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Ouderen die zelfstandig thuis wonen, lopen het risico ondervoed te raken. Wageningen UR onderzoekt hoe dat is te voorkomen met producten en maaltijden die verrijkt zijn met extra eiwit. Maar hoe breng je die op de markt? De meeste ouderen voelen zich niet oud en zijn zich totaal niet bewust van hun voedingsstatus.

Introductie Het doel van deze pilotstudie was het verkrijgen van inzicht in de voedingsstatus van Nederlandse patiënten met chronische inflammatoire darmziekten (IBD). Methoden De voedingsstatus werd onderzocht op basis van MUST-score, handknijpkracht, micronutriëntstatus in het bloed en voedingsinname. Daarnaast werden leeftijd, geslacht, ziektebeeld, ziekteactiviteit, kwaliteit van leven en medicatiegebruik geïnventariseerd en gecorreleerd aan ziekteactiviteit. Resultaten 41 personen met IBD (17 mannen en 24 vrouwen, 19-74 jaar), onder wie 22 met colitis ulcerosa en 19 met de ziekte van Crohn, namen deel aan het onderzoek. 4 deelnemers hadden volgens de MUST-score een verhoogd risico op ondervoeding. Van 4 deelnemers was de handknijpkracht onder de referentiewaarde. 14 personen hadden een tekort aan vitamine D, 3 aan selenium, 3 aan foliumzuur, 1 aan vitamine B12 en 1 aan magnesium. De micronutriëntconcentraties verschilden niet tussen deelnemers met verschillende ziektebeelden, MUST-scores of handknijpkracht. Serum vitamine B1 verschilde als enige micronutriënt tussen mannen en vrouwen (p=0,047). Foliumzuurconcentraties waren hoger bij hogere ziekteactiviteit (p=0,022) en bij lagere kwaliteit van leven (p=0,030). Serumspiegels van vitamine D en vitamine E waren hoger voor deelnemers boven de leeftijdsmediaan dan voor deelnemers daaronder (50 jaar, respectievelijk: p

Background/Aims: Higher interdialytic weight gain (IDWG) is associated with higher predialysis blood pressure and increased mortality. IDWG is also increasingly being recognized as an indicator of nutritional status. We studied in detail the associations of various patient factors and nutritional parameters with IDWG. Methods: We collected data during one week for IDWG and hemodynamic parameters in 138 prevalent adult haemodialysis patients on a thrice-weekly haemodialysis schedule. A multivariate linear regression analysis was employed to identify factors that are associated with IDWG. Results: The mean (±SD) age was 62.5 (±18.2) years, 36% were female, 36% had diuresis, and 23% had diabetes. Patients in the highest IDWG tertile were significantly younger, more frequently male, and had a significantly higher subjective global assessment score (SGA). A higher IDWG as a percentage of body weight (%IDWG) was associated with a younger age, greater height and weight, absence of diuresis, and lower postdialysis plasma sodium levels. The model with these five parameters explained 37% of the variance of %IDWG. Predialysis, intradialysis, and postdialysis diastolic blood pressure was significantly higher in the highest tertile of IDWG. Conclusion: The most important associations of %IDWG are age, height, weight, diuresis, and postdialysis sodium. Patients with the highest IDWG have significantly higher diastolic blood pressures.

Lichaamssamenstelling is een maat voor de voedingstoestand. Een groot scala aan methoden staat ter beschikking om lichaamssamenstelling te meten. Sommige van deze methoden zijn geschikt voor toepassing in de eerste lijn, zoals antropometrie en bio-impedantie. Andere, meer kostbare en geavanceerde technieken - zoals MRI, CT, DEXA en isotopen-verdunningsmethoden - zijn geschikter voor toepassing in een onderzoeksomgeving. Met name bio-impedantie wordt steeds populairder

Ouderen die zelfstandig thuis wonen, lopen het risico ondervoed te raken. Wageningen UR onderzoekt hoe dat is te voorkomen met producten en maaltijden die verrijkt zijn met extra eiwit. Maar hoe breng je die op de markt? De meeste ouderen voelen zich niet oud en zijn zich totaal niet bewust van hun voedingsstatus.

Background: Iodine deficiency (ID) during pregnancy has been recognized as a major cause of hypothyroidism and adverse health consequences in both mothers and children. Although urinary iodine concentration (UIC) in school-aged children is recommended as an indicator to assess ID in the general population, it may not be a good surrogate for directly assessing iodine status in pregnant women. Iodine supplementation of mildly iodine-deficient pregnant women has been recommended worldwide; however, long-term benefit and safety of iodine supplementation in this group is uncertain. Finally, pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) may negatively affect thyroid function and pregnancy outcomes. Objectives: 1) to measure UIC in pairs of pregnant women and their school-aged children living in the same household; 2) to investigate the effects of iodine supplementation on maternal thyroid function, pregnancy and birth outcomes, and newborn development; 3) to evaluate the association between pre-pregnancy BMI and GWG with thyroid function and pregnancy outcomes. Methods: 1) In a cross-sectional pilot study, UIC was measured in spot urine samples from pairs (n=302) of healthy pregnant mothers and their school-aged children in Bangkok; 2) Arandomized controlled trial was conducted with 200 µg iodine per day or placebo given to mildly ID pregnant Thai women from 500 µg/L. Maternal thyroid function, thyroid volume and the prevalence of all thyroid dysfunction subtypes did not differ significantly between treatment groups during the study (p>0.05). At 6-week postpartum, the prevalence of postpartum thyroiditis (hyperthyroidism) was significantly lower in the iodine group (3%) as compared to the placebo group (9%) (OR: 95%CI, 0.17: 0.04-0.70). There were no significant differences between newborn groups in thyroid function, thyroid volume, birth characteristics, UIC and NBAS score (p>0.05); 3) Pre-pregnancy BMI was a negative predictor of free thyroxine (fT4) (β=-0.20, P

Background: Iodine deficiency (ID) during pregnancy has been recognized as a major cause of hypothyroidism and adverse health consequences in both mothers and children. Although urinary iodine concentration (UIC) in school-aged children is recommended as an indicator to assess ID in the general population, it may not be a good surrogate for directly assessing iodine status in pregnant women. Iodine supplementation of mildly iodine-deficient pregnant women has been recommended worldwide; however, long-term benefit and safety of iodine supplementation in this group is uncertain. Finally, pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) may negatively affect thyroid function and pregnancy outcomes. Objectives: 1) to measure UIC in pairs of pregnant women and their school-aged children living in the same household; 2) to investigate the effects of iodine supplementation on maternal thyroid function, pregnancy and birth outcomes, and newborn development; 3) to evaluate the association between pre-pregnancy BMI and GWG with thyroid function and pregnancy outcomes. Methods: 1) In a cross-sectional pilot study, UIC was measured in spot urine samples from pairs (n=302) of healthy pregnant mothers and their school-aged children in Bangkok; 2) Arandomized controlled trial was conducted with 200 µg iodine per day or placebo given to mildly ID pregnant Thai women from 500 µg/L. Maternal thyroid function, thyroid volume and the prevalence of all thyroid dysfunction subtypes did not differ significantly between treatment groups during the study (p>0.05). At 6-week postpartum, the prevalence of postpartum thyroiditis (hyperthyroidism) was significantly lower in the iodine group (3%) as compared to the placebo group (9%) (OR: 95%CI, 0.17: 0.04-0.70). There were no significant differences between newborn groups in thyroid function, thyroid volume, birth characteristics, UIC and NBAS score (p>0.05); 3) Pre-pregnancy BMI was a negative predictor of free thyroxine (fT4) (β=-0.20, P

Background: Biofortified yellow cassava has great potential to alleviate vitamin A deficiency in sub-Saharan Africa and can be used as a complementary approach to other interventions. However, direct evidence whether yellow cassava can significantly contribute to the vitamin A intake and status of populations is required. The overall aim of this thesis is to provide proof of principle whether biofortified yellow cassava can improve the vitamin A status of schoolchildren in Kenya. Methods: The research was conducted in Kibwezi district, Eastern Kenya. First the effect of daily consumption of yellow cassava was assessed in 342 primary school children in Kenya in a randomized controlled feeding trial with serum retinol concentration as primary outcome. Furthermore we investigated the sensory and cultural acceptability of yellow cassava in a cross-sectional study (n=140) in three primary schools for children as well as their caretakers. Next we studied the diagnostic performance of several proxy markers to assess vitamin A deficiency in comparison with serum retinol concentration as a field based method to assess vitamin A deficiency (n=375). And last we used the dietary intake data of children in the randomized controlled trial to model the potential contribution of yellow cassava to the nutrient adequacy of micronutrient intake using linear programming. Results: The randomized controlled feeding trial collected complete data for 337 children with a compliance of 100%. Primary analyses (per protocol) showed that serum retinol concentrations in the yellow cassava group, increased with 0.04 μmol/L (95%CI: 0.00‒0.07 μmol/L) compared to the white cassava group and secondary analyses showed that serum β-carotene concentration increased with 524% (448%‒608%). No evidence of effect modification by initial vitamin A status, zinc status, or polymorphisms in the β-carotene monooxygenase gene was found. In the acceptability study 72% of caretakers and children were able to detect a significant difference in taste between white and yellow cassava and indicated to prefer yellow cassava because of its soft texture, sweet taste and attractive color. Serum concentrations of retinol binding protein, transthyretin and C-reactive protein combined showed excellent diagnostic performance in estimating vitamin A deficiency in primary school children, with an area under the curve of 0.98. Adding yellow cassava to the diet as a school lunch improved the nutrient adequacy of the diet of schoolchildren, however, even with the addition of nutrient dense foods such as fish and oil, nutrient adequacy could not be ensured for fat, riboflavin, niacin, folate and vitamin A. Conclusions: Consumption of yellow cassava is acceptable and improves the serum retinol concentrations of primary school children in Kenya. The combination of three proxy markers is a promising approach to measure vitamin A deficiency in a low resource setting. Yellow cassava contributes to a better nutrient adequacy but should be accompanied by additional dietary guidelines and interventions to fill the remaining nutrient gaps.

Introductie Het doel van deze pilotstudie was het verkrijgen van inzicht in de voedingsstatus van Nederlandse patiënten met chronische inflammatoire darmziekten (IBD). Methoden De voedingsstatus werd onderzocht op basis van MUST-score, handknijpkracht, micronutriëntstatus in het bloed en voedingsinname. Daarnaast werden leeftijd, geslacht, ziektebeeld, ziekteactiviteit, kwaliteit van leven en medicatiegebruik geïnventariseerd en gecorreleerd aan ziekteactiviteit. Resultaten 41 personen met IBD (17 mannen en 24 vrouwen, 19-74 jaar), onder wie 22 met colitis ulcerosa en 19 met de ziekte van Crohn, namen deel aan het onderzoek. 4 deelnemers hadden volgens de MUST-score een verhoogd risico op ondervoeding. Van 4 deelnemers was de handknijpkracht onder de referentiewaarde. 14 personen hadden een tekort aan vitamine D, 3 aan selenium, 3 aan foliumzuur, 1 aan vitamine B12 en 1 aan magnesium. De micronutriëntconcentraties verschilden niet tussen deelnemers met verschillende ziektebeelden, MUST-scores of handknijpkracht. Serum vitamine B1 verschilde als enige micronutriënt tussen mannen en vrouwen (p=0,047). Foliumzuurconcentraties waren hoger bij hogere ziekteactiviteit (p=0,022) en bij lagere kwaliteit van leven (p=0,030). Serumspiegels van vitamine D en vitamine E waren hoger voor deelnemers boven de leeftijdsmediaan dan voor deelnemers daaronder (50 jaar, respectievelijk: p

Background: Biofortified yellow cassava has great potential to alleviate vitamin A deficiency in sub-Saharan Africa and can be used as a complementary approach to other interventions. However, direct evidence whether yellow cassava can significantly contribute to the vitamin A intake and status of populations is required. The overall aim of this thesis is to provide proof of principle whether biofortified yellow cassava can improve the vitamin A status of schoolchildren in Kenya. Methods: The research was conducted in Kibwezi district, Eastern Kenya. First the effect of daily consumption of yellow cassava was assessed in 342 primary school children in Kenya in a randomized controlled feeding trial with serum retinol concentration as primary outcome. Furthermore we investigated the sensory and cultural acceptability of yellow cassava in a cross-sectional study (n=140) in three primary schools for children as well as their caretakers. Next we studied the diagnostic performance of several proxy markers to assess vitamin A deficiency in comparison with serum retinol concentration as a field based method to assess vitamin A deficiency (n=375). And last we used the dietary intake data of children in the randomized controlled trial to model the potential contribution of yellow cassava to the nutrient adequacy of micronutrient intake using linear programming. Results: The randomized controlled feeding trial collected complete data for 337 children with a compliance of 100%. Primary analyses (per protocol) showed that serum retinol concentrations in the yellow cassava group, increased with 0.04 μmol/L (95%CI: 0.00‒0.07 μmol/L) compared to the white cassava group and secondary analyses showed that serum β-carotene concentration increased with 524% (448%‒608%). No evidence of effect modification by initial vitamin A status, zinc status, or polymorphisms in the β-carotene monooxygenase gene was found. In the acceptability study 72% of caretakers and children were able to detect a significant difference in taste between white and yellow cassava and indicated to prefer yellow cassava because of its soft texture, sweet taste and attractive color. Serum concentrations of retinol binding protein, transthyretin and C-reactive protein combined showed excellent diagnostic performance in estimating vitamin A deficiency in primary school children, with an area under the curve of 0.98. Adding yellow cassava to the diet as a school lunch improved the nutrient adequacy of the diet of schoolchildren, however, even with the addition of nutrient dense foods such as fish and oil, nutrient adequacy could not be ensured for fat, riboflavin, niacin, folate and vitamin A. Conclusions: Consumption of yellow cassava is acceptable and improves the serum retinol concentrations of primary school children in Kenya. The combination of three proxy markers is a promising approach to measure vitamin A deficiency in a low resource setting. Yellow cassava contributes to a better nutrient adequacy but should be accompanied by additional dietary guidelines and interventions to fill the remaining nutrient gaps.

Protein or energy supplementation of the diet of malnourished older people leads to body weight gain and an improved nutritional status. There are no indications for an effect on functional endpoints. In contrast, according to Prof. Lisette de Groot (Wageningen University), vitamin supplementation reportedly leads to functional improvements

De wisselwerking tussen erfelijke constitutie en leefwijze van mensen is belicht

The aim of this thesis was to evaluate micronutrient intake and status of socioeconomic disadvantaged populations, such as from Central and Eastern European (CEE) as compared to other European populations, and low socioeconomic status (SES) groups as compared to high SES groups within European countries. We addressed the micronutrients that have been prioritized because of their relevance for nutritional health by the EC-funded EURRECA Network of Excellence. Moreover, we assessed the association between folate intake and status which can be used in the process of setting folate DRVs. Micronutrient intake and status of CEE countries versus other European countries CEE countries have recently experienced rising income inequalities over a period of economic transition. There is some evidence that these reforms have been accompanied by health inequalities. Inadequacy in micronutrient intake and status may contribute to these inequalities. Because in more affluent Western European countries wide ranges in micronutrient intake and status are observed, we studied if low micronutrient intake and status levels are prevailing in CEE. The findings from this thesis signal no differences in micronutrient intake and status between CEE populations in comparison to those of other European regions with the exception of calcium intake in adults and iodine status in children that were lower in CEE than in other European regions. Since data from Western Europe indicate that inadequacies do exist among SES strata, more insight in the nutritional situation of lower SES populations in CEE and an understanding of both its determinants and consequences is needed. It is important to mention that evidence from grey literature added to that from open access sources. Fundamental to further studying of nutritional health in CEE, is suitable data. We underline the necessity for conducting nutritional surveillances on micronutrient intake and status in CEE as we have identified significant knowledge gaps for many life-stage groups. Differences in micronutrient intake between SES groups Considering that not enough studies have addressed the relationship between SES and micronutrient intake and status in their analyses of nutritional health, we performed a systematic review on this topic and we used data from the large European EPIC cohort to address that issue. To be able to conclude on socioeconomic, i.e. educational, occupational and income, inequalities associated with intake and status of prioritized micronutrients for all life stages in Europe, substantial knowledge gaps should be filled. Currently, data are mostly available for the intake of calcium, vitamin C and iron as collected from adults in Western European countries. When either of the above mentioned SES indicators was applied to estimate relative differences in micronutrient intake and status between the lowest and the highest SES category within one study, the results often, but not consistently, indicated a lower intake and/or status in low versus high SES groups. For example, in eight out of ten studies a lower intake for calcium intake was found with relative differences ranging from -2 to -14%. Similar patterns were found for vitamin C and iron: in eleven out of twelve studies relative differences ranged from -5 to -48% for vitamin C, whereas in nine of ten studies on iron relative differences went up to -14%. Studies on intake and/or status of folate, vitamin B12, zinc, iodine, and intake of vitamin D, selenium and copper were limited. Still, when differences were observed, it appeared that lower intake in low than in high SES groups was found except for vitamin B12 and zinc for which the findings were inconsistent. Furthermore, using education as a proxy for SES, we assessed differences in micronutrient intake between educational levels using the individual-participant data on European adults and elderly from the EPIC cohort. Based on data from 10 Western European countries it appeared that intake of calcium (except in France and a distinctive ‘health-conscious’ group in the UK), folate (except in Greece), and vitamin C was lower in the lowest than in the highest education groups: relative differences ranged up to 12, 13 and 23%, respectively. The intake of iron differed marginally, whereas the variation in intake of vitamins D and B12 was inconsistent. The observed association between educational level and intake of micronutrients was the same for men and women. Furthermore, differences in micronutrient intake were found to be larger between countries than between SES groups. With respect to SES differences in micronutrient intake and status, there are significant gaps in the open source literature for many life-stage groups in Europe, but particularly in CEE countries. There is a clear need for cross-country and within country comparative research and for the monitoring of trends in dietary intake across different SES groups and European countries. Relationship between folate intake and status to add complementary evidence for deriving folate dietary reference values (DRVs) DRVs are under continuous review and periodic revision as the cumulative evidence base and body of knowledge evolve. Folate is considered a public health priority micronutrient for which re-evaluation of DRVs is needed. For this micronutrient, a systematic review of observational studies on the relationship between intake and status was done followed by meta-analysis. The intake of folate was significantly associated with markers of folate status. The results of our meta-analysis showed that an average person with a folate intake of 100 µg/day has a serum/plasma folate status concentration that is 26% higher and a red blood cell folate status that is 21% higher than a person who has a folate intake of 50 µg/day; plasma homocysteine was found to be 16% lower. The difference between natural food folate and that from supplements and fortified foods (folic acid) significantly influenced the estimated relationship between folate intake and serum/plasma status. Associations were stronger when assessed as folate from the diet than as folate from diet and supplements. Dietary assessment method did not significantly influence the association, although pooled estimates were somewhat higher when FFQs were used as compared to 24-hour recalls combined with food records. To focus on the impact of poor intakes on related health outcomes, data modelling can be conducted to produce estimates for Average Nutrient Requirements. For this analysis datasets and statistical models developed within the EURRECA NoE are available and can be used. Overall, further research would benefit from methodologically comparable data on food intake in all age ranges, especially on so far understudied CEE populations. Both intakes obtained through diet and from supplements and fortified foods should be assessed. Monitoring of trends across SES strata should be done with standardized SES measurements that would also facilitate cross-country comparative research. The findings on the level and distribution of micronutrient intake and status could be used for development of food based dietary guidelines. To make them effective in meeting populations’ micronutrient needs, they should be created accounting for the country specific dietary patterns giving consideration to the socioeconomic context.

Background Iron deficiency anemia (IDA) is a major nutrition related problem in China, especially affecting pregnant women,like in most developing countries. Deficiencies of vitamins also play an important role, such that iron, retinol and riboflavin deficiencies tend to coexist in anemic pregnant women. However, vitamin and/or mineral supplements are not routinely used by pregnant women at or below low income levels. Besides being an essential trace element, iron plays a central role in oxygen radical generation, whereas susceptibility during pregnancy is elevated. There is evidence that both iron deficiency and excess may result in free radical damage. Objectives Based on this background, objectives of this thesis were to investigate the current prevalence of anemia among pregnant women in different sites of China, and todescribe the micronutrient status of anemic and non-anemic pregnant women in China. In addition, in anemic pregnant women, the effect of retinol and riboflavin supplementation on top of iron plus folic acid on anemia and changes in hematological status wasassessed. Also oxidative stress and erythrocyte membrane fluidity were evaluated. Finally, we compared the effect of sodium iron ethylenediaminetetraacetate (NaFeEDTA) and ferrous sulfate on hemoglobin (Hb), iron bioavailability and oxidative stress. Subjects and Methods A total of 6413 women in their third trimester of pregnancy were recruited from five rural areas in China (years 2000~2003) for screening anemia or iron deficiency. A random subset was selected for measuring micronutrient status. In three supplementation trials, effects of iron, folic acid, retinol and riboflavin were assessed among anemic pregnant women. Outcomes included hematological status, micronutrient status and parameters of oxidative stress. Samples of fasting blood were collected from subjects before and at the end of the interventions for measurements. Results The overall prevalence of anemia was 58.6%, ranging between 48.1%~70.5% in the five areas. Serum concentrations of micronutrients were significantly lower in anemic women than non-anemic women. After the 2-mo intervention, the increase of Hb concentration in the group, supplemented with iron and folic acid combined with retinol and riboflavin, was 5.4g/L greater than in the group with iron and folic acid only (p

ABackground An elevated homocysteine level has been indicated as a risk factor for cardiovascular disease, cognitive decline, and fractures. Supplementation of vitamin B12 and folic acid in order to normalize homocysteine levels might be of substantial public health importance as this might reduce the risk for several age-related conditions. This thesis focuses on two health outcomes frequently associated with elevated homocysteine levels and low levels of vitamin B12 and folate: osteoporosis and cognitive decline later in life. Methods Findings are presented in the context of a model which links dietary intake to biomarkers of nutritional status and subsequently to health outcomes. Two systematic reviews with meta-analyses investigated the current status of knowledge about the association of vitamin B12 intake and status with cognitive function, and the association of homocysteine, vitamin B12 and folate status with bone health. Baseline data of the B-PROOF study were used to assess 1) the association of vitamin B12 intake with status according to four biomarkers (vitamin B12, holotranscobalamin (holoTC), methylmalonic acid (MMA) and homocysteine), 2) the mutual association among these four vitamin B12 biomarkers and 3) the association between homocysteine, vitamin B12 biomarkers, folate and cognitive function. The effect of 2-year daily vitamin B12 (500 μg) and folic acid (400 μg) supplementation on fracture risk was assessed in the B-PROOF study, a large (N=2919) randomized controlled trial in elderly people (aged ≥65 years) with an elevated homocysteine level (≥12.0 µmol/L). Results The systematic review of the literature showed no or inconsistent associations of vitamin B12 intake with cognitive function. Furthermore, serum vitamin B12 was not associated with risk of dementia, global cognition or memory. Studies on MMA and holoTC reported significant associations with risk of dementia, Alzheimer’s disease and global cognition. A meta-analysis showed that serum/plasma vitamin B12 per 50 pmol/L was borderline significantly associated with a lower fracture risk (RR=0.96, 95% CI = 0.92-1.00) and that homocysteine was significantly associated with a higher fracture risk (RR=1.04, 95% CI = 1.02-1.07). Meta-analyses regarding vitamin B12, folate and homocysteine levels and BMD did not show significant associations. In the B-PROOF study a doubling of vitamin B12 intake was associated with 9% higher levels of vitamin B12, 15% higher holoTC, 9% lower MMA and 2% lower homocysteine, saturation of biomarkers occurs with dietary intakes of >5 μg B12. Levels of MMA and homocysteine were higher when vitamin B12 levels were below 330 pmol/L and when holoTC levels were below 100 pmol/L, with a steep elevation when levels of vitamin B12 and HoloTC were below 220 and 50 pmol/L respectively. At baseline, levels of vitamin B12 and holoTC were not associated with cognitive function in any cognitive domain. Levels of homocysteine (β= -0.009), folate (β= 0.002), MMA (β= -0.163) and the wellness score – a vitamin B12 biomarker combination score - (β= 0.048) were significantly associated with the domain of episodic memory. Additionally, homocysteine (β= -0.015) and the wellness score (β= 0.103) were significantly associated with the domain information processing speed. The B-PROOF intervention did not lower the risk of fracture in the total population (HR=0.84, 95% CI = 0.58-1.22). Per protocol subgroup analysis of elderly aged >80 years, showed a lower risk of fracture in the intervention group (HR=0.28, 95% CI 0.10-0.74). We observed more cancer cases in the intervention group (HR=1.55, 95% CI = 1.04-2.30) compared to the placebo group. We cannot rule out the possibility of accelerated cancer progression as a possible negative side effect. Conclusion Our literature reviews and observational data confirm an association of levels of homocysteine, vitamin B12 and folate with cognitive function and fracture risk in elderly. Supplementation with vitamin B12 and folic acid did not lower the risk of fracture in the total study population. Though positive effects on fracture incidence emerged in elderly aged >80 years, these benefits should be weighed against potential risks.

Else van den Berg onderzocht de rol van voeding bij hart- en vaatziekten waar veel mensen na een niertransplantatie last van krijgen of houden. Niertransplantatiepatiënten blijken minder zout te gebruiken dan gezonde mensen in een controlegroep, maar nog steeds meer dan in de richtlijn voor de algemene bevolking wordt geadviseerd. Als mensen zich na een niertransplantatie zouden houden aan de aanbevolen hoeveelheid zout, zouden zij een lagere bloeddruk hebben. Hun risico op hart- en vaatziekten zou daarmee kunnen worden beperkt, concludeert Van den Berg. De rol van voedingscomponenten als eiwitten, calcium en vitamine K werden ook door Van den Berg onderzocht. Omdat deze voedingsmiddelen op complexe wijze bijdragen aan gezondheid en het ontstaan van hart- en vaatziekten, kan zij nog geen eenduidige aanbevelingen doen voor niertransplantatiepatiënten. Wel worden de patiënten die aan dit onderzoek deelnemen ook de komende jaren nog vervolgd. Verder is het onderzoek van Van den Berg de basis voor het starten van het programma Lifestyle Medicine in het UMCG. In dit programma worden patiënten kort na de transplantatie begeleid in het omschakelen naar gezonde voedingsgewoontes. Van den Berg verwacht dat dit zal bijdragen aan een langere overleving van patiënten na een niertransplantatie.

Stabiliteit persoonlijkheid en regulering stresshormoon Giulia Gracceva onderzocht bij knaagdieren hoe vroeg in het leven persoonlijkheid verschijnt en in hoeverre deze kan veranderen, bijvoorbeeld als aanpassing aan omgevingscondities in het begin van het leven. De laatste decennia is duidelijk geworden dat ook dieren over persoonlijkheid beschikken. Deze consistente verschillen in gedrag tussen individuen gelijk in geslacht en soort trekt veel aandacht van gedragsecologen en evolutionair-biologen. Er wordt vaak verondersteld dat de persoonlijkheid relatief stabiel blijft tijdens het leven, maar in hoeverre persoonlijkheid tijdens de ontwikkeling kan veranderen is nog nauwelijks bestudeerd. Gracceva onderzocht bij wildtype ratten of voeding, lichaam en hormonale toestand van de moeder tijdens de zwangerschap alsmede het aantal broers ten opzichte van zusters, de persoonlijkheid van een jong beïnvloeden. Daarnaast bestudeerde zij bij de wilde veldmuis of deze in het vroege leven zijn persoonlijkheid aanpast aan de wisseling van de seizoenen. Tijden het voorjaar zijn er namelijk sterke verschillen in de sociale omgeving en voedselbeschikbaarheid voor een pasgeboren dier. Gracceva’s drie belangrijkste bevindingen zijn: 1) In de wildtype-rat zijn belangrijke gedragstrekken van persoonlijkheid - zoals de mate van agressie en angst - relatief ongevoelig voor de gemanipuleerde omgevingsaspecten. Echter, een belangrijk kenmerk van persoonlijkheid, de koppeling tussen verschillende gedragingen (bijvoorbeeld: agressieve dieren reageren anders op niet-sociale stressoren dan niet-aggressieve dieren), werd makkelijk verbroken door aspecifieke omgevingsfactoren zoals het regelmatig hanteren van de dieren. 2) In de veldmuis was dit andersom, (wel effect op de expressie van afzonderlijke gedragingen, maar niet op de koppeling tussen deze gedragingen), hetgeen het belang van vergelijkende studies onderstreept, 3) Variatie in persoonlijkheid is gerelateerd aan aan de regulering van het stresshormoon corticosteron.

Stabiliteit persoonlijkheid en regulering stresshormoon Giulia Gracceva onderzocht bij knaagdieren hoe vroeg in het leven persoonlijkheid verschijnt en in hoeverre deze kan veranderen, bijvoorbeeld als aanpassing aan omgevingscondities in het begin van het leven. De laatste decennia is duidelijk geworden dat ook dieren over persoonlijkheid beschikken. Deze consistente verschillen in gedrag tussen individuen gelijk in geslacht en soort trekt veel aandacht van gedragsecologen en evolutionair-biologen. Er wordt vaak verondersteld dat de persoonlijkheid relatief stabiel blijft tijdens het leven, maar in hoeverre persoonlijkheid tijdens de ontwikkeling kan veranderen is nog nauwelijks bestudeerd. Gracceva onderzocht bij wildtype ratten of voeding, lichaam en hormonale toestand van de moeder tijdens de zwangerschap alsmede het aantal broers ten opzichte van zusters, de persoonlijkheid van een jong beïnvloeden. Daarnaast bestudeerde zij bij de wilde veldmuis of deze in het vroege leven zijn persoonlijkheid aanpast aan de wisseling van de seizoenen. Tijden het voorjaar zijn er namelijk sterke verschillen in de sociale omgeving en voedselbeschikbaarheid voor een pasgeboren dier. Gracceva’s drie belangrijkste bevindingen zijn: 1) In de wildtype-rat zijn belangrijke gedragstrekken van persoonlijkheid - zoals de mate van agressie en angst - relatief ongevoelig voor de gemanipuleerde omgevingsaspecten. Echter, een belangrijk kenmerk van persoonlijkheid, de koppeling tussen verschillende gedragingen (bijvoorbeeld: agressieve dieren reageren anders op niet-sociale stressoren dan niet-aggressieve dieren), werd makkelijk verbroken door aspecifieke omgevingsfactoren zoals het regelmatig hanteren van de dieren. 2) In de veldmuis was dit andersom, (wel effect op de expressie van afzonderlijke gedragingen, maar niet op de koppeling tussen deze gedragingen), hetgeen het belang van vergelijkende studies onderstreept, 3) Variatie in persoonlijkheid is gerelateerd aan aan de regulering van het stresshormoon corticosteron.

ABackground An elevated homocysteine level has been indicated as a risk factor for cardiovascular disease, cognitive decline, and fractures. Supplementation of vitamin B12 and folic acid in order to normalize homocysteine levels might be of substantial public health importance as this might reduce the risk for several age-related conditions. This thesis focuses on two health outcomes frequently associated with elevated homocysteine levels and low levels of vitamin B12 and folate: osteoporosis and cognitive decline later in life. Methods Findings are presented in the context of a model which links dietary intake to biomarkers of nutritional status and subsequently to health outcomes. Two systematic reviews with meta-analyses investigated the current status of knowledge about the association of vitamin B12 intake and status with cognitive function, and the association of homocysteine, vitamin B12 and folate status with bone health. Baseline data of the B-PROOF study were used to assess 1) the association of vitamin B12 intake with status according to four biomarkers (vitamin B12, holotranscobalamin (holoTC), methylmalonic acid (MMA) and homocysteine), 2) the mutual association among these four vitamin B12 biomarkers and 3) the association between homocysteine, vitamin B12 biomarkers, folate and cognitive function. The effect of 2-year daily vitamin B12 (500 μg) and folic acid (400 μg) supplementation on fracture risk was assessed in the B-PROOF study, a large (N=2919) randomized controlled trial in elderly people (aged ≥65 years) with an elevated homocysteine level (≥12.0 µmol/L). Results The systematic review of the literature showed no or inconsistent associations of vitamin B12 intake with cognitive function. Furthermore, serum vitamin B12 was not associated with risk of dementia, global cognition or memory. Studies on MMA and holoTC reported significant associations with risk of dementia, Alzheimer’s disease and global cognition. A meta-analysis showed that serum/plasma vitamin B12 per 50 pmol/L was borderline significantly associated with a lower fracture risk (RR=0.96, 95% CI = 0.92-1.00) and that homocysteine was significantly associated with a higher fracture risk (RR=1.04, 95% CI = 1.02-1.07). Meta-analyses regarding vitamin B12, folate and homocysteine levels and BMD did not show significant associations. In the B-PROOF study a doubling of vitamin B12 intake was associated with 9% higher levels of vitamin B12, 15% higher holoTC, 9% lower MMA and 2% lower homocysteine, saturation of biomarkers occurs with dietary intakes of >5 μg B12. Levels of MMA and homocysteine were higher when vitamin B12 levels were below 330 pmol/L and when holoTC levels were below 100 pmol/L, with a steep elevation when levels of vitamin B12 and HoloTC were below 220 and 50 pmol/L respectively. At baseline, levels of vitamin B12 and holoTC were not associated with cognitive function in any cognitive domain. Levels of homocysteine (β= -0.009), folate (β= 0.002), MMA (β= -0.163) and the wellness score – a vitamin B12 biomarker combination score - (β= 0.048) were significantly associated with the domain of episodic memory. Additionally, homocysteine (β= -0.015) and the wellness score (β= 0.103) were significantly associated with the domain information processing speed. The B-PROOF intervention did not lower the risk of fracture in the total population (HR=0.84, 95% CI = 0.58-1.22). Per protocol subgroup analysis of elderly aged >80 years, showed a lower risk of fracture in the intervention group (HR=0.28, 95% CI 0.10-0.74). We observed more cancer cases in the intervention group (HR=1.55, 95% CI = 1.04-2.30) compared to the placebo group. We cannot rule out the possibility of accelerated cancer progression as a possible negative side effect. Conclusion Our literature reviews and observational data confirm an association of levels of homocysteine, vitamin B12 and folate with cognitive function and fracture risk in elderly. Supplementation with vitamin B12 and folic acid did not lower the risk of fracture in the total study population. Though positive effects on fracture incidence emerged in elderly aged >80 years, these benefits should be weighed against potential risks.

Else van den Berg onderzocht de rol van voeding bij hart- en vaatziekten waar veel mensen na een niertransplantatie last van krijgen of houden. Niertransplantatiepatiënten blijken minder zout te gebruiken dan gezonde mensen in een controlegroep, maar nog steeds meer dan in de richtlijn voor de algemene bevolking wordt geadviseerd. Als mensen zich na een niertransplantatie zouden houden aan de aanbevolen hoeveelheid zout, zouden zij een lagere bloeddruk hebben. Hun risico op hart- en vaatziekten zou daarmee kunnen worden beperkt, concludeert Van den Berg. De rol van voedingscomponenten als eiwitten, calcium en vitamine K werden ook door Van den Berg onderzocht. Omdat deze voedingsmiddelen op complexe wijze bijdragen aan gezondheid en het ontstaan van hart- en vaatziekten, kan zij nog geen eenduidige aanbevelingen doen voor niertransplantatiepatiënten. Wel worden de patiënten die aan dit onderzoek deelnemen ook de komende jaren nog vervolgd. Verder is het onderzoek van Van den Berg de basis voor het starten van het programma Lifestyle Medicine in het UMCG. In dit programma worden patiënten kort na de transplantatie begeleid in het omschakelen naar gezonde voedingsgewoontes. Van den Berg verwacht dat dit zal bijdragen aan een langere overleving van patiënten na een niertransplantatie.

Background Iron deficiency anemia (IDA) is a major nutrition related problem in China, especially affecting pregnant women,like in most developing countries. Deficiencies of vitamins also play an important role, such that iron, retinol and riboflavin deficiencies tend to coexist in anemic pregnant women. However, vitamin and/or mineral supplements are not routinely used by pregnant women at or below low income levels. Besides being an essential trace element, iron plays a central role in oxygen radical generation, whereas susceptibility during pregnancy is elevated. There is evidence that both iron deficiency and excess may result in free radical damage. Objectives Based on this background, objectives of this thesis were to investigate the current prevalence of anemia among pregnant women in different sites of China, and todescribe the micronutrient status of anemic and non-anemic pregnant women in China. In addition, in anemic pregnant women, the effect of retinol and riboflavin supplementation on top of iron plus folic acid on anemia and changes in hematological status wasassessed. Also oxidative stress and erythrocyte membrane fluidity were evaluated. Finally, we compared the effect of sodium iron ethylenediaminetetraacetate (NaFeEDTA) and ferrous sulfate on hemoglobin (Hb), iron bioavailability and oxidative stress. Subjects and Methods A total of 6413 women in their third trimester of pregnancy were recruited from five rural areas in China (years 2000~2003) for screening anemia or iron deficiency. A random subset was selected for measuring micronutrient status. In three supplementation trials, effects of iron, folic acid, retinol and riboflavin were assessed among anemic pregnant women. Outcomes included hematological status, micronutrient status and parameters of oxidative stress. Samples of fasting blood were collected from subjects before and at the end of the interventions for measurements. Results The overall prevalence of anemia was 58.6%, ranging between 48.1%~70.5% in the five areas. Serum concentrations of micronutrients were significantly lower in anemic women than non-anemic women. After the 2-mo intervention, the increase of Hb concentration in the group, supplemented with iron and folic acid combined with retinol and riboflavin, was 5.4g/L greater than in the group with iron and folic acid only (p

Children in sub-Saharan Africa are more likely to have survived the critical first 1000 days of life carrying along unresolved micronutrient deficiencies into the school-age. Iron-deficiency is the most prevalent micronutrient problem affecting school-age children in sub-Saharan Africa and yet the most difficult to resolve. It is necessary to ensure an adequate iron intake through the diet of school-age children and school-based feeding intervention may be a way to improve iron intake of schoolchildren. Such a feeding intervention would be more sustainable if it relies on locally produced food(s) with the potential to support food sovereignty. In this context, this thesis investigated whether foods based on cowpeas, an indigenous legume crop originating from Africa, can be used in a school feeding setting to improve iron status of school-age children in Ghana. The investigations in this thesis comprised cross-sectional dietary and iron status assessment of schoolchildren (n=383), cowpea acceptability among schoolchildren (n=120 mother-child pairs), chemical analysis of cowpea landraces (n=14), an in vivo iron bioavailability among young women (n=16) and a randomized cowpea intervention trial (n=241) conducted mainly in Tolon-Kumbungu district of Ghana. The results indicated that iron-deficiency and iron-deficiency anaemia affect 8 and 7 out of every 10 schoolchildren respectively. It also showed that the probability of adequate dietary iron intake is 0.32 but much larger (~0.90) if schoolchildren benefitted from a school feeding programme. Mothers/caregivers intended to give cowpeas to their schoolchildren 2–3 times per week. The positive attitudes of mothers towards cowpea predicted their intention to give them to their schoolchildren but they were worried about the cost, long cooking time and the discomfort their children may suffer after consuming cowpeas. The chemical analysis showed that cowpeas contain appreciable amounts of iron (4.9–8.2 mg/ 100 gd.w) and zinc (2.7–4.1 mg/100 gd.w) but also high amounts of inhibitory phytate (477–1110 mg/100 gd.w) and polyphenol (327–1055 mg/100 gd.w). Polyphenol concentration in particular was higher (P

Else van den Berg onderzocht de rol van voeding bij hart- en vaatziekten waar veel mensen na een niertransplantatie last van krijgen of houden. Niertransplantatiepatiënten blijken minder zout te gebruiken dan gezonde mensen in een controlegroep, maar nog steeds meer dan in de richtlijn voor de algemene bevolking wordt geadviseerd. Als mensen zich na een niertransplantatie zouden houden aan de aanbevolen hoeveelheid zout, zouden zij een lagere bloeddruk hebben. Hun risico op hart- en vaatziekten zou daarmee kunnen worden beperkt, concludeert Van den Berg. De rol van voedingscomponenten als eiwitten, calcium en vitamine K werden ook door Van den Berg onderzocht. Omdat deze voedingsmiddelen op complexe wijze bijdragen aan gezondheid en het ontstaan van hart- en vaatziekten, kan zij nog geen eenduidige aanbevelingen doen voor niertransplantatiepatiënten. Wel worden de patiënten die aan dit onderzoek deelnemen ook de komende jaren nog vervolgd. Verder is het onderzoek van Van den Berg de basis voor het starten van het programma Lifestyle Medicine in het UMCG. In dit programma worden patiënten kort na de transplantatie begeleid in het omschakelen naar gezonde voedingsgewoontes. Van den Berg verwacht dat dit zal bijdragen aan een langere overleving van patiënten na een niertransplantatie.

Children in sub-Saharan Africa are more likely to have survived the critical first 1000 days of life carrying along unresolved micronutrient deficiencies into the school-age. Iron-deficiency is the most prevalent micronutrient problem affecting school-age children in sub-Saharan Africa and yet the most difficult to resolve. It is necessary to ensure an adequate iron intake through the diet of school-age children and school-based feeding intervention may be a way to improve iron intake of schoolchildren. Such a feeding intervention would be more sustainable if it relies on locally produced food(s) with the potential to support food sovereignty. In this context, this thesis investigated whether foods based on cowpeas, an indigenous legume crop originating from Africa, can be used in a school feeding setting to improve iron status of school-age children in Ghana. The investigations in this thesis comprised cross-sectional dietary and iron status assessment of schoolchildren (n=383), cowpea acceptability among schoolchildren (n=120 mother-child pairs), chemical analysis of cowpea landraces (n=14), an in vivo iron bioavailability among young women (n=16) and a randomized cowpea intervention trial (n=241) conducted mainly in Tolon-Kumbungu district of Ghana. The results indicated that iron-deficiency and iron-deficiency anaemia affect 8 and 7 out of every 10 schoolchildren respectively. It also showed that the probability of adequate dietary iron intake is 0.32 but much larger (~0.90) if schoolchildren benefitted from a school feeding programme. Mothers/caregivers intended to give cowpeas to their schoolchildren 2–3 times per week. The positive attitudes of mothers towards cowpea predicted their intention to give them to their schoolchildren but they were worried about the cost, long cooking time and the discomfort their children may suffer after consuming cowpeas. The chemical analysis showed that cowpeas contain appreciable amounts of iron (4.9–8.2 mg/ 100 gd.w) and zinc (2.7–4.1 mg/100 gd.w) but also high amounts of inhibitory phytate (477–1110 mg/100 gd.w) and polyphenol (327–1055 mg/100 gd.w). Polyphenol concentration in particular was higher (P

Stabiliteit persoonlijkheid en regulering stresshormoon Giulia Gracceva onderzocht bij knaagdieren hoe vroeg in het leven persoonlijkheid verschijnt en in hoeverre deze kan veranderen, bijvoorbeeld als aanpassing aan omgevingscondities in het begin van het leven. De laatste decennia is duidelijk geworden dat ook dieren over persoonlijkheid beschikken. Deze consistente verschillen in gedrag tussen individuen gelijk in geslacht en soort trekt veel aandacht van gedragsecologen en evolutionair-biologen. Er wordt vaak verondersteld dat de persoonlijkheid relatief stabiel blijft tijdens het leven, maar in hoeverre persoonlijkheid tijdens de ontwikkeling kan veranderen is nog nauwelijks bestudeerd. Gracceva onderzocht bij wildtype ratten of voeding, lichaam en hormonale toestand van de moeder tijdens de zwangerschap alsmede het aantal broers ten opzichte van zusters, de persoonlijkheid van een jong beïnvloeden. Daarnaast bestudeerde zij bij de wilde veldmuis of deze in het vroege leven zijn persoonlijkheid aanpast aan de wisseling van de seizoenen. Tijden het voorjaar zijn er namelijk sterke verschillen in de sociale omgeving en voedselbeschikbaarheid voor een pasgeboren dier. Gracceva’s drie belangrijkste bevindingen zijn: 1) In de wildtype-rat zijn belangrijke gedragstrekken van persoonlijkheid - zoals de mate van agressie en angst - relatief ongevoelig voor de gemanipuleerde omgevingsaspecten. Echter, een belangrijk kenmerk van persoonlijkheid, de koppeling tussen verschillende gedragingen (bijvoorbeeld: agressieve dieren reageren anders op niet-sociale stressoren dan niet-aggressieve dieren), werd makkelijk verbroken door aspecifieke omgevingsfactoren zoals het regelmatig hanteren van de dieren. 2) In de veldmuis was dit andersom, (wel effect op de expressie van afzonderlijke gedragingen, maar niet op de koppeling tussen deze gedragingen), hetgeen het belang van vergelijkende studies onderstreept, 3) Variatie in persoonlijkheid is gerelateerd aan aan de regulering van het stresshormoon corticosteron.

The aim of this thesis was to evaluate micronutrient intake and status of socioeconomic disadvantaged populations, such as from Central and Eastern European (CEE) as compared to other European populations, and low socioeconomic status (SES) groups as compared to high SES groups within European countries. We addressed the micronutrients that have been prioritized because of their relevance for nutritional health by the EC-funded EURRECA Network of Excellence. Moreover, we assessed the association between folate intake and status which can be used in the process of setting folate DRVs. Micronutrient intake and status of CEE countries versus other European countries CEE countries have recently experienced rising income inequalities over a period of economic transition. There is some evidence that these reforms have been accompanied by health inequalities. Inadequacy in micronutrient intake and status may contribute to these inequalities. Because in more affluent Western European countries wide ranges in micronutrient intake and status are observed, we studied if low micronutrient intake and status levels are prevailing in CEE. The findings from this thesis signal no differences in micronutrient intake and status between CEE populations in comparison to those of other European regions with the exception of calcium intake in adults and iodine status in children that were lower in CEE than in other European regions. Since data from Western Europe indicate that inadequacies do exist among SES strata, more insight in the nutritional situation of lower SES populations in CEE and an understanding of both its determinants and consequences is needed. It is important to mention that evidence from grey literature added to that from open access sources. Fundamental to further studying of nutritional health in CEE, is suitable data. We underline the necessity for conducting nutritional surveillances on micronutrient intake and status in CEE as we have identified significant knowledge gaps for many life-stage groups. Differences in micronutrient intake between SES groups Considering that not enough studies have addressed the relationship between SES and micronutrient intake and status in their analyses of nutritional health, we performed a systematic review on this topic and we used data from the large European EPIC cohort to address that issue. To be able to conclude on socioeconomic, i.e. educational, occupational and income, inequalities associated with intake and status of prioritized micronutrients for all life stages in Europe, substantial knowledge gaps should be filled. Currently, data are mostly available for the intake of calcium, vitamin C and iron as collected from adults in Western European countries. When either of the above mentioned SES indicators was applied to estimate relative differences in micronutrient intake and status between the lowest and the highest SES category within one study, the results often, but not consistently, indicated a lower intake and/or status in low versus high SES groups. For example, in eight out of ten studies a lower intake for calcium intake was found with relative differences ranging from -2 to -14%. Similar patterns were found for vitamin C and iron: in eleven out of twelve studies relative differences ranged from -5 to -48% for vitamin C, whereas in nine of ten studies on iron relative differences went up to -14%. Studies on intake and/or status of folate, vitamin B12, zinc, iodine, and intake of vitamin D, selenium and copper were limited. Still, when differences were observed, it appeared that lower intake in low than in high SES groups was found except for vitamin B12 and zinc for which the findings were inconsistent. Furthermore, using education as a proxy for SES, we assessed differences in micronutrient intake between educational levels using the individual-participant data on European adults and elderly from the EPIC cohort. Based on data from 10 Western European countries it appeared that intake of calcium (except in France and a distinctive ‘health-conscious’ group in the UK), folate (except in Greece), and vitamin C was lower in the lowest than in the highest education groups: relative differences ranged up to 12, 13 and 23%, respectively. The intake of iron differed marginally, whereas the variation in intake of vitamins D and B12 was inconsistent. The observed association between educational level and intake of micronutrients was the same for men and women. Furthermore, differences in micronutrient intake were found to be larger between countries than between SES groups. With respect to SES differences in micronutrient intake and status, there are significant gaps in the open source literature for many life-stage groups in Europe, but particularly in CEE countries. There is a clear need for cross-country and within country comparative research and for the monitoring of trends in dietary intake across different SES groups and European countries. Relationship between folate intake and status to add complementary evidence for deriving folate dietary reference values (DRVs) DRVs are under continuous review and periodic revision as the cumulative evidence base and body of knowledge evolve. Folate is considered a public health priority micronutrient for which re-evaluation of DRVs is needed. For this micronutrient, a systematic review of observational studies on the relationship between intake and status was done followed by meta-analysis. The intake of folate was significantly associated with markers of folate status. The results of our meta-analysis showed that an average person with a folate intake of 100 µg/day has a serum/plasma folate status concentration that is 26% higher and a red blood cell folate status that is 21% higher than a person who has a folate intake of 50 µg/day; plasma homocysteine was found to be 16% lower. The difference between natural food folate and that from supplements and fortified foods (folic acid) significantly influenced the estimated relationship between folate intake and serum/plasma status. Associations were stronger when assessed as folate from the diet than as folate from diet and supplements. Dietary assessment method did not significantly influence the association, although pooled estimates were somewhat higher when FFQs were used as compared to 24-hour recalls combined with food records. To focus on the impact of poor intakes on related health outcomes, data modelling can be conducted to produce estimates for Average Nutrient Requirements. For this analysis datasets and statistical models developed within the EURRECA NoE are available and can be used. Overall, further research would benefit from methodologically comparable data on food intake in all age ranges, especially on so far understudied CEE populations. Both intakes obtained through diet and from supplements and fortified foods should be assessed. Monitoring of trends across SES strata should be done with standardized SES measurements that would also facilitate cross-country comparative research. The findings on the level and distribution of micronutrient intake and status could be used for development of food based dietary guidelines. To make them effective in meeting populations’ micronutrient needs, they should be created accounting for the country specific dietary patterns giving consideration to the socioeconomic context.

Vijf artikelen waarin de volgende aspecten zijn belicht: -) vijftig jaar eten in Nederland; -) sociale klasseverschillen in (op)voeding; -) voedingsaankopen in het gezin; -) invloed sociale omgeving; -) effectiviteit van vet- en suikervervangers

Wageningen Universiteit heeft een project opgezet om de ambiance tijdens de maaltijden in verpleeghuizen te verbeteren. Onderzocht is op welke wijze de ambiance kan worden verbeterd en wat de bewoners en personeel daarvan vinden. De bedoeling van het project is om een succesvolle methode in meerdere verpleeghuizen te implementeren. Een goede sfeer tijdens de maaltijden heeft namelijk een positief effect op de voedingstoestand en kwaliteit van leven van verpleeghuisbewoners. De eerste reacties van bewoners en personeel zijn positief

Het LIGA-concept is als case-study gebruikt met het doel de aandacht voor voeding en gezondheid in de vroegere en huidige produktontwikkeling te analyseren

Background With the increasing nutritional and health problems related to the global food crisis, the potential contribution of traditional foods to alleviation of poverty, nutritional deficiencies and health issues has been emphasized. Fonio (Digitaria exilis) is the most ancient West African cereal representing a key crop in food supply during crop shortfall periods. Less is known about the potential of fonio to contribute to nutrition and health in West Africa. The value chain approach for nutritional goals is a set of strategies through which values are added to products for improvement of nutrition among vulnerable groups, while creating benefits for stakeholders. Strategies in a value chain approach comprise agricultural strategies, processing, and consumer-oriented actions to enhance acceptability. Objectives In this thesis we explored value chain strategies as possible solutions to existing nutritional problems among West African women, using fonio as product. To achieve this objective, specific research questions were investigated through the following cross-sectional studies: i) baseline assessment of nutrition (iron) status, iron intake and adequacy to define the nutritional context for operating the value chain approach; ii) assessment of socio-cultural acceptability of fonio as strategic entry point for consumer-oriented activities; iii) investigating processing (dephytinisation and fortification) as strategy for adding nutritional value to fonio. Methods Subjects involved were women of reproductive age randomly selected in Bamako, the capital city of Mali (108 women aged 15-49 y-old from 3-stage cluster sampling procedure), and Cotonou, the largest city of Benin (16 women aged 18-30 y-old from simple random sampling for an iron absorption study). Data collection included anthropometric and blood indicators measurement; dietary assessment based on a duplicate 24-h dietary recall, indirect and rapid assessment techniques; food ethnography focused on fonio, including an availability survey on market, a food consumption survey on the uses of fonio, and an acceptability survey based on a behavioral model; and an iron absorption study using stable isotopes. consumption (68% consuming 1 to 3 times/month) and daily portion size of fonio (152 g) was relatively low as compared to other staples like rice and millet. Fonio consumption was strongly predicted by intention to consume (r = 0.78, P < 0.001), which was influenced by positive beliefs and attributes (β = 0.32, P < 0.05). Subjective norms, namely the opinion of the husband, the family and the neighborhood motivated intention to consume fonio (r = 0.26, P < 0.001). Perceived barriers such as time-consuming processing and lack of skills in cooking fonio had a significant interaction between intention to consume and fonio consumption (β = -0.72, P < 0.05). Exploring processing as strategy for adding nutritional value to fonio showed that dephytinisation with intrinsic wheat phytase reduced phytate-to-iron molar ratio from 23.7:1 to 2.7:1 and iron fortification decreased the molar ratio to 0.3:1. Dephytinisation with wheat phytase and fortification significantly increased iron absorption from 2.6% to 8.2% in fonio porridges. Conclusions and recommendations Dephytinisation with native wheat phytase and iron fortification appeared relevant for adding nutritional value to fonio. Nonetheless, the achievement in iron absorption might not be sufficient to consider fonio as an appropriate food for improving iron status through iron fortification. However, as staple food contributing to food security, consumer-oriented activities for enhancing fonio consumption should emphasize positive attitudes and opinions of men, family and neighbors, while strengthening skills of women in cooking good quality fonio meals. For the value chain approach to be relevant, the impact of value-added fonio products on smallholders’ income should be assessed, as well as the effect of the improved income on the nutritional outcome of vulnerable communities

Background With the increasing nutritional and health problems related to the global food crisis, the potential contribution of traditional foods to alleviation of poverty, nutritional deficiencies and health issues has been emphasized. Fonio (Digitaria exilis) is the most ancient West African cereal representing a key crop in food supply during crop shortfall periods. Less is known about the potential of fonio to contribute to nutrition and health in West Africa. The value chain approach for nutritional goals is a set of strategies through which values are added to products for improvement of nutrition among vulnerable groups, while creating benefits for stakeholders. Strategies in a value chain approach comprise agricultural strategies, processing, and consumer-oriented actions to enhance acceptability. Objectives In this thesis we explored value chain strategies as possible solutions to existing nutritional problems among West African women, using fonio as product. To achieve this objective, specific research questions were investigated through the following cross-sectional studies: i) baseline assessment of nutrition (iron) status, iron intake and adequacy to define the nutritional context for operating the value chain approach; ii) assessment of socio-cultural acceptability of fonio as strategic entry point for consumer-oriented activities; iii) investigating processing (dephytinisation and fortification) as strategy for adding nutritional value to fonio. Methods Subjects involved were women of reproductive age randomly selected in Bamako, the capital city of Mali (108 women aged 15-49 y-old from 3-stage cluster sampling procedure), and Cotonou, the largest city of Benin (16 women aged 18-30 y-old from simple random sampling for an iron absorption study). Data collection included anthropometric and blood indicators measurement; dietary assessment based on a duplicate 24-h dietary recall, indirect and rapid assessment techniques; food ethnography focused on fonio, including an availability survey on market, a food consumption survey on the uses of fonio, and an acceptability survey based on a behavioral model; and an iron absorption study using stable isotopes. consumption (68% consuming 1 to 3 times/month) and daily portion size of fonio (152 g) was relatively low as compared to other staples like rice and millet. Fonio consumption was strongly predicted by intention to consume (r = 0.78, P < 0.001), which was influenced by positive beliefs and attributes (β = 0.32, P < 0.05). Subjective norms, namely the opinion of the husband, the family and the neighborhood motivated intention to consume fonio (r = 0.26, P < 0.001). Perceived barriers such as time-consuming processing and lack of skills in cooking fonio had a significant interaction between intention to consume and fonio consumption (β = -0.72, P < 0.05). Exploring processing as strategy for adding nutritional value to fonio showed that dephytinisation with intrinsic wheat phytase reduced phytate-to-iron molar ratio from 23.7:1 to 2.7:1 and iron fortification decreased the molar ratio to 0.3:1. Dephytinisation with wheat phytase and fortification significantly increased iron absorption from 2.6% to 8.2% in fonio porridges. Conclusions and recommendations Dephytinisation with native wheat phytase and iron fortification appeared relevant for adding nutritional value to fonio. Nonetheless, the achievement in iron absorption might not be sufficient to consider fonio as an appropriate food for improving iron status through iron fortification. However, as staple food contributing to food security, consumer-oriented activities for enhancing fonio consumption should emphasize positive attitudes and opinions of men, family and neighbors, while strengthening skills of women in cooking good quality fonio meals. For the value chain approach to be relevant, the impact of value-added fonio products on smallholders’ income should be assessed, as well as the effect of the improved income on the nutritional outcome of vulnerable communities

Background: Jiangsu Province is an economically booming area in East China, where soil zinc concentrations are low. Nutrition transition to a dietary pattern with more animal source foods may have improved zinc intake in this area. However, such a transition may also have increased the burden of non-communicable diseases (NCDs), such as hypertension and obesity. Investigation of dietary patterns in relation to undernutrition and overnutrition could help to better address both problems. Objectives: The first aim of this thesis was to assess zinc status in Jiangsu Province using dietary zinc intake, serum zinc and stunting as indicators, as well to investigate the potential of biofortified rice to improve zinc intake. The second aim was to investigate the association between dietary patterns and high blood pressure, taking obesity into account. Methods:Data from the 2002 National Nutrition and Health Survey in Jiangsu Province were used to assess zinc intake in the population aged 4-89 years (n=3,867). Primary school children (n=2,268) were selected from three counties in the Province with relatively low soil zinc for assessment of stunting. Serum zinc was measured among children in the county where stunting was highest (n=297). Thirteen women were recruited in the same county for three test rounds with rice meals (zinc biofortified rice, zinc extruded fortified rice and control rice). Fractional zinc absorption (FAZ) was measured with the use of the double isotope tracer ratio method. Effect of biofortified rice with zinc, at a level of 2.7 and 3.8 mg/100g, on zinc intake was simulated in adults (n=2.819). For adults, four distinct dietary patterns were identified, named “traditional”, “Macho”, “sweet tooth” and “healthy” pattern. Associations were assessed between the four dietary patterns and blood pressure in adults (n=2,518) by using Poisson regression analysis. Results:The overall prevalence of insufficient intake of zinc was 22.9%, with a higher prevalence in children (64.6%) and adolescents (64.9%), and in those with low socio-economic status (27.3%). Around 4% of the primary school children were stunted, and the prevalence of zinc deficiency measured by serum and hair zinc was 0.7%, and 15.2%, respectively. Biofortified 70Zn enriched rice with an intrinsic label was found to have higher fractional zinc absorption (FAZ) than extrinsically labeled fortified extruded rice. However, FAZ could not be accurately quantified because we could not determine the exact amount of isotope infused to subjects due to adhesion of zinc to the vial. When simulating zinc intake by replacing normal rice with zinc biofortified rice with either 2.7 and 3.8 mg/100g of zinc, the prevalence of insufficient zinc intake decreased from 15.4% to 6.5% and 4.4%, respectively. The “traditional” dietary pattern in Jiangsu Province was most strongly associated with high blood pressure (P for trend = 0.005). This pattern is characterized primarily by consumption of rice and fresh vegetable; secondary of pork and fish; and lastly of root vegetable and wheat flour, but also by high salt intake. Subjects with overweight and obesity were more likely to have high blood pressure than those with normal weight. Conclusion: Children and adolescents had low dietary zinc intake, in Jiangsu Province, where the soil is also deficient in zinc. However, these findings did not match with the low prevalence of stunting and zinc deficiency based on serum zinc concentrations in primary school children from three rural areas of the Province. Zinc appears to be better absorbed from biofortified rice than from control rice or from extruded fortified rice, which needs further investigation. Simulated zinc intake from biofortified rice with zinc at a level of 2.7 mg/kg has the potential to significantly improve zinc intake, especially in the “traditional” dietary pattern. However, this pattern is also related to high blood pressure, which may be due to high salt intake. High blood pressure is also positively and independently related to obesity. Nutrition education is required to improve knowledge and awareness of healthy diets in Jiangsu Province.

Background Acute diarrhea and acute respiratory tract infections (ARTIs) continue to lead the infectious cause of morbidity and mortality among children

Background Acute diarrhea and acute respiratory tract infections (ARTIs) continue to lead the infectious cause of morbidity and mortality among children

Background: The nutritional status of HIV-infected children is reported to be poor. Diarrhoea and acute respiratory infections tend to be more common and severe in HIV-infected children than in uninfected ones. Deficiencies of micronutrients may result in poor growth and increased risk of diarrhoea and respiratory infections. Micronutrient deficiencies are common in HIV-infected children. The poor growth, diarrhoea and respiratory infections seen in HIV-infected children may be partly due to micronutrient deficiencies. The studies in this thesis had two main objectives: (1) to evaluate the effect of short-term (during hospitalization) and long-term (6 months) multi-micronutrient supplementation on episodes of diarrhoea and respiratory infections in HIV-infected children who are not yet on antiretroviral therapy (ART), and (2) to assess the effects of long-term multi-micronutrient supplementation on appetite and growth performance of HIV-infected who are not on ART. Methods and results: Four studies were conducted. Initially a cross-sectional study was performed in which the duration of hospitalization, weight, length, micronutrient status and appetite of HIV-infected children admitted with diarrhoea or pneumonia was compared with the results of HIV-uninfected children. Duration of hospitalization was 2.8 days (52%) longer in HIV-infected children. Appetite as measured by amount of test food eaten (g per kg body weight) was 26% poorer in HIV-infected children. Mean length-for-age Z-scores were lower in HIV-infected children; there was no difference in level of wasting. Subsequently multi-micronutrient supplementation studies were performed, one short-term and two long-term studies. The effect of supplementation on the duration of hospitalization in HIV-infected children with diarrhoea or pneumonia was assessed in the short-term study. One long-term study assessed the supplement’s impact on growth and frequency of episodes of diarrhoea and of pneumonia in HIV-infected children. The other evaluated the effect of the supplement on the appetite of these children. The supplement contained vitamins A, B complex, C, D, E and folic acid, and the minerals copper, iron, selenium and zinc at levels based on recommended dietary allowances. In the short-term supplementation study HIV-infected children aged 4-24 months who were hospitalized with pneumonia or diarrhoea received the supplement or a placebo until discharge from hospital. The duration of hospitalization was 1.7 days (19%) shorter in the supplement group. Long-term multi-micronutrient supplementation improved the weight-for-age and weight-for-height Z-scores of HIV-infected children aged 4-24 months by 0.4 over the 6-month period. There was no improvement in stunting. Children in the supplement group had substantially fewer episodes of respiratory symptoms per month than the placebo group (0.66 ± 0.51) per month vs (1.01 ± 0.67) (P < 0.05) and marginally fewer episodes of diarrhoea per month (0.25 ± 0.31) vs (0.36 ± 0.36) (P = 0.09). There was no effect on CD4 lymphocytes. Long-term supplementation with micronutrients had benefits on the appetite of HIV-infected children aged 6-24 months as well. Improvements in amount of test food eaten over the 6-month period were much higher among children who received the supplement (4.7 ± 14.7 g/kg body weight) than the changes in those who received the placebo (-1.4 ± 11.6 g/kg body weight). Conclusion: Multi-micronutrient supplementation reduces the duration of diarrhoea and of pneumonia and incidence of diarrhoea and of respiratory symptoms in HIV-infected children who are not yet on ART. Multi-micronutrient supplementation also improves appetite and weight in these children but not height. The results of these studies indicate that multi-micronutrient supplementation should be considered in HIV-infected infant and young children who have not commenced ART.

Background: The nutritional status of HIV-infected children is reported to be poor. Diarrhoea and acute respiratory infections tend to be more common and severe in HIV-infected children than in uninfected ones. Deficiencies of micronutrients may result in poor growth and increased risk of diarrhoea and respiratory infections. Micronutrient deficiencies are common in HIV-infected children. The poor growth, diarrhoea and respiratory infections seen in HIV-infected children may be partly due to micronutrient deficiencies. The studies in this thesis had two main objectives: (1) to evaluate the effect of short-term (during hospitalization) and long-term (6 months) multi-micronutrient supplementation on episodes of diarrhoea and respiratory infections in HIV-infected children who are not yet on antiretroviral therapy (ART), and (2) to assess the effects of long-term multi-micronutrient supplementation on appetite and growth performance of HIV-infected who are not on ART. Methods and results: Four studies were conducted. Initially a cross-sectional study was performed in which the duration of hospitalization, weight, length, micronutrient status and appetite of HIV-infected children admitted with diarrhoea or pneumonia was compared with the results of HIV-uninfected children. Duration of hospitalization was 2.8 days (52%) longer in HIV-infected children. Appetite as measured by amount of test food eaten (g per kg body weight) was 26% poorer in HIV-infected children. Mean length-for-age Z-scores were lower in HIV-infected children; there was no difference in level of wasting. Subsequently multi-micronutrient supplementation studies were performed, one short-term and two long-term studies. The effect of supplementation on the duration of hospitalization in HIV-infected children with diarrhoea or pneumonia was assessed in the short-term study. One long-term study assessed the supplement’s impact on growth and frequency of episodes of diarrhoea and of pneumonia in HIV-infected children. The other evaluated the effect of the supplement on the appetite of these children. The supplement contained vitamins A, B complex, C, D, E and folic acid, and the minerals copper, iron, selenium and zinc at levels based on recommended dietary allowances. In the short-term supplementation study HIV-infected children aged 4-24 months who were hospitalized with pneumonia or diarrhoea received the supplement or a placebo until discharge from hospital. The duration of hospitalization was 1.7 days (19%) shorter in the supplement group. Long-term multi-micronutrient supplementation improved the weight-for-age and weight-for-height Z-scores of HIV-infected children aged 4-24 months by 0.4 over the 6-month period. There was no improvement in stunting. Children in the supplement group had substantially fewer episodes of respiratory symptoms per month than the placebo group (0.66 ± 0.51) per month vs (1.01 ± 0.67) (P < 0.05) and marginally fewer episodes of diarrhoea per month (0.25 ± 0.31) vs (0.36 ± 0.36) (P = 0.09). There was no effect on CD4 lymphocytes. Long-term supplementation with micronutrients had benefits on the appetite of HIV-infected children aged 6-24 months as well. Improvements in amount of test food eaten over the 6-month period were much higher among children who received the supplement (4.7 ± 14.7 g/kg body weight) than the changes in those who received the placebo (-1.4 ± 11.6 g/kg body weight). Conclusion: Multi-micronutrient supplementation reduces the duration of diarrhoea and of pneumonia and incidence of diarrhoea and of respiratory symptoms in HIV-infected children who are not yet on ART. Multi-micronutrient supplementation also improves appetite and weight in these children but not height. The results of these studies indicate that multi-micronutrient supplementation should be considered in HIV-infected infant and young children who have not commenced ART.

Is het gebruik van bio-impedantiemeting in de eerstelijnsgezondheidszorg geschikt of ongeschikt? Paul Hulshof, universitair docent afdeling Humane Voeding, Wageningen Universiteit en Peter Weijs, Lector Gewichtsmanagement en coördinator onderzoek Diëtetiek en Voedingswetenschappen, VU medisch centrum, geven over deze kwestie hun mening

Protein or energy supplementation of the diet of malnourished older people leads to body weight gain and an improved nutritional status. There are no indications for an effect on functional endpoints. In contrast, according to Prof. Lisette de Groot (Wageningen University), vitamin supplementation reportedly leads to functional improvements Suppletie van de voeding van ondervoede ouderen met eiwit of energie leidt tot toename van het lichaamsgewicht en verbetering van de voedingsstatus. Er zijn geen aanwijzingen voor een effect op functionele eindpunten. Bij suppletie met vitamines zijn wel functionele verbeteringen gezien, zegt prof. Lisette de Groot (Wageningen Universiteit)