Nonfermented milk and other dairy products: associations with all-cause mortality

Background: A positive association between nonfermented milk intake and increased all-cause mortality was recently reported, but overall, the association between dairy intake and mortality is inconclusive.Objective: We studied associations between intake of dairy products and all-cause mortality with an emphasis on nonfermented milk and fat content.Design: A total of 103,256 adult participants (women: 51.0%) from Northern Sweden were included (7121 deaths; mean follow-up: 13.7 y). Associations between all-cause mortality and reported intakes of nonfermented milk (total or by fat content), fermented milk, cheese, and butter were tested with the use of Cox proportional hazards models that were adjusted for age, sex, body mass index, smoking status, education, energy intake, examination year, and physical activity. To circumvent confounding, Mendelian randomization was applied in a subsample via the lactase LCT-13910 C/T single nucleotide polymorphism that is associated with lactose tolerance and milk intake.Results: High consumers of nonfermented milk (≥2.5 times/d) had a 32% increased hazard (HR: 1.32; 95% CI: 1.18, 1.48) for all-cause mortality compared with that of subjects who consumed milk ≤1 time/wk. The corresponding value for butter was 11% (HR: 1.11; 95% CI: 1.07, 1.21). All nonfermented milk-fat types were independently associated with increased HRs, but compared with full-fat milk, HRs were lower in consumers of medium- and low-fat milk. Fermented milk intake (HR: 0.90; 95% CI: 0.86, 0.94) and cheese intake (HR: 0.93; 95% CI: 0.91, 0.96) were negatively associated with mortality. Results were slightly attenuated by lifestyle adjustments but were robust in sensitivity analyses. Mortality was not significantly associated with the LCT-13910 C/T genotype in the smaller subsample. The amount and type of milk intake was associated with lifestyle variables.Conclusions: In the present Swedish cohort study, intakes of nonfermented milk and butter are associated with higher all-cause mortality, and fermented milk and cheese intakes are associated with lower all-cause mortality. Residual confounding by lifestyle cannot be excluded, and Mendelian randomization needs to be examined in a larger sample.

Does diet intervention in line with nutrition recommendations affect dietary carbon footprint? Results from a weight loss trial among lactating women

BACKGROUND/OBJECTIVES

Results from studies evaluating the sustainability of diets combining environmental and nutritional aspects have been diverse; thus, greenhouse gas emissions (that is, carbon footprint (CF)) of diets in line with dietary recommendations in free-living individuals warrants further examination. Here, changes in dietary CF related to changes in food choice during a weight loss trial among lactating women who received a 12-week diet intervention based on the Nordic Nutrition Recommendations (NNR) 2004 were analyzed. The objective of this study was to examine if a diet intervention based on NNR 2004 results in reduced dietary CF.

SUBJECTS/METHODS

Changes in dietary CF were analyzed among 61 lactating women participating in a weight loss trial. Food intake data from 4-day weighed diet records and results from life cycle analyses were used to examine changes in dietary CF across eight food groups during the intervention, specified in the unit carbon dioxide equivalent (CO₂eq/day). Differences in changes in dietary CF between women receiving diet treatment (D-group) and women not receiving it (ND-group) were compared.

RESULTS

There was no difference in change in dietary CF of the overall diet between D- and ND-group (P>0.05). As for the eight food groups, D-group increased their dietary CF from fruit and vegetables (+0.06±0.13 kg CO₂eq/day) compared with a decrease in ND-group (-0.01±0.01 kg CO₂eq/day) during the intervention, P=0.01.

CONCLUSIONS

A diet intervention in line with NNR 2004 produced clinically relevant weight loss, but did not reduce dietary CF among lactating women with overweight and obesity. Dietary interventions especially designed to decrease dietary CF and their coherence with dietary recommendations need further exploration.

Longitudinal 10-year changes in dietary intake and associations with cardio-metabolic risk factors in the Northern Sweden Health and Disease Study

BACKGROUND

Dietary risks today constitute the largest proportion of disability-adjusted life years (DALYs) globally and in Sweden. An increasing number of people today consume highly processed foods high in saturated fat, refined sugar and salt and low in dietary fiber, vitamins and minerals. It is important that dietary trends over time are monitored to predict changes in disease risk.

METHODS

In total, 15,995 individuals with two visits 10 (±1) years apart in the population-based Västerbotten Intervention Programme 1996-2014 were included. Dietary intake was captured with a 64-item food frequency questionnaire. Percent changes in intake of dietary components, Healthy Diet Score and Dietary Inflammatory Index were calculated and related to body mass index (BMI), serum cholesterol and triglyceride levels and blood pressure at the second visit in multivariable regression analyses.

RESULTS

For both sexes, on group level, proportion of energy intake (E%) from carbohydrates and sucrose decreased (largest carbohydrate decrease among 40 year-olds) and E% protein and total fat as well as saturated and poly-unsaturated fatty acids (PUFA) increased (highest protein increase among 30 year-olds and highest fat increase among 60 year-olds) over the 10-year period. Also, E% trans-fatty acids decreased. On individual basis, for both sexes decreases in intake of cholesterol and trans-fatty acids were associated with lower BMI and serum cholesterol at second visit (all P < 0.05). For men, increases in intake of whole grain and Healthy Diet Score were associated with lower BMI and serum cholesterol at second visit (all P < 0.05). Also for men, decreases in intake of trans-fatty acids and increases in Healthy Diet Score were associated with lower systolic blood pressure at second visit (P = 0.002 and P < 0.000). For women, increases in intake of PUFA and Healthy Diet Score were associated with lower BMI at second visit (P = 0.01 and P < 0.05). Surprisingly, increases in intake of sucrose among women were associated with lower BMI at second visit (P = 0.02).

CONCLUSIONS

In this large population-based sample, dietary changes over 10 years towards less carbohydrates and more protein and fat were noted. Individual changes towards the Nordic dietary recommendations were associated with healthier cardio-metabolic risk factor profile at second visit.

Metabolic profiles from two different breakfast meals characterized by 1H NMR-based metabolomics

It is challenging to measure dietary exposure with techniques that are both accurate and applicable to free-living individuals. We performed a cross-over intervention, with 24 healthy individuals, to capture the acute metabolic response of a cereal breakfast (CB) and an egg and ham breakfast (EHB). Fasting and postprandial urine samples were analyzed using ¹H nuclear magnetic resonance (NMR) spectroscopy and multivariate data analysis. Metabolic profiles were distinguished in relation to ingestion of either CB or EHB. Phosphocreatine/creatine and citrate were identified at higher concentrations after consumption of EHB. Beverage consumption (i.e., tea or coffee) could clearly be seen in the data. 2-furoylglycine and 5-hydroxymethyl-2-furoic acid - potential biomarkers for coffee consumption were identified at higher concentrations in coffee drinkers. Thus ¹H NMR urine metabolomics is applicable in the characterization of acute metabolic fingerprints from meal consumption and in the identification of metabolites that may serve as potential biomarkers.

Parity, weight change, and maternal risk of cardiovascular events

BACKGROUND

High parity has been suggested to increase risk of maternal cardiovascular disease independent of body mass index measured after childbearing. Pregnancy is, however, associated with persistent weight gain and metabolic changes that, independent of parity, increase the risk of cardiovascular disease. It could therefore be questioned if high parity independently increases the risk of cardiovascular disease or if this association may be confounded, mediated, or modified by other parity-related factors.

OBJECTIVE

We sought to investigate the association between parity and risk of cardiovascular disease, and secondary outcomes in terms of myocardial infarction and cerebral infarction, with particular focus on potential mediation by anthropometric measures and effect modification by lactation.

STUDY DESIGN

We used data from 16,515 female participants (age 44.5-73.6 years) of the population-based Malmö Diet and Cancer Study with baseline examination from 1991 through 1996. The Malmö Diet and Cancer Study was followed up throughout 2010, with a median follow-up of 15.8 years. We used Cox proportional hazards model to examine the association between parity and cardiovascular disease.

RESULTS

Adjusted for age and other potential confounders, grand multiparous women (≥5 children) had an increased risk of cardiovascular disease (hazard ratio, 1.60; 95% confidence interval, 1.20-2.14), myocardial infarction (hazard ratio, 1.68; 95% confidence interval, 1.15-2.45), and cerebral infarction (hazard ratio, 1.74; 95% confidence interval, 1.18-2.58) compared to women with 2 children. Additional adjustment for baseline body mass index and weight change since age 20 years attenuated the risk, but the increased risk for cardiovascular disease (hazard ratio, 1.38; 95% confidence interval, 1.02-1.87) and myocardial infarction (hazard ratio, 1.53; 95% confidence interval, 1.04-2.26) in grand multiparous women remained significant. Models stratified by lactation time showed that risk was only raised in grand multiparous women who had a mean lactation time of <4 mo/child. In sensitivity analyses excluding women with a history of diabetes at baseline, risk estimates for grand multiparous women became nonsignificant in the full model.

CONCLUSION

Part of the increased risk of cardiovascular disease and myocardial infarction in grand multiparous women seems to be mediated by weight gain and potentially by higher likelihood of type 2 diabetes mellitus. Lactation may modify the increased risk of grand multiparity in that longer duration might offset the cardiovascular disease risk.

An Epidemic of Scurvy in Afghanistan: Assessment and Response

In March 2002, there were reports of a hemorrhagic fever outbreak in western Afghanistan. It was later confirmed that the hemorrhagic symptoms and increased mortality were actually due to scurvy. Most aid workers did not include scurvy in the initial differential diagnosis because it is uncommon throughout the world and has mainly been reported in refugee populations in recent times. A rapid assessment confirmed the cases clinically, estimated a prevalence rate of 6.3% (a severe public health problem), and determined that the attack rates peaked each year in January and February (the end of the winter). Many Afghans have limited dietary diversity due to isolated locations, lengthy winters, the continuing drought of the last four years, asset depletion, and loss of livelihood. After numerous food and fortification options to prevent future outbreaks had been considered, vitamin C tablet supplementation was selected because of the relatively rapid response time as compared with other prevention methods. A three-month course of vitamin C tablets was distributed to 827 villages in at-risk areas. The tablets were acceptable and compliance was good. No cases of scurvy were reported for the winter of 2002–03. The case study from Afghanistan demonstrates that scurvy can occur in nonrefugee or nondisplaced populations; vitamin C supplementation can be an effective prevention strategy; there is an urgent need to develop field-friendly techniques to diagnose micronutrient-deficiency diseases; food-security tools should be used to assess and predict risks of nutritional deficiencies; and the humanitarian community should address prevention of scurvy in outbreak-prone areas.

Determinants of microstructural, dimensional and bone mineral changes postpartum in Swedish women

During lactation, areal (a) and volumetric (v) bone mineral density (BMD) are known to temporarily decrease. Factors that affect skeletal changes postpartum are not fully elucidated. The aim was to study determinants of the previously observed changes in aBMD at lumbar spine, and cortical vBMD, microstructure and dimensions at ultra-distal tibia postpartum. Women (25-40 years) were studied longitudinally at 2 weeks (baseline) and 4 months (n 81), 12 months (n 79) and 18 months (n 58) postpartum. At each visit, blood samples were collected, body weight and height were measured and information about lactation habits, oestrogen contraceptives and physical activity was obtained. Ca intake was measured using 4-d food diaries at 4 months postpartum. Serum 25-hydroxyvitamin D (25OHD) was analysed by liquid chromatography-tandem MS. Skeletal changes were assessed with dual-energy X-ray absorptiometry and high-resolution peripheral quantitative computed tomography. Mean baseline BMI was 24·8 (sd 3·1) kg/m2. Median (quartiles 1-3) duration of total lactation was 8·1 (6·8-10·4) months. Longer duration of full lactation was associated with larger decreases of lumbar spine aBMD and tibia vBMD and microstructure. Higher baseline body weight was associated with smaller decreases in tibia vBMD and microstructure. Higher Ca intake was associated with smaller decreases in tibia cortical vBMD and thickness. Higher baseline 25OHD was only associated with larger decreases in lumbar spine aBMD. In conclusion, lactation and body weight were the main determinants of skeletal changes during the first 18 months postpartum. Ca intake and serum concentrations of 25OHD appear to have different associations with cortical and trabecular bone.

Main nutrient patterns and colorectal cancer risk in the European Prospective Investigation into Cancer and Nutrition study

BACKGROUND

Much of the current literature on diet-colorectal cancer (CRC) associations focused on studies of single foods/nutrients, whereas less is known about nutrient patterns. We investigated the association between major nutrient patterns and CRC risk in participants of the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

METHODS

Among 477 312 participants, intakes of 23 nutrients were estimated from validated dietary questionnaires. Using results from a previous principal component (PC) analysis, four major nutrient patterns were identified. Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed for the association of each of the four patterns and CRC incidence using multivariate Cox proportional hazards models with adjustment for established CRC risk factors.

RESULTS

During an average of 11 years of follow-up, 4517 incident cases of CRC were documented. A nutrient pattern characterised by high intakes of vitamins and minerals was inversely associated with CRC (HR per 1 s.d.=0.94, 95% CI: 0.92-0.98) as was a pattern characterised by total protein, riboflavin, phosphorus and calcium (HR (1 s.d.)=0.96, 95% CI: 0.93-0.99). The remaining two patterns were not significantly associated with CRC risk.

CONCLUSIONS

Analysing nutrient patterns may improve our understanding of how groups of nutrients relate to CRC.

Parity, breastfeeding and risk of coronary heart disease: A pan-European case-cohort study

OBJECTIVE

There is uncertainty about the direction and magnitude of the associations between parity, breastfeeding and the risk of coronary heart disease (CHD). We examined the separate and combined associations of parity and breastfeeding practices with the incidence of CHD later in life among women in a large, pan-European cohort study.

METHODS

Data were used from European Prospective Investigation into Cancer and Nutrition (EPIC)-CVD, a case-cohort study nested within the EPIC prospective study of 520,000 participants from 10 countries. Information on reproductive history was available for 14,917 women, including 5138 incident cases of CHD. Using Prentice-weighted Cox regression separately for each country followed by a random-effects meta-analysis, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for CHD, after adjustment for age, study centre and several socioeconomic and biological risk factors.

RESULTS

Compared with nulliparous women, the adjusted HR was 1.19 (95% CI: 1.01-1.41) among parous women; HRs were higher among women with more children (e.g., adjusted HR: 1.95 (95% CI: 1.19-3.20) for women with five or more children). Compared with women who did not breastfeed, the adjusted HR was 0.71 (95% CI: 0.52-0.98) among women who breastfed. For childbearing women who never breastfed, the adjusted HR was 1.58 (95% CI: 1.09-2.30) compared with nulliparous women, whereas for childbearing women who breastfed, the adjusted HR was 1.19 (95% CI: 0.99-1.43).

CONCLUSION

Having more children was associated with a higher risk of CHD later in life, whereas breastfeeding was associated with a lower CHD risk. Women who both had children and breastfed did have a non-significantly higher risk of CHD.

Comparison of a web-based food record tool and a food-frequency questionnaire and objective validation using the doubly labelled water technique in a Swedish middle-aged population

Two web-based dietary assessment tools have been developed for use in large-scale studies: the Riksmaten method (4-d food record) and MiniMeal-Q (food-frequency method). The aim of the present study was to examine the ability of these methods to capture energy intake against objectively measured total energy expenditure (TEE) with the doubly labelled water technique (TEEDLW), and to compare reported energy and macronutrient intake. This study was conducted within the pilot study of the Swedish CArdioPulmonary bioImage Study (SCAPIS), which included 1111 randomly selected men and women aged 50-64 years from the Gothenburg general population. Of these, 200 were enrolled in the SCAPIS diet substudy. TEEDLW was measured in a subsample (n 40). Compared with TEEDLW, both methods underestimated energy intake: -2·5 (sd  2·9) MJ with the Riksmaten method; -2·3 (sd 3·6) MJ with MiniMeal-Q. Mean reporting accuracy was 80 and 82 %, respectively. The correlation between reported energy intake and TEEDLW was r 0·4 for the Riksmaten method (P < 0·05) and r 0·28 (non-significant) for MiniMeal-Q. Women reported similar average intake of energy and macronutrients in both methods whereas men reported higher intakes with the Riksmaten method. Energy-adjusted correlations ranged from 0·14 (polyunsaturated fat) to 0·77 (alcohol). Bland-Altman plots showed acceptable agreement for energy and energy-adjusted protein and carbohydrate intake, whereas the agreement for fat intake was poorer. According to energy intake data, both methods displayed similar precision on energy intake reporting. However, MiniMeal-Q was less successful in ranking individuals than the Riksmaten method. The development of methods to achieve limited under-reporting is a major challenge for future research.

The association of substituting carbohydrates with total fat and different types of fatty acids with mortality and weight change among diabetes patients

BACKGROUND

Substitution of carbohydrates with fat in a diet for type 2 diabetes patients is still debated.

OBJECTIVE

This study aimed to investigate the association between dietary carbohydrate intake and isocaloric substitution with (i) total fat, (ii) saturated fatty acids (SFA), (iii) mono-unsaturated fatty acids (MUFA) and (iv) poly-unsaturated fatty acids (PUFA) with all-cause and cardiovascular (CVD) mortality risk and 5-year weight change in patients with type 2 diabetes.

METHODS

The study included 6192 patients with type 2 diabetes from 15 cohorts of the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at recruitment with country-specific food-frequency questionnaires. Cox and linear regression were used to estimate the associations with (CVD) mortality and weight change, adjusting for confounders and using different methods to adjust for energy intake.

RESULTS

After a mean follow-up of 9.2 y ± SD 2.3 y, 791 (13%) participants had died, of which 268 (4%) due to CVD. Substituting 10 g or 5 energy% of carbohydrates by total fat was associated with a higher all-cause mortality risk (HR 1.07 [1.02-1.13]), or SFAs (HR 1.25 [1.11-1.40]) and a lower risk when replaced by MUFAs (HR 0.89 [0.77-1.02]). When carbohydrates were substituted with SFAs (HR 1.22 [1.00-1.49]) or PUFAs (HR 1.29 [1.02-1.63]) CVD mortality risk increased. The 5-year weight was lower when carbohydrates were substituted with total fat or MUFAs. These results were consistent over different energy adjustment methods.

CONCLUSIONS

In diabetes patients, substitution of carbohydrates with SFAs was associated with a higher (CVD) mortality risk and substitution by total fat was associated with a higher all-cause mortality risk. Substitution of carbohydrates with MUFAs may be associated with lower mortality risk and weight reduction. Instead of promoting replacement of carbohydrates by total fat, dietary guideline should continue focusing on replacement by fat-subtypes; especially SFAs by MUFAs.

Meal patterns across ten European countries - results from the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study

OBJECTIVE

To characterize meal patterns across ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study.

DESIGN

Cross-sectional study utilizing dietary data collected through a standardized 24 h diet recall during 1995-2000. Eleven predefined intake occasions across a 24 h period were assessed during the interview. In the present descriptive report, meal patterns were analysed in terms of daily number of intake occasions, the proportion reporting each intake occasion and the energy contributions from each intake occasion.

SETTING

Twenty-seven centres across ten European countries.

SUBJECTS

Women (64 %) and men (36 %) aged 35-74 years (n 36 020).

RESULTS

Pronounced differences in meal patterns emerged both across centres within the same country and across different countries, with a trend for fewer intake occasions per day in Mediterranean countries compared with central and northern Europe. Differences were also found for daily energy intake provided by lunch, with 38-43 % for women and 41-45 % for men within Mediterranean countries compared with 16-27 % for women and 20-26 % for men in central and northern European countries. Likewise, a south-north gradient was found for daily energy intake from snacks, with 13-20 % (women) and 10-17 % (men) in Mediterranean countries compared with 24-34 % (women) and 23-35 % (men) in central/northern Europe.

CONCLUSIONS

We found distinct differences in meal patterns with marked diversity for intake frequency and lunch and snack consumption between Mediterranean and central/northern European countries. Monitoring of meal patterns across various cultures and populations could provide critical context to the research efforts to characterize relationships between dietary intake and health.

Environmental organic pollutants in human milk before and after weight loss

Many persistent organic pollutants (POPs) are banned because they accumulate in organisms and are toxic. Lipophilic POPs are stored in maternal adipose tissue and concentrations in human milk (HM) may increase during weight loss. Our aim was to examine associations between weight loss and concentrations of chlorinated POPs in HM in lactating women participating in a weight loss study. We analysed POPs (PCB 28, PCB 153, HCB, DDE) in HM at 12 and 24 weeks postpartum from 32 women who participated in a randomized, 2 × 2 factorial trial of diet and exercise for postpartum weight loss. Participants donated milk before and after the intervention period. We examined associations between weight loss and change in POP concentrations and estimated the intake of POPs by their breastfed infants. Most (n = 27) women lost weight during intervention, 0.45 ± 0.30 kg/week (mean ± SD). Among these women, the concentration of PCB 153 in HM was significantly (p = 0.04) higher at follow-up than at baseline. Weight loss was significantly positively associated with changes in concentrations of all studied POPs (2.0-2.4% increase per percent weight loss). Estimated mean intakes of POPs (ng/day) remained stable because infant milk consumption decreased during the study period. As infants gained weight, estimated mean intakes per kg body weight decreased 17-22%. Changes in concentrations of POPs in HM correlated positively with maternal weight loss, but it is unlikely that the balance between the benefits and risks of breastfeeding will change if the weight loss is restricted to 0.5 kg per week.

Changes in Dietary Fat Intake and Projections for Coronary Heart Disease Mortality in Sweden: A Simulation Study

Objective

In Sweden, previous favourable trends in blood cholesterol levels have recently levelled off or even increased in some age groups since 2003, potentially reflecting changing fashions and attitudes towards dietary saturated fatty acids (SFA). We aimed to examine the potential effect of different SFA intake on future coronary heart disease (CHD) mortality in 2025.

Methods

We compared the effect on future CHD mortality of two different scenarios for fat intake a) daily SFA intake decreasing to 10 energy percent (E%), and b) daily SFA intake rising to 20 E%. We assumed that there would be moderate improvements in smoking (5%), salt intake (1g/day) and physical inactivity (5% decrease) to continue recent, positive trends.

Results

In the baseline scenario which assumed that recent mortality declines continue, approximately 5,975 CHD deaths might occur in year 2025. Anticipated improvements in smoking, dietary salt intake and physical activity, would result in some 380 (-6.4%) fewer deaths (235 in men and 145 in women). In combination with a mean SFA daily intake of 10 E%, a total of 810 (-14%) fewer deaths would occur in 2025 (535 in men and 275 in women). If the overall consumption of SFA rose to 20 E%, the expected mortality decline would be wiped out and approximately 20 (0.3%) additional deaths might occur.

Conclusion

CHD mortality may increase as a result of unfavourable trends in diets rich in saturated fats resulting in increases in blood cholesterol levels. These could cancel out the favourable trends in salt intake, smoking and physical activity.

Effectiveness of a weight loss intervention in postpartum women: results from a randomized controlled trial in primary health care

BACKGROUND

Reproduction has been identified as an important factor for long-term weight gain among women. A previous efficacy trial has successfully produced postpartum weight loss; however, the effectiveness of this intervention needs to be established.

OBJECTIVE

This study was designed to evaluate the short- and long-term effectiveness of a diet behavior modification treatment to produce weight loss in postpartum women within the primary health care setting in Sweden.

DESIGN

During 2011-2014, 110 women with a self-reported body mass index (BMI; in kg/m(2)) of ≥27 at 6-15 wk postpartum were randomly assigned to the diet behavior modification group (D group) or the control group (C group). Women randomly assigned to the D group (n = 54) received a structured 12-wk diet behavior modification treatment by a dietitian and were instructed to gradually implement a diet plan based on the Nordic Nutrition Recommendations and to self-weigh ≥3 times/wk. Women randomly assigned to the C group (n = 56) were given a brochure on healthy eating. The primary outcome was change in body weight after 12 wk and 1 y. The retention rate was 91% and 85% at 12 wk and 1 y, respectively.

RESULTS

At baseline, women had a median (1st, 3rd quartile) BMI of 31.0 (28.8, 33.6), and 84% were breastfeeding. After 12 wk, median weight change in the D group was -6.1 kg (-8.4, -3.2 kg) compared with -1.6 kg (-3.5, -0.4 kg) in the C group (P < 0.001). The difference was maintained at the 1-y follow-up for the D group, -10.0 kg (-11.7, -5.9 kg) compared with -4.3 kg (-10.2, -1.0 kg) in the C group (P = 0.004). In addition, the D group reduced BMI, waist circumference, hip circumference, and body fat percentage more than did the C group at both 12 wk and 1 y (all P < 0.05).

CONCLUSION

A low-intensity diet treatment delivered by a dietitian within the primary health care setting can produce clinically relevant and sustainable weight loss in postpartum women with overweight and obesity. This trial was registered at clinicaltrials.gov as NCT01949558.

Dietary intake, leisure time activities and obesity among adolescents in Western Sweden: a cross-sectional study

BACKGROUND

Overweight and obesity among adolescents are increasing worldwide. Risk factors include dietary intake characteristics and high levels of physical inactivity. In Sweden, few large comprehensive population-based surveys of dietary intake and lifestyle among adolescents have been carried out. Thus, the purpose of the current study was to describe dietary intake and food choices as well as leisure time activities in relation to overweight and obesity in a total sample of all schoolchildren aged 15 years in Western Sweden.

METHODS

In 2008, a questionnaire was sent to all 21,651 adolescents born in 1992 in Västra Götaland Region, Sweden. Participation rate was 54.3 % (50.7 % girls/49.3 % boys). The questionnaire included a 73-item semi-quantitative food frequency questionnaire and questions on lifestyle. Results were evaluated against the Nordic Nutrition Recommendations and Swedish indicators of healthy diet and exercise habits. Associations with concurrent overweight and obesity were evaluated in multiple linear regression analysis.

RESULTS

Among girls, 49.5 % reached the goal of consuming fruit and vegetables at least daily, whereas for boys the figure was 34.4 %. Among both sexes, 15 % reached the goal of consuming fish at least twice weekly. Two-thirds of both sexes reached the goal of regular moderate or vigorous physical activity weekly. In total, 12.4 % were overweight and 2.4 % were obese. More girls than boys were underweight, whereas more boys than girls were overweight or obese (p < 0.001). Boys exhibited a more frequent intake of sodas and concentrated fruit juices, milk 3 % fat, bread and potatoes and fast food (p < 0.001). Frequent intake of candies and chocolate was reported by both sexes. Among girls and boys, living in rural areas, living in apartments and reporting no frequent leisure time physical activity were significant risk factors for being overweight or obese, also when adjusted for other risk factors.

CONCLUSIONS

Dietary habits of adolescents in Western Sweden warrant improvements. Public health actions should be taken to increase consumption of fruit, vegetables and fish, and decrease consumption of sodas and candies and also to increase frequency of physical activity. These actions may be helpful in reducing risks for overweight and obesity.

A treelet transform analysis to relate nutrient patterns to the risk of hormonal receptor-defined breast cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC)

OBJECTIVE

Pattern analysis has emerged as a tool to depict the role of multiple nutrients/foods in relation to health outcomes. The present study aimed at extracting nutrient patterns with respect to breast cancer (BC) aetiology.

DESIGN

Nutrient patterns were derived with treelet transform (TT) and related to BC risk. TT was applied to twenty-three log-transformed nutrient densities from dietary questionnaires. Hazard ratios (HR) and 95 % confidence intervals computed using Cox proportional hazards models quantified the association between quintiles of nutrient pattern scores and risk of overall BC, and by hormonal receptor and menopausal status. Principal component analysis was applied for comparison.

SETTING

The European Prospective Investigation into Cancer and Nutrition (EPIC).

SUBJECTS

Women (n 334 850) from the EPIC study.

RESULTS

The first TT component (TC1) highlighted a pattern rich in nutrients found in animal foods loading on cholesterol, protein, retinol, vitamins B12 and D, while the second TT component (TC2) reflected a diet rich in β-carotene, riboflavin, thiamin, vitamins C and B6, fibre, Fe, Ca, K, Mg, P and folate. While TC1 was not associated with BC risk, TC2 was inversely associated with BC risk overall (HRQ5 v. Q1=0·89, 95 % CI 0·83, 0·95, P trend<0·01) and showed a significantly lower risk in oestrogen receptor-positive (HRQ5 v. Q1=0·89, 95 % CI 0·81, 0·98, P trend=0·02) and progesterone receptor-positive tumours (HRQ5 v. Q1=0·87, 95 % CI 0·77, 0·98, P trend<0·01).

CONCLUSIONS

TT produces readily interpretable sparse components explaining similar amounts of variation as principal component analysis. Our results suggest that participants with a nutrient pattern high in micronutrients found in vegetables, fruits and cereals had a lower risk of BC.

Vegetable and fruit consumption and the risk of hormone receptor-defined breast cancer in the EPIC cohort

BACKGROUND

The recent literature indicates that a high vegetable intake and not a high fruit intake could be associated with decreased steroid hormone receptor-negative breast cancer risk.

OBJECTIVE

This study aimed to investigate the association between vegetable and fruit intake and steroid hormone receptor-defined breast cancer risk.

DESIGN

A total of 335,054 female participants in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort were included in this study (mean ± SD age: 50.8 ± 9.8 y). Vegetable and fruit intake was measured by country-specific questionnaires filled out at recruitment between 1992 and 2000 with the use of standardized procedures. Cox proportional hazards models were stratified by age at recruitment and study center and were adjusted for breast cancer risk factors.

RESULTS

After a median follow-up of 11.5 y (IQR: 10.1-12.3 y), 10,197 incident invasive breast cancers were diagnosed [3479 estrogen and progesterone receptor positive (ER+PR+); 1021 ER and PR negative (ER-PR-)]. Compared with the lowest quintile, the highest quintile of vegetable intake was associated with a lower risk of overall breast cancer (HRquintile 5-quintile 1: 0.87; 95% CI: 0.80, 0.94). Although the inverse association was most apparent for ER-PR- breast cancer (ER-PR-: HRquintile 5-quintile 1: 0.74; 95% CI: 0.57, 0.96; P-trend = 0.03; ER+PR+: HRquintile 5-quintile 1: 0.91; 95% CI: 0.79, 1.05; P-trend = 0.14), the test for heterogeneity by hormone receptor status was not significant (P-heterogeneity = 0.09). Fruit intake was not significantly associated with total and hormone receptor-defined breast cancer risk.

CONCLUSION

This study supports evidence that a high vegetable intake is associated with lower (mainly hormone receptor-negative) breast cancer risk.

Dietary assessment among women with overweight and obesity in early postpartum

BACKGROUND

The present study aimed to assess dietary intake and evaluate the degree of agreement of group-level dietary intake as measured by 24-h recall against a 4-day diet record among postpartum women with overweight and obesity.

METHODS

A cross-sectional study was conducted of 110 Swedish women with a body mass index of ≥27 kg m(-2) at 6-15 weeks postpartum who were recruited to a weight loss trial and randomised to diet intervention or control. One 24-h recall was conducted among all women prior to randomisation. In addition, women subsequently randomised to diet intervention also conducted a 4-day diet record before receiving dietary treatment (n = 54). Paired tests were used to evaluate agreement of group-level dietary intake as measured by 24-h recall against 4-day diet record among women randomised to diet intervention.

RESULTS

Women reported a median (25th and 75th percentiles) energy intake of 9.1 (6.9, 11.7) MJ day(-1) and an intake of fibre, vitamin D, folate and iron below the recommended intake as assessed by 24-h recall prior to randomisation (n = 110). Group-level median intakes of energy (9.9 versus 10.0 MJ day(-1) ), fibre (21.9 versus 21.3 g day(-1) ), vitamin D (4.8 versus 6.5 μg day(-1) ), folate (296 versus 287 μg day(-1) ), iron (11.0 versus 11.3 mg day(-1) ) and calcium (915 versus 968 mg day(-1) ) did not differ significantly between the methods; however, the record captured a higher energy-adjusted intake of fat, saturated fat and alcohol, as well as a lower intake of carbohydrates, compared to the recall (n = 54).

CONCLUSIONS

We found no difference in group-level estimates of energy or micronutrients between the recall and the record; however, there were some differences for macronutrients.

Maternal Prepregnant Body Mass Index and Gestational Weight Gain Are Associated with Initiation and Duration of Breastfeeding among Norwegian Mothers

BACKGROUND

Pregnancy is associated with weight gain. Moreover, overweight and obese women subsequently have difficulties with breastfeeding. Both of these factors may contribute to the observed relations between reproduction and weight problems.

OBJECTIVE

In this study we evaluated the combined effects of maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG) on the ability to initiate and sustain breastfeeding in a large, population-based study, the MoBa (Norwegian Mother and Child Cohort Study).

METHODS

Initiation and maintenance of breastfeeding for 4 and 6 mo postpartum in relation to prepregnancy BMI and GWG were evaluated among 49,669 women with complete information on BMI, GWG, and breastfeeding by using multivariable logistic regression analyses.

RESULTS

An excess risk of unsuccessful initiation of breastfeeding was observed among all categories of prepregnant overweight and obese women as well as among most GWG categories of prepregnant underweight women. For all of these groups, risks of unsuccessful initiation of breastfeeding were significantly higher with GWG below recommendations. The same patterns were seen among all categories of prepregnant overweight and obese women with respect to risks of inability to sustain full or any breastfeeding for 4 and 6 mo postpartum. However, prepregnant obese women had the highest risk of inability to sustain full or any breastfeeding if they had also experienced GWG above recommendations. The associations between prepregnancy BMI and breastfeeding were modified by Apgar scores and maternal asthma.

CONCLUSIONS

The results show the importance of encouraging women to start pregnancy with a healthy BMI as well as to have GWG within recommendations for the benefit of successful breastfeeding. The interactions with medical conditions further highlight the complexity of the associations.

Isocaloric substitution of carbohydrates with protein: the association with weight change and mortality among patients with type 2 diabetes

Background

The health impact of dietary replacement of carbohydrates with protein for patients with type 2 diabetes is still debated. This study aimed to investigate the association between dietary substitution of carbohydrates with (animal and plant) protein and 5-year weight change, and all-cause and cardiovascular (CVD) mortality risk in patients with type 2 diabetes.

Methods

The study included 6,107 diabetes patients from 15 European cohorts. Patients with type 1 diabetes were excluded. At recruitment, validated country-specific food-frequency questionnaires were used to estimate dietary intake. Multivariable adjusted linear regression was used to examine the associations between dietary carbohydrate substitution with protein and 5-year weight change, and Cox regression to estimate hazard ratios (HRs) for (CVD) mortality.

Results

Annual weight loss of patients with type 2 diabetes was 0.17 (SD 1.24) kg. After a mean follow-up of 9.2 (SD 2.3)y, 787 (13%) participants had died, of which 266 (4%) deaths were due to CVD. Substitution of 10 gram dietary carbohydrate with total (ß = 187 [75;299]g) and animal (ß = 196 [137;254]g) protein was associated with mean 5-year weight gain. Substitution for plant protein was not significantly associated with weight change (β = 82 [−421;584]g). Substitution with plant protein was associated with lower all-cause mortality risk (HR = 0.79 [0.64;0.97]), whereas substitution with total or animal protein was not associated with (CVD) mortality risk.

Conclusions

In diabetes patients, substitution with plant protein was beneficial with respect to weight change and all-cause mortality as opposed to substitution with animal protein. Therefore, future research is needed whether dietary guidelines should not actively promote substitution of carbohydrates by total protein, but rather focus on substitution of carbohydrates with plant protein.

Lifestyle and health status in a sample of Swedish women four years after pregnancy: a comparison of women with a history of normal pregnancy and women with a history of gestational diabetes mellitus

Background

Despite the recommendations to continue the regime of healthy food and physical activity (PA) postpartum for women with previous gestational diabetes mellitus (GDM), the scientific evidence reveals that these recommendations may not be complied to. This study compared lifestyle and health status in women whose pregnancy was complicated by GDM with women who had a normal pregnancy and delivery.

Methods

The inclusion criteria were women with GDM (ICD-10: O24.4 A and O24.4B) and women with uncomplicated pregnancy and delivery in 2005 (ICD-10: O80.0). A random sample of women fulfilling the criteria (n = 882) were identified from the Swedish Medical Birth Register. A questionnaire was sent by mail to eligible women approximately four years after the pregnancy. A total of 444 women (50.8%) agreed to participate, 111 diagnosed with GDM in their pregnancy and 333 with normal pregnancy/delivery.

Results

Women with previous GDM were significantly older, reported higher body weight and less PA before the index pregnancy. No major differences between the groups were noticed regarding lifestyle at the follow-up. Overall, few participants fulfilled the national recommendations of PA and diet. At the follow-up, 19 participants had developed diabetes, all with previous GDM. Women with previous GDM reported significantly poorer self-rated health (SRH), higher level of sick-leave and more often using medication on regular basis. However, a history of GDM or having overt diabetes mellitus showed no association with poorer SRH in the multivariate analysis. Irregular eating habits, no regular PA, overweight/obesity, and regular use of medication were associated with poorer SRH in all participants.

Conclusions

Suboptimal levels of PA, and fruit and vegetable consumption were found in a sample of women with a history of GDM as well as for women with normal pregnancy approximately four years after index pregnancy. Women with previous GDM seem to increase their PA after childbirth, but still they perform their PA at lower intensity than women with a history of normal pregnancy. Having GDM at index pregnancy or being diagnosed with overt diabetes mellitus at follow-up did not demonstrate associations with poorer SRH four years after delivery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0487-2) contains supplementary material, which is available to authorized users.

Plasma elaidic acid level as biomarker of industrial trans fatty acids and risk of weight change: report from the EPIC study

BACKGROUND

Few epidemiological studies have examined the association between dietary trans fatty acids and weight gain, and the evidence remains inconsistent. The main objective of the study was to investigate the prospective association between biomarker of industrial trans fatty acids and change in weight within the large study European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.

METHODS

Baseline plasma fatty acid concentrations were determined in a representative EPIC sample from the 23 participating EPIC centers. A total of 1,945 individuals were followed for a median of 4.9 years to monitor weight change. The association between elaidic acid level and percent change of weight was investigated using a multinomial logistic regression model, adjusted by length of follow-up, age, energy, alcohol, smoking status, physical activity, and region.

RESULTS

In women, doubling elaidic acid was associated with a decreased risk of weight loss (odds ratio (OR) = 0.69, 95% confidence interval (CI) = 0.55-0.88, p = 0.002) and a trend was observed with an increased risk of weight gain during the 5-year follow-up (OR = 1.23, 95% CI = 0.97-1.56, p = 0.082) (p-trend<.0001). In men, a trend was observed for doubling elaidic acid level and risk of weight loss (OR = 0.82, 95% CI = 0.66-1.01, p = 0.062) while no significant association was found with risk of weight gain during the 5-year follow-up (OR = 1.08, 95% CI = 0.88-1.33, p = 0.454). No association was found for saturated and cis-monounsaturated fatty acids.

CONCLUSIONS

These data suggest that a high intake of industrial trans fatty acids may decrease the risk of weight loss, particularly in women. Prevention of obesity should consider limiting the consumption of highly processed foods, the main source of industrially-produced trans fatty acids.

Changes in cortical volumetric bone mineral density and thickness, and trabecular thickness in lactating women postpartum

CONTEXT

Lactation is associated with decreased areal bone mineral density (aBMD). Replenishment occurs especially after ceased lactation. Changes in volumetric bone mineral density (vBMD), microstructure, and dimensional parameters are unknown and may clarify the role of lactation for skeletal health. OBJECTIVE AND MAIN OUTCOMES: The objective of the study was to test the hypothesis that lactation is associated with changes in aBMD, vBMD, microstructure, and dimensional parameters.

DESIGN

At baseline (0.5 mo after delivery) and 4, 12, and 18 months thereafter, bone was assessed using dual-energy x-ray absorptiometry and high-resolution peripheral quantitative computed tomography.

PARTICIPANTS AND SETTING

Eighty-one fair-skinned postpartum women and 21 controls aged 25-40 years were recruited. The completion ratio was 73%. Postpartum women were categorized depending on duration of lactation: 0-3.9, 4-8.9, and 9 months or longer.

RESULTS

During the first 4 months, aBMD decreased at several sites (geometric mean ± SE; -0.73% ± 0.21% to -3.98% ± 0.76%) in women lactating at least 4 months. During the same time, cortical vBMD at the ultradistal tibia decreased in women lactating 4-8.9 months (-0.26% ± 0.08%) and 9 months or longer (-0.49% ± 0.10%). At 12 months postpartum, cortical thickness (≥ 9 mo, -2.48% ± 0.41%) and trabecular thickness (4-8.9 mo, -2.14% ± 0.92%; ≥ 9 mo, -2.56% ± 1.21%) also were lower than baseline. No decreases were found in women lactating less than 4 months or in controls in these parameters. At 18 months postpartum, both cortical vBMD (≥ 9 mo, -0.77% ± 0.17%) and trabecular thickness (4-8.9 mo, -2.25% ± 1.25%; ≥ 9 mo, -3.21% ± 1.41%) were lower in women with long lactation.

CONCLUSIONS

Decreases in cortical vBMD, thickness, and trabecular thickness at the ultradistal tibia were found in women lactating 4 months or longer. Longer follow-up is needed to confirm whether women with extended lactation recover fully or whether the changes could potentially lead to an increased risk of fracture in later life.