

In evaluating dietary data with reference to guidelines for a healthy diet, some potential pitfalls (i.e., method of food consumption assessment and calculation to include or exclude energy derived from alcohol) were investigated. The percentage of energy intake (en%) derived from total fat, saturated fatty acids (SFA), mono- and disaccharides (MD) and intake of cholesterol and dietary fiber per megajoule were calculated using 2-day records obtained in the Dutch National Food Consumption Survey of 1987-1988. Subjects (aged 4-85, n = 5595) were classified into age-sex groups. Mean values and intake distributions were calculated with and without adjustment for within-person variation. Except for the intake of cholesterol and MD, mean intake levels were not in accord with guidelines. About 20% of the women and 23% of the men met the goal for fat intake, 20% of the men and 27% of the women for dietary fiber, and about 60 and 70% for MD and cholesterol. Only 3% of subjects had SFA intake < or = 10 en%, whereas < 1% had a diet in accord with all criteria studied. After adjustment for within-person variation, percentages meeting the guidelines were generally lower for fat, SFA and dietary fiber and slightly higher for cholesterol and MD. Among elderly, unadjusted results were more in agreement with the prevalence estimates based on habitual dietary intake data than with adjusted ones. Fat intake (en%) was inversely related with intake of added MD and alcohol. Our data indicate that guidelines should state explicitly whether energy-related recommendations include energy derived from alcohol, and that the prevalence of a high-fat intake is more affected by the calculation method than by food consumption assessment.

The vitamin C status in blood fractions in 135 elderly women aged 65 years and older was studied within the framework of the Dutch Nutrition Surveillance System. Mean (+/- standard deviation) vitamin C intake (mg/day) was lower among women living in a nursing home (54 +/- 27 mg/day) than among women living in service flats (97 +/- 55 mg/day) and women living independently (132 +/- 44 mg/day). (Service flats are apartments in which the rent includes housekeeping and, when ordered, meal service.) Marginal vitamin C values (< 23 mumol/L) in blood fractions and even levels as low as those found in clinical scurvy (< 11 mumol/L) were frequently observed. In the nursing home, 35% of the women had plasma vitamin C values below 11 mumol/L, and 23% had values between 11 and 23 mumol/L. Blood levels were not significantly affected by age, smoking status, or use of particular drugs but were strongly (r = .47 or, after logarithmic transformation, r = .64) associated with daily intake of vitamin C. Low intake of vitamin C resulted from an overall low food consumption and selective restriction of food products rich in vitamin C. Vitamin C losses caused by food preparation practices and distribution in the nursing home's catering system reduced actual vitamin C intake levels but these losses were not substantially greater than those that are assumed to occur as a result of preparation practices by women living independently.

The habitual intake of energy and nutrients (assessed through dietary history) among elderly women (aged 65 and over) living in a nursing home (n = 54), elderly women living in service flats and receiving their dinners from the nursing home kitchen (n = 29), and elderly women living independently (n = 52) was evaluated within the framework of the Dutch Nutrition Surveillance System. Intake of energy and nutrients was lowest among women in the nursing home and highest among those living independently. Almost all differences in absolute intake found were significant, both unadjusted and adjusted for age. In the nursing home the intake of energy and nutrients was lower at higher age. In qualitative terms the differences among the groups of women were less striking. Mean daily intakes of iron, vitamin A, thiamin, vitamin B6 and vitamin C were below the Dutch recommended dietary allowances (RDAs) among the nursing home women. Several interrelationships among nutrient intakes were found, low intake levels clustering somewhat among elderly subjects. Our data indicate that these nutritional risks are due to a lower food intake resulting in a lower intake of energy and nutrients, and owing to differences in food choice resulting in a lower nutrient density. We conclude that it is difficult to design a diet containing all essential nutrients at the RDA level in a nursing home with residents who have a relatively low intake of energy, especially among those at higher age.

Study Objective: The aim was to investigate whether dietary factors cluster in a favourable or unfavourable way and to characterise the groups identified by lifestyle and sociodemographic variables., Design and Setting: This cross sectional study was based on data of the 1987-1988 Dutch national food consumption survey (DNFCS), obtained from a panel by a stratified probability sample of the non-institutionalised Dutch population., Participants: 3781 adults (1802 males and 1979 females) of the DNFCS, aged 19 to 85 years, were studied., Measurements and Main Results: To estimate dietary intake two day food records were used. Lifestyle factors were collected by structured questionnaire and sociodemographic variables were available from panel information. Cluster analysis was used to classify subjects into groups based on similarities in dietary variables. Subsequently, these groups were characterised by sociodemographic and lifestyle factors as well as by the consumption of food groups. Eight clusters were found. In comparison with the guidelines, the dietary quality in four clusters was poor. The cluster with the poorest dietary intake (high intake of fat, cholesterol, and alcohol; low intake of dietary fibre) showed on average a high consumption of animal products (except milk), fats and oils, snacks, and alcoholic beverages, and a low consumption of fruit, potatoes, vegetables, and sugar rich products. Smoking, body mass index, dietary regimen on own initiative, hours of sleep, gender, age, socioeconomic status, and day of the week were found to discriminate among the clusters., Conclusions: Cluster analysis resulted in substantial differences in mean nutrient intake and seems useful for dietary risk group identification. Undesirable lifestyle habits were interrelated in some clusters, but an exclusive lifestyle for health risk has not been found.

This study was designed to test the reproducibility of a food frequency questionnaire used in a population-based case-control study on diet and pancreatic cancer. Repeat questionnaires covering the same time period were obtained using 63 male and female population controls, 35-79 years of age. For selected food items included in the case-control study, the attenuation of the odds ratios due to random error was estimated. Using 54 male and female population controls, 35-79 years of age, we conducted a second study to examine the agreement between original and repeat interviews when the time interval between interview and the period of interest was constant. In the first study, the median correlation coefficient was 0.72 for foods (ranging from 0.36 and 0.59 for subgroups of vegetables to 0.96 for alcoholic beverages) and 0.77 for nutrients (ranging from 0.62 for beta-carotene to 0.85 for energy and 0.91 for ethanol). In the second study, the median correlation coefficient was 0.68 for foods (ranging from 0.28 for eggs to 0.87 for alcoholic beverages) and 0.75 for nutrients (ranging from 0.48 for beta-carotene to 0.76 for energy). We conclude that for most items the agreement between original and repeat estimates was moderate (r > 0.50) to high (r > 0.70). Moderate agreement was found for 28 of 33 food items (85%) and for all 21 nutrient items (100%) and high agreement for 19 of 33 of food items (56%) and 15 of 21 nutrient items (71%). In the second study, agreement was somewhat lower but closely paralleled the results of the first study. On average, random error presumably attenuated most of the observed diet-cancer relationships only moderately; i.e., an observed odds ratio of 1.5 and a correlation coefficient of 0.70 yield an unattenuated odds ratio of 2.1.

Insight into the occurrence of and the association between certain socio-economic variables and life-style characteristics is necessary for preventive nutrition and health policy. The prevalence of and the interdependencies among these variables were examined in 1930 men and 2204 women aged 19 to 85 who participated in the Dutch National Food Consumption Survey 1987-1988. Dietary data were based on a two-day record. The associations among discrete variables were analysed using log-linear models. Analysis of covariance was used to explore the effects of the aggregate socio-economic status (SES) on dietary intake and anthropometry, whereas differences in food intake and SES were assessed by the non-parametric test of Kruskal and Wallis. In comparison to subjects with a high SES in people with a low SES a higher proportion of smokers (48 vs 32 per cent) was observed, a higher prevalence of obesity (39 vs 28 per cent), a higher percentage of heavy coffee drinkers (greater than six cups per day, 23 vs 17 per cent), and more subjects who skipped breakfast (19 vs 11 per cent). In the highest SES class more subjects used nutritional supplements (18 vs 11 per cent), more subjects followed a dietary rule (five vs two per cent), such as a vegetarian diet, and a higher proportion used more than three alcoholic drinks per day (19 vs 15 per cent). A higher SES was associated with a lower fat intake, but the differences (expressed as per cent of energy intake) were rather small and even absent among women when the contribution of alcohol to energy was not taken into account. In general, dietary intake among subjects in higher SES groups tended to be closer to dietary recommendations. The results indicate that a lower SES is accompanied by a higher prevalence of several indicators of an unhealthy life-style.

Associations between blood pressure and nutrition-related variables (body mass index, dietary intake, and 24-hr excretion of sodium, potassium, magnesium, and calcium in the urine) were investigated in men (n = 138) and women (n = 117) 65-79 years old not using drugs known to affect blood pressure and not on a diet. Among men, body mass index was positively and creatinine clearance was inversely associated with systolic blood pressure, whereas body mass index and urinary sodium:potassium ratio were positively associated with diastolic blood pressure. Among women, both age and urinary calcium:creatinine ratio were positively associated with systolic as well as diastolic blood pressure. Coffee consumption was positively correlated with blood pressure and urinary calcium:creatinine ratio among the women. From the results it appears that, besides "normal" weight, increased potassium intake and urinary excretion may exert a protective effect among elderly men against hypertension when sodium exposure is relatively high. The positive association between urinary calcium:creatinine ratio and blood pressure among the women may be partly due to coffee consumption.

To assess the adequacy of a vegetarian diet at old age, the dietary intake (assessed through dietary history with cross-check) of 44 apparently healthy lacto-(ovo-)vegetarians, aged 65-97 years, was evaluated. Adequacy was assessed by a comparison of nutrient intake with (Dutch) recommendations and by evaluating data on nutritional status. The results were also compared with data of elderly omnivores. In contrast to elderly omnivores, percentages of energy from protein (13%), fat (37%), and carbohydrates (50%) as well as P/S ratio (0.63) were close to or within the range of Dutch guidelines regarding a healthy diet (percentages of energy from protein, fat, and carbohydrates 10-15, 30-35, and 55%, respectively: P/S ratio 0.5-1.0). For most of the micronutrients studied intake was adequate, and nutrient density of the vegetarian diet was higher than of the omnivorous diet. However, the supply of zinc (average daily intake 8.5 and 7.6 mg for men and women, respectively), iron (because of lower bioavailability of nonheme iron), vitamin B12 (women only: intake 2.3 micrograms/day), and water (daily intake less than 1600 ml for 30% of the vegetarians) need special attention, considering the relatively high prevalence of a marginal status of these nutrients. In conclusion, a lacto-(ovo-)vegetarian diet can be adequate at old age, provided that it is carefully planned, especially with respect to the supply of iron, zinc, and vitamin B12.

At the end of the winter circulating concentrations of 25-hydroxyvitamin D (25-OHD) in Asian and Mediterranean immigrants in northwestern European countries are usually very low. This may lead to vitamin D deficiency and eventually to rickets. Children are more prone to develop vitamin D deficiency. The vitamin D status of 8-year-old Turkish, Moroccan and Caucasian children was assessed by measuring plasma concentrations of 25-OHD and parathyroid hormone (PTH) and related to the cumulated global sun radiation (CGSR). The study population was selected from school children in The Hague and Rotterdam (The Netherlands). In each city blood samples were examined from 40 migrant children and a Caucasian reference group (n = 40) (matched for age and sex). Children in The Hague were examined at the end of the winter and early spring (February/April) and those in Rotterdam in late spring and early summer (May/June). Mean plasma 25-OHD concentrations for the migrant children in both cities were significantly lower than for the Caucasian reference group. The lowest 25-OHD values were measured in migrant children in The Hague: 42 per cent of the Turkish and 23 per cent of the Moroccan children had plasma levels less than 20 nmol/l. In these groups hyperparathyroidism (PTH greater than 85 pmol/l) was significantly more prevalent. With all pooled data a significant correlation between plasma 25-OHD and PTH was observed (r = -0.24; P less than 0.001). Regression analysis indicated that the relationship between both variables did not differ among the three ethnic groups. As expected, 25-OHD concentrations were higher for increased CGSR. Differences in 25-OHD level are mainly explained by differences in skin pigmentation and calcium intake between Mediterranean and Caucasian children. The secondary hyperparathyroidism observed in some children confirms that migrant children have a higher risk of developing nutritional rickets when living in areas with a moderate climate.

To obtain more insight into the effect of dietary fiber on vitamin B6 status among elderly people, we studied dietary interrelationships as well as associations between dietary intake and plasma pyridoxal-5'-phosphate (PLP) and cofactor stimulation of aspartate aminotransferase in erythrocytes (EAST-AC) among 441 nonvegetarian (aged 65-79) and 32 vegetarian elderly (aged 65-94). EAST-AC was found to be inversely related with intake of vitamin B6 and dietary fiber in bivariate regression analyses. After adjustment for age, intake of energy, protein, and fiber, the intake of vitamin B6 was still inversely related with EAST-AC. The association between EAST-AC and dietary fiber disappeared in the multivariate analysis, whereas total protein intake proved to be positively related with EAST-AC in the multivariate analysis only. The differences between bi- and multivariate analyses are most likely due to the observed interrelationships between intake of vitamin B6, fiber, and protein. It is concluded that dietary fiber does not have a significant impact on the vitamin B6 status among Dutch elderly people, since only protein (positively) and vitamin B6 (inversely) intake appeared to be related with EAST-AC in the multivariate analysis.

In 460 apparently healthy Dutch elderly, aged 65-79 years, serum uric acid correlates were studied by linear regression analyses, for men and women separately. Diuretic therapy, total serum cholesterol (women only) and creatinine clearance (in bivariate analysis only) were significantly associated with serum uric acid level. Positive associations of serum uric acid with body weight, body mass index, body fatness (men) and lean body mass (men) were observed, with and without adjustment for diuretic therapy, creatinine clearance and age. Serum uric acid levels, whether adjusted or not for these variables and for body mass index, were positively associated with alcohol intake (men) and consumption of meat and fish (women), and inversely with consumption of bread, margarine and milk products (women). These results indicate that limited medication with diuretics, weight control and restriction of alcohol use may help to prevent hyperuricemia in the elderly.

In one study a group of 10 young adult male volunteers were given two experimental diets, differing in fat content. In a second study another group of 12 such volunteers received two experimental diets differing in linoleic acid content. The retention of calcium, magnesium and iron was measured during the dietary periods, each lasting 1 month. Decreasing the fat intake from 42 to 22 energy % did not result in statistically significant changes of the mineral balance. An increase in linoleic acid intake from 4 to 16 energy % (at a constant level of fat intake of 42 energy %) caused a decrease in the iron balance from 3.3 to 2.3 mg/day (p less than 0.01), while the calcium and magnesium retention did not change significantly. During the high linoleic acid dietary period haemoglobin levels decreased from 9.6 to 9.1 mmol/1 and packed cell volume from 0.48 to 0.46 1/1 (p less than 0.001). This effect of linoleic acid on iron utilization needs further investigation.

The dietary intake (assessed through dietary history) of 539 apparently healthy, independently living elderly aged 65-79 years, was evaluated in a nationwide random sample. Except for pyridoxine, the intake of vitamins, minerals, and water was adequate according to the Dutch recommended dietary allowances. Fat intake (40 energy%) as well as P/S ratio (0.41) was assessed as being unfavorable, whereas the intake of vitamin B6 was marginal. The prevalence of obesity was higher among the women, while food selection was healthier as reflected in the higher nutrient density than among the men. Food consumption of elderly men (26%) and women (33%) on a dietary regimen was more prudent and nutrient density higher than among the elderly not on a diet. Our results are in accordance with previous food consumption studies among elderly in The Netherlands, but differ substantially from dietary intake figures for American elderly. Although the intake of energy and nutrients was lower among elderly men than among younger men, we conclude that age per se is not an important determinant of dietary intake among Dutch apparently healthy elderly aged 65-79 years.

1. During a period of 2 years, every 2 months 126 different food items forming a 'market basket' were purchased, prepared and divided into twelve food commodity groups. The 'market basket' was based on a study of the dietary pattern of 16- to 18-year-old male adolescents. In the (homogenized) food groups various additives and components of nutritional importance were determined. From the concentrations of the additives and components in the food groups and the daily consumption of each food group, a mean daily intake of all components analysed was calculated. 2. The mean daily amounts of benzoic acid (34 mg), sorbic acid (6 mg), glutamic acid (660 mg) and sulphite (3 mg) were all far below the acceptable daily intake (ADI) value. Butylated hydroxytoluene and gallates were not detectable, while butylated hydroxyanisole (BHA) was found in only a few instances; the maximum amount of BHA was also very low (4 mg). 3. The mean daily intakes of fluorine (0.8 mg), iodine (0.21 mg), phosphorus (1860 mg) and alpha-tocopherol (9.4 mg) seem safe and adequate. Cholesterol intakes of 25% above the maximum of 300 mg/d, as advised by the Dutch Bureau for Nutrition Education, were found. The mean fat intake appeared to be 40% of total daily energy, protein content 13% of total energy and total (available) carbohydrate 46% of total energy. The daily dietary fibre content (18 g) and the daily amount of linoleic + linolenic acid (6% of total energy) were considered too low. The daily level of sodium (4.2 g) was not considered too high. 4. It is recommended that the study should be repeated regularly, e.g. every few years, in order to monitor trends in the concentrations of significant food components in total diets.

Food intake, meal frequency and occurrence of vomiting and purging were assessed in 20 female patients with anorexia nervosa (AN) by two dietitians by means of a dietary history over the past month. Ten lean healthy women and 10 of normal weight served as two groups of controls. Two self-administered questionnaires, consisting of 51 questions each were developed and applied: one to get an insight into food preference and food aversion, another to evaluate the dietary pattern. A significant difference in energy intake was found between the patient group and both control groups, but not between the two control groups. Self-induced vomiting and weekly laxative use was only mentioned by the patients with AN. Between the patients and the controls significant differences were found in preference and aversion for several food products such as sugar, potatoes, meat, dates and bananas as well as in eating habits. Stepwise discriminant analysis of the data of the two questionnaires resulted in eight food items and three dietary pattern statements which specify group differences. It is concluded that the questionnaires used reveal important differences between anorexia patients and control subjects in attitudes towards foodstuffs, and can be a useful tool for early diagnosis when validated in larger samples of patients and controls.

We studied the effect of menopausal status and risk factors on lumbar bone mineral density (BMD) and metacarpal cortical thickness (MCT) in 286 women of 46-55 years of age. Body mass index (height/weight) was measured and the family history of osteoporosis, reproductive history, menopausal status, calcium intake, amount of physical activity and the consumption of tobacco and alcohol were assessed. Lumbar BMD and MCT decreased substantially in the perimenopausal and postmenopausal period. In the premenopausal women a significant (P = 0.03) lower lumbar BMD was observed in the lowest tertile of calcium intake (less than or equal to 900 mg/day) compared to the highest tertile (greater than or equal to 1200 mg/day). This difference was not apparent in the peri- and postmenopausal women. This suggests that dietary calcium intake is more important in the development and/or maintenance of peak bone mass, than in the modulation of postmenopausal bone loss. Apart from menopausal status and low calcium intake, no other significant determinant of bone mass could be identified. We conclude, therefore, that the assessment of risk factor status is not an efficient tool for the identification of perimenopausal women with low bone mass.

Changes in dietary intake, nutritional status, body composition and well-being were studied in 108 cancer patients over a period of 20 weeks. The patients, constituting a group of elderly women with uterine cancer, a group of elderly men with urological cancer and a group of male and female patients of various ages with malignant lymphoma, were prospectively followed during and after aggressive treatment given with curative intent. Detailed information on the dietary intake was measured by a dietary history and cross-check method covering the 2 months prior to the onset of therapy and a 48-hr dietary record which was applied seven times during the observation period. The nutritional status was monitored by anthropometric measurements and laboratory assays in blood and urine. The patient's well-being was assessed by the use of standard performance scales by the observers and the application of patient's questionnaires concerning complaints, ability to self-care, mobility and daily activities. The main results are described here, indicating that: (1) most patients studied had a more than adequate diet during the 2 months preceding cancer therapy when compared to the Dutch Recommended Dietary Allowances; (2) the impact on dietary intake and nutritional status was relatively minor and generally transient; and (3) the treatment course was accompanied by distinct changes of well-being associated with, but not necessarily resulting from or leading to, changes of dietary intake.

The dietary intake of 105 adult Dutch Caucasian patients (28 women with endometrial or cervical cancer, 50 men with bladder or prostate cancer and 14 men and 13 women with malignant lymphoma) was studied for 19 weeks. Energy and nutrient intakes of all patients were assessed by a dietary history with cross-check over 2 months prior to treatment and by seven 48-h dietary records filled in just before, during and after cancer therapy. No differences were observed between the results obtained with the dietary history and the first 48-h diary. In females treated with abdominal irradiation the mean daily intake of fat, dietary fibre, iron and thiamin decreased during therapy. In men treated with radiotherapy the intake of vegetable protein, polysaccharides, dietary fibre and thiamin also decreased during treatment. This may be partly explained by the observation that many of these patients had spontaneously chosen a 'constipating diet' because of diarrhoea. As compared with the Dutch Recommended Dietary Allowance only the iron intake of the women gave rise to some concern. In our study we did not observe marked changes in dietary intake and nutritional status. In females who underwent irradiation therapy especially, the dietary intake increased after a period of intensive treatment. This demonstrates that food intake of these groups of cancer patients is not consistently reduced by chemotherapy or even abdominal radiotherapy.

Elderly persons are vulnerable to nutritional risks. Factors such as living alone make the elderly prone to poor nutritional status as a result of inadequate diets. The results of a Dutch national nutrition survey of food consumption and nutritional status among 539 independently living, apparently healthy elderly persons, aged 65 to 79 years, show that in general the intake of macronutrients deviates from the Dutch recommendations. In particular, saturated fat intake and P:S ratio were unfavorable, especially for the solitary elderly persons (saturated fat intake 19.0 +/- 3.2% and 17.7 +/- 3.3% total energy for men and women, respectively). Except for vitamin B-6 (about 92% of the recommendation on a group level for men and 78% for women), the intake of micronutrients studied is considered to be adequate. Elderly women living alone had a higher calcium:phosphorus ratio (0.76 +/- 0.12), lower meat consumption (90 +/- 31 gm), and a lower mean HDL-cholesterol concentration (1.22 +/- 0.28 mmol/L) in serum than non-solitary elderly women (Ca:P ratio 0.73 +/- 0.12, meat consumption 100 +/- 36 gm, HDL-cholesterol concentration 1.45 +/- 0.38 mmol/L). Potatoes, vegetables, and meat were more often prepared for more than one day at a time by elderly persons living alone than by the non-solitary elderly.