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Monitoring population salt intake is operationally and economically challenging. We explored whether a questionnaire assessment and a prediction of Na intake from spot-urine could replace or complement the recommended measurement of Na in 24-h urine (24-h U).Compare the agreement of a Na-specific food record checklist (FRCL) and a late-afternoon spot-urine measurement (PM-spot) with 24-h U measurement in estimating Na intake at group level. Each participant's use of these methods extended over 3 d. Agreement was assessed using mean (95 % CI) differences, linear regression models and Bland-Altman plots.The validation study was part of a 1-year workplace intervention trial to lower salt intake in Switzerland.Seventy women and 71 men, aged 21-61 years, completed three FRCL, and acceptable PM-spot and 24-h U samples at baseline (April-October 2015).Mean Na intake estimates varied slightly across methods (3·5-3·9 g/d). Mean Na intake differences from 24-h U were 0·2 (95 % CI (0, 0·5)) g/d for FRCL and 0·4 (95 % CI (0·2, 0·6)) g/d for PM-spot. Linear regression models and Bland-Altmann plots more clearly depicted differences by sex and discretionary salt use.Although 24-h U remains the best reference method for monitoring Na intake at the population level, PM-spot and FRCL might be more practical instruments for frequent, periodic Na intake assessments. Population-specific prediction models to estimate 24-h U could be developed and evaluated.

The short food literacy questionnaire (SFLQ) was developed to measure a broad range of skills including functional, interactive, and critical elements of FL. This study evaluated SFLQ measurement properties. We used a workplace intervention trial to reduce salt intake in Switzerland to explore the underlying structure of the questionnaire with 350 respondents and identify the ideal number of SFLQ items to capture the different elements of FL. Exploratory factor analysis showed a unidimensional structure of the final 12-item questionnaire. A sum score based on all 12 items (Cronbach's α = 0.82) showed expected positive associations with health literacy and knowledge of recommended salt intake. The findings indicate the SFLQ is a feasible and reliable tool to assess FL among adults that can be helpful in public health practices focusing on FL.

This paper informs about the implementation of the first trilingual Swiss nutrition pilot survey and lessons learnt in terms of recruitment, participation, data collection feasibility, and data management. The population-based cross-sectional nutrition pilot survey took place between June and November 2013. Six trained dietitians interviewed 276 adults aged 18-75 years residing in the cantons of Bern (German), Vaud (French) or Ticino (Italian). Food consumption was assessed with two non-consecutive computer-assisted 24-Hour Dietary Recalls (24HDR), applying a trilingual version of GloboDiet® adapted to specific requirements of Switzerland. The first interview was face-to-face and included anthropometric measurements while the second was by phone. Quality controls consisted mainly in the descriptive analysis of data at food level, and the observation and rating of 21 interviews (4%) by coordinators. Net participation rate was 29%. Participants and non-participants were similar: mean [±SD] age was 49±16 and 47±16 years, and women proportion 49.6% and 49.8%, respectively. Training and data collection proved feasible and deliverable in the six months using the newly developed survey instruments. Dietitians followed the standard operating procedures. Quality controls on food consumption data showed comparable results between face-to-face and phone 24HDR, and across dietitians (median number of reported food items per 24HDR: 27). Procedures to transfer and clean food consumption data were developed. The implementation concept proved applicable in the trilingual Swiss context. Additional resources were planned for increasing participation rate and facilitating data cleaning.

Blood pressure is a primary cardiovascular disease risk factor. Population-wide governmental strategies aim to reduce lifestyle and dietary risk factors for hypertension, one of which is an unbalanced diet with high sodium and low potassium intakes. Nutrition interventions in the workplace are considered a promising approach in encouraging health-promoting behaviors. We developed and conducted the health promoting sodium reduction trial “Healthful & Tasty: Sure!” in worksites in the German-speaking part of Switzerland from May 2015 to Nov 2016, for which we present the study protocol and baseline characteristics. Healthful & Tasty, a cluster nonrandomized single-arm trial with calibration arm, aimed to demonstrate the effectiveness of a combined educational and environmental intervention in the workplace in reducing employees’ average daily sodium/salt intake by 15%. To this end, health and food literacy of employees and guideline compliance among the catering facility team needed to be improved. The primary outcome measure was sodium/salt intake estimated from sodium excretion in a 24-h urine sample. Secondary outcome measures included changes in the overall qualitative diet composition, blood pressure, anthropometric indices, and health and food literacy. Of eight organizations with catering facilities, seven organizations took part in the nutrition education and catering salt reduction interventions, and one organization participated as a control. Overall, 145 consenting employees were included in the staggered, one-year four-phase trial, of which 132 participated in the intervention group. In addition to catering surveys and food sampling, the trial included five follow-up health assessments including questionnaires, blood pressure measurements, anthropometrics, and sodium, potassium, and iodine intake measurements obtained from 24-h and spot urine samples, and a food record checklist. Exploratory and hypothesis generating baseline statistical analysis included 141 participants with adequate 24-h urine samples. Despite practice-driven limitations to the study design and small cluster and participant numbers, this trial has methodological strength and will provide important insights into the effectiveness of a combined educational and environmental intervention to reduce salt intake among female and male Swiss employees. German Clinical Trials Register, DRKS00006790 . Registered 23 September 2014.

Switzerland is a multilingual country located between Germany, France and Italy, which differ by dietary habits and related outcomes. We explored differences in food consumption as well as compliance to the Swiss food-based dietary guidelines (FBDG) across the German-, French-, and Italian-speaking regions. The 2014-2015 nationwide cross-sectional survey was conducted among a stratified random sample of 2057 adults aged 18 to 75 years. Trained dietitians assessed food consumption via two non-consecutive 24-h dietary recalls using the international validated software GloboDiet ® . Recorded foods and beverages were classified into six groups and 31 subgroups relevant for assessing compliance to the FBDG (Swiss Food Pyramid). Usual daily intake distributions were modelled and weighted for sampling design, non-response, weekdays and season. Participation rate was 38%. Significant differences across regions were observed in 18 of 31 food subgroups ( p ≤ 0.01). Weighted mean daily intakes in the German-, French- and Italian-speaking regions were, respectively, 245 g, 155 g, 140 g for soft drinks, 273 g, 214 g, 135 g for coffee, 127 g, 72 g, 109 g for milk, 32 g, 45 g, 43 g for red meat, 18 g, 29 g, 34 g for fish/seafood, 8.1 g, 6.4 g, 3.7 g for butter, and 206 g, 214 g, 168 g for vegetables. The seven FBDGs were followed by

Background and aims: High sodium (Na) and low potassium (K) intake are associated with hypertension and CVD risk. This study explored the associations of health literacy (HL), food literacy (FL), and salt awareness with salt intake, K intake, and Na/K ratio in a workplace intervention trial in Switzerland. Methods and results: The study acquired baseline data from 141 individuals, mean age 44.6 years. Na and K intake were estimated from a single 24-h urine collection. We applied validated instruments to assess HL and FL, and salt awareness. Multiple linear regression was used to investigate the association of explanatory variables with salt intake, K intake, and Na/K. Mean daily salt intake was 8.9 g, K 3.1 g, and Na/K 1.18. Salt intake was associated with sex (p

Aims To determine the prevalence of atrial fibrillation (AF) in a population-based sample of adults. Methods and results Between January 2005 and December 2007 individuals aged ≥50 years, residents of the city of Geneva, who had participated in a previous random survey were invited for follow-up examination. AF was assessed on a single resting 6-lead ECG. Reported prevalences were standardized for the age distribution of Canton Geneva. Overall participation was 72.8%. Twenty-nine cases of AF (22 men) were diagnosed among 3285 subjects (1696 men). The crude prevalence of AF (95% CI) was 0.88% (0.86, 0.90) overall, but higher in men [1.30% (1.26, 1.34)] than in women [0.44% (0.41, 0.47)]. The age-standardized AF prevalence was slightly higher [overall: 0.94% (0.91, 0.97), men: 1.23% (1.19, 1.27), women: 0.54% (0.47, 0.61)]. AF prevalence increased with age in both sexes. A ‘history of suspected arterial embolism’ (brain or legs) was higher in the AF cases (10.3 vs. 3.3%; P = 0.03). Conclusion This population-based survey of a general Swiss population indicates that the prevalence of AF remains below 1%. These results are less alarming than those from previous studies based on patients seeking medical care.

ObjectiveTo develop and integrate the assessment of functional foods (FuF; manufactured foods with altered composition carrying a health claim) consumption into an existing risk factor surveillance system.DesignFuF market research followed by an experimental FuF intake study incorporated into an ongoing community-based survey. Concurrent completion of a self-administered semi-quantitative FFQ and a self-administered, qualitative FuF frequency questionnaire (FuFFQ) followed by a face-to-face control step using FuF photographs and combined food group-based data analyses.Setting‘Bus Santé’ risk factor surveillance programme, Geneva/Switzerland.SubjectsPopulation-based random sample of 639 residents (52 % women, aged 35–74 years) surveyed from September 2003 to April 2004.ResultsLocal Geneva/French neighbourhood market research identified 148 FuF in five major FuF food groups which were compiled into a functional ingredient database. Prior to the face-to-face verification, 210 (33 %) individuals categorized themselves as FuF consumers, 429 (67 %) as non-consumers. The control step revealed that 70 % of the 639 participants were already familiar with the FuF concept, and thus were correctly self-categorized as FuF consumers or non-consumers. For the remaining 30 % of participants the true FuF consumption status was established, resulting in a final number of 285 FuF consumers (45 %; 12 % net increase) and 354 (55 %) non-consumers.ConclusionsThe developed self-administered, brief, qualitative food group-based FuF frequency check list in combination with an FFQ and a photo-assisted control step provides a flexible assessment tool for measuring FuF consumption in the context of a specific fluctuating FuF market and may be applicable to other population settings and times.

Investigate dietary salt intake trends by gender, and their associations with risk factors for cardiovascular diseases in Geneva, Switzerland.Continuous surveillance of the Geneva general adult (35-74 years) population for 12 years (1993-2004) using a validated, semi-quantitative food frequency questionnaire (FFQ) in random, cross-sectional, representative samples (6688 men, 6647 women). Dietary salt intake assessment by FFQ excluded discretionary salt, but was calibrated on total salt intake using an independent validation substudy of 100 volunteers who additionally provided 24-h urine collections.Quartiles (mean) of calibrated dietary salt intake (g per day) were 9.9, 10.5, 11.2 (10.6) in men, and 7.0, 7.8, 8.9 (8.1) in women and were above current recommendations. Quartiles (mean) of salt density (g MJ(-1)) were 0.99, 1.16, 1.39 (1.23) in men, and 0.98, 1.12, 1.30 (1.17) in women. Both measures were stable during the 12-year surveillance period, regardless of hypertension treatment. Salt-density differences between cardiovascular disease risk factor subgroups were moderate. Salt density increased with age and body mass index. The main dietary non-discretionary salt food sources (men/women: 47/48%) were breads (17/17%), cheeses (11/10%), meat and meat products (8/7%), soups (6/9%) and ready-to-eat foods (5/5%).Salt intakes from all sources for the Geneva, and perhaps the Swiss adult population are above current recommendations. The quantitative and qualitative data provided in this paper could be used to develop and implement strategies for salt-intake reduction in Switzerland.

Objectives. We estimated the amount of physical activity required for individuals to expend an additional 418.4 kJ (100 kcal) per day with the goal of achieving energy balance at the population level. Methods. Data on total daily energy expenditures were derived from a random sample of adults residing in Geneva, Switzerland, who completed a self-administered physical activity frequency questionnaire. These data were used to simulate the effects of typical physical activity pyramid recommendations on average population energy expenditures for various activity intensities and rates of population compliance with pyramid recommendations. Results. If an average 418.4 kJ (100 kcal) per day increase in energy expenditures is to be achieved, assuming 100% compliance with physical activity pyramid recommendations, the bottom tier of the pyramid must correspond to everyday activities performed at moderate to high intensity levels (e.g., moderate walking or biking). Expected population gains in energy expenditures would be only 167.4 to 251.0 kJ (40 to 60 kcal) per day at a 50% compliance rate. Conclusions. Achieving population-level energy balance through increasing energy expenditures with physical activity increases alone would require profound structural and environmental changes promoting more active lifestyles.

Nutrition literacy and food literacy have become increasingly important concepts in health promotion. Researchers use one or the other term to describe the competencies needed to maintain a healthy diet. This systematic review examines whether these terms are synonymous or if their meanings are substantially different. We searched major bibliographic databases (Web of Science, PubMed, ScienceDirect, CINAHL, SocIndex and ERIC) for publications that provided an original definition of nutrition or food literacy. Then we used Nutbeam's tripartite health literacy model as an analytical grid. The definitions we found included specific competencies, which we mapped to the domains of functional, interactive, or critical literacy. In the 173 full-text publications we screened, we found six original definitions of nutrition literacy, and 13 original definitions of food literacy. Seven food literacy definitions were integrated into a conceptual framework. Analysing their structure revealed that nutrition literacy and food literacy are seen as specific forms of health literacy, and represent distinct but complementary concepts. Definitions of nutrition literacy mainly described the abilities necessary to obtain and understand nutrition information. Definitions of food literacy incorporated a broader spectrum of theoretical and practical knowledge and skills. To be food literate also means to apply information on food choices and critically reflect on the effect of food choice on personal health and on society. Since food literacy is based on a more comprehensive understanding of health behaviours, it is the more viable term to use in health promotion interventions. For the practical implication, a harmonization of the different definitions is desirable.

Objective: To determine and describe the extent to which European dietary data collected in disparate surveys can be meaningfully compared. Design: Seven independent population-based surveys from six European countries were initially included. Differences in study designs and methodological approaches were examined. Risk factor data for 31, 289 adults aged 40–59 y were harmonized and pooled in a common, centralized database. Results: Direct comparisons of dietary measures across studies were not deemed appropriate due to methodological heterogeneity. Nonetheless, comparisons of intra-population contrasts by gender across sites were considered valid. Women consumed fruit and vegetables more often than men. Age-standardized gender differences in the prevalence of low fruit and vegetable consumption ranged from 7 to 18% and 5 to 15%, respectively. Data on energy intake showed good agreement across study populations. The proportion of total energy from macronutrients was similar for women and men. Gender differences for relative intakes of saturated fatty acids (percentage energy) were small and only in France were they significant. Dietary fibre density was significantly higher in women than in men. Overall, the participating Southern European populations from Italy and Spain exhibited more healthful food composition patterns. Conclusions: Contrasts in dietary patterns by gender across populations may provide the basis for health promotion campaigns. The most favourable patterns observed may serve as attainable goals for other populations. An international risk factor surveillance programme based upon locally run, good quality studies has the potential to provide the needed data. Sponsorship: European Community (DG V), project 96CVVF3-446-0; Swiss Federal Office for Education and Science, OFES 96.0089. European Journal of Clinical Nutrition (2000) 54, 253–262

Objective: To assess differences in dietary habits in the general population of Geneva, Switzerland, after the 1996 (BSE) crisis. Design: Repeated population-based survey during 1993, 1994, 1995 and 1996. Setting: The Bus Sante 2000 epidemiological observatory of Geneva, Switzerland. Subjects: A representative sample of 1190 men and 1154 women. Main outcome measure: Dietary habits assessed by a semi-quantitative food frequency questionnaire. Results: The proportion of women who reported not having eaten beef was 7.7% in 1993–1995 and went up to 14.6% in 1996 (age-adjusted difference +6.4%, 95% CI +2.4 to +10.4). Among men, the proportion of non-beef-eaters remained constant (5%). There was a sharp increase of women who did not eat liver (+14.7%, +9.1 to +20.3) but less so in men (++5.1%, −0.7 to +10.8). Among women who ate meat, the amount of beef intake decreased by 120 g/month (95% CI −208 to −36). While chicken intake increased (+44 g/month, −2 to 88), overall intake of meat (including poultry but not fish) declined by 204 g/month (or 2.7 kg per year). In men the decrease in beef intake was not statistically significant (−48 g/month, −172 to 80), but consumption of chicken increased (++56 g/month, +8 to +104). Fish intake was stable in both genders. The reduction in intake of animal protein (−3.5 g/day) in women and of retinol intake in both sexes (women −77 μg/day; men −56 μg/day) was statistically significant. Conclusions: The BSE crisis coincided with spontaneous differences in food habits, especially in women, that may have nutritional consequences at the population level. Sponsorship: Grant no. 32-049847.96 of the Swiss National Science Foundation.

Various studies have linked different genetic single nucleotide polymorphisms (SNPs) to different blood lipids (BL), but whether these "connections" were identified using cross-sectional or longitudinal (i.e., changes over time) designs has received little attention. Cross-sectional and longitudinal assessments of BL [total, high-, low-density lipoprotein cholesterol (TC, HDL, LDL), triglycerides (TG)] and non-genetic factors (body mass index, smoking, alcohol intake) were measured for 2,002 Geneva, Switzerland, adults during 1999-2008 (two measurements, median 6 years apart), and 20 SNPs in 13 BL metabolism-related genes. Fixed and mixed effects repeated measures linear regression models, respectively, were employed to identify cross-sectional and longitudinal SNP:BL associations among the 1,516 (76%) study participants who reported not being treated for hypercholesterolemia at either measurement time. One-third more (12 vs. 9) longitudinal than cross-sectional associations were found [Bonferroni-adjusted two-tailed p < 0.00125 (=0.05/2)/20) for each of the four ensembles of 20 SNP:individual BL associations tested under the two study designs]. There was moderate consistency between the cross-sectional and longitudinal findings, with eight SNP:BL associations consistently identified across both study designs: [APOE.2 and APOE.4 (rs7412 and rs429358)]:TC; HL/LIPC (rs2070895):HDL; [APOB (rs1367117), APOE.2 and APOE.4 (rs7412 and rs429358)]:LDL; [APOA5 (rs2072560) and APOC III (rs5128)]:TG. The results suggest that cross-sectional studies, which include most genome-wide association studies (GWAS), can assess the large majority of SNP:BL associations. In the present analysis, which was much less powered than a GWAS, the cross-sectional study was around 2/3 (67%) as efficient as the longitudinal study.

Objective To evaluate the reliability of anthropometric measurements (weight, height, Body Mass Index (BMI), waist and hip circumferences (WC; HC) and waist-to-hip ratio (WHR)) performed by doctors to assess obesity. Method Repeated anthropometric measurements were performed by 12 primary care physicians on 24 adult volunteers in Geneva, Switzerland, 2006. Volunteers (54% women, mean age 41) had a mean BMI of 28.1 (respective mean values for WC, HC and WHR: 91.4, 108.3, 0.84). Inter-observer reliability coefficient ( R ) and percent disagreement in categorisation of volunteers (normal weight, overweight, obesity, abdominal obesity) were computed according to these measurements. Results The inter-observer reliability for weight, height, and derived BMI were excellent ( R > 0.99), but unsatisfactory for WC ( R = 0.92), HC ( R = 0.76) and WHR ( R = 0.51). Based on the BMI, only 1% of the volunteers were misclassified as overweight or obese, whereas the use of WC and WHR lead to misclassification in 6% and 23% respectively. Reliability for the measurements improved after a one-hour training in anthropometric measurements ( R = 0.97 for WC, 0.92 for HC and 0.89 for WHR), but the proportion who were misclassified remained high despite the training session for WC (5%) and WHR (9%). Conclusions BMI remains the most reliable measure to detect obesity in medical practice, whereas WC, HC and WHR are less reliable. These results challenge current recommendations on obesity-related cardio-vascular risk management based on WC and WHR and underline the need for further research to improve the reliability of anthropometric measurements by doctors.

Objective: To assess whether the rapid increase in obesity prevalence among persons with higher education levels observed in one U.S. study is also observed in a European adult population. Research Methods and Procedures: This study involved continuous surveillance of the adult population of Geneva, Switzerland (1993 to 2004), with annual random, independent, cross-sectional, representative samples (6635 men and 6558 women, ages 35 to 74 years) and analysis of 12-year trends in obesity prevalence across educational level subgroups. Results: Obesity prevalence in men had an upward trend in the medium education subgroup (p < 0.02), a borderline upward trend in the high education subgroup (p < 0.08), but no trend in the low education subgroup. There was a borderline trend interaction between the male low and medium education subgroups (p < 0.09). Obesity prevalence in women had a borderline increase in the low education subgroup (p < 0.08), an almost borderline increase in the high education subgroup (p = 0.11), but no significant trend in the medium education subgroup. There was no evidence of trend interaction between the female education groups. Discussion: In Geneva, as in the United States, the inverse association between education level and obesity rates has weakened over time among men, but, inconsistent with the U.S. findings, has persisted for women. Explanations may include more physically demanding occupations for men with low education levels and different attitudes toward body image between the sexes.

Sigrid Beer-Borst is supervisor of the surveillance system “Bus Sante”, Division of Clinical Epidemiology, Geneva University Hospital, Geneva, Switzerland. Salvatore Panico is the head of the Laboratory of Clinical Epidemiology, Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy. S. Beer-Borst and S. Panico were guest editors of this issue and responsible for the original articles on nutrition behaviour Editorial l Editorial Sigrid Beer-Borst, Salvatore Panico

Previous chapters of this book have stressed the growing interest in continuously monitoring and comparing distributions of health determinants across populations to better inform public health workers and guide needed actions. Several authors have pointed to the need for a worldwide collection of survey data. We deal in this chapter with what appears to be a major paradox of global surveillance projects to date: data are currently available from many independent and locally based health studies, but the results cannot be directly compared across populations because of methodological variability.

STUDY OBJECTIVE—EURALIM (EURope ALIMentation), a European collaborative study, aimed to determine and describe the extent to which European data on risk factor distributions from different populations could be pooled and harmonised in a common database for international comparisons. SETTING—Seven independent population-based surveys from six European countries (France, Italy, Northern Ireland/United Kingdom, Spain, Switzerland, the Netherlands). METHODS—Data for 18 381 women and 12 908 men aged 40-59 were pooled in a common database. Central statistical analyses on major cardiovascular risk factors were conducted with careful consideration of methodological issues, including differences in study designs, data assessment tools, and analytic techniques used. MAIN RESULTS—Because of the detected variability among methods used, direct comparisons of risk factor distributions and prevalences between studies were problematic. None the less, comparisons of within population contrasts by sex, age group, and other health determinants were considered to be meaningful and apt, as illustrated here for obesity. Results were targeted and disseminated to both the general public and public health professionals and framed in the context of a European information campaign. CONCLUSIONS—International and national comparisons between existing locally run studies are feasible and useful, but harmonisation methods need improvement. Development of an international risk factor surveillance programme based on decentralised data collection is warranted. In the meantime, risk factor contrasts across populations can be used as a basis for targeting needed public health intervention programmes. Keywords: comparative study; obesity; risk factor surveillance

Food consumption (divided into 10 food groups) as well as energy and main nutrient intake of a Swiss collective (n = 3653) aged 7 years and older was studied. The caloric density was much improved for all five age groups considered as compared with findings in former studies. Carbohydrates gained and alcohol lost significance as main energy suppliers. These results indicate a positive trend in the dietary habits of the collective and suggest an improvement in the dietary habits of the Swiss population as a whole.

This study investigated the relative validity of a self-administered 24-h recall questionnaire in a dietary survey on 3,653 men and women 7 years of age and older. The validation was carried out in a group of 41 men. An estimated dietary record kept over 3 days served as reference method. Comparison of the questionnaire and the estimated 3-day record showed good agreement. The Wilcoxon matched-pairs ranked signs test (p < 0.05) demonstrated that the only differences were the crude energy and carbohydrate intake and the estimated nutrient density of protein. The estimated proportion of calories from carbohydrate, fat, protein, and alcohol differed by no more than 2.4%. The median percentage differences in crude nutrient intakes and nutrient densities between the two assessment techniques ranged from -9% to 22%. The daily food intake differed significantly in only three of ten food groups. Spearman's correlation coefficients were higher than 0.35 for all density measurements. The highest correlation coefficients of about 0.60 were observed for alcohol and dietary fiber intake. It is concluded that the self-administered 24-hour recall questionnaire is a valid method for estimating the median and mean dietary intake of large groups of subjects.