National Food, Nutrition, and Physical Activity Survey of the Portuguese General Population (2015-2016): Protocol for Design and Development

Exploring dietary patterns and their association with environmental sustainability and body mass index in children and adolescents: Insights from the National Food, Nutrition and Physical Activity Survey 2015-2016

OBJECTIVE

To adapt four dietary patterns for children and adolescents, and study their associations with sustainability (greenhouse-gas emissions-GHGE and land use-LU), and health (body mass index-BMI) indicators.

RESEARCH METHODS & PROCEDURES

Dietary intake of children (3-9y) and adolescents (10-17y) from the National Food, Nutrition and Physical Activity Survey 2015-2016, Portugal (n = 1153) was assessed through two non-consecutive interviews: one-day food diaries (children), and 24-h recalls (adolescents), using an automated multiple-pass method, including a picture book for portion sizes estimation. Adherence to the Eat-Lancet and World Health Organization (WHO) recommendations, Mediterranean and Atlantic diets were evaluated using adapted versions for pediatrics of the World Index for Sustainability and Health (WISH), Diet Quality Index (DQI), Mediterranean Diet Score (MDS) and Southern-European Atlantic Diet (SEAD), respectively. Diet-related GHGE and LU were estimated using the SHARP-Indicators database. BMI (measured) z-scores were classified according to WHO criteria. A standardized weighted health-sustainability composite index was created (BMI + 0.5*GHGE+0.5*LU). Adjusted linear regression models were computed.

RESULTS

WISH, DQI, MDS, and SEAD had weighted mean scores (range) of 50 (0-130), 24 (9-36), 20 (8-32), and 17 (8-32), respectively. All dietary patterns were associated with lower environmental impact, particularly in children, but not with BMI. Only MDS explained both health and sustainability indicators in childhood (composite index: sd.β = -0·223,95%CI:-0·347,-0·072,R2 = 25.1 %), and adolescence (composite index: sd.β = -0·159,95%CI:-0·315,-0·003,R2 = 31.3 %).

CONCLUSION

The Mediterranean diet was the most related to (higher) environmental sustainability and (lower) BMI. However, in children (not adolescents), the WISH, DQI, and SEAD showed then same associations.

Association between calcium intake from different food sources during childhood and cardiometabolic risk on adolescence: The Generation XXI birth cohort

BACKGROUND

Calcium intake has been associated with lower adiposity, but few studies explored the longitudinal relation of calcium from different sources and cardiometabolic markers in young population.

OBJECTIVE

Prospectively estimate the association between dairy and non-dairy calcium intake at 4, 7, and 10 years (y) of age and cardiometabolic risk at 13 y.

METHODS

The sample included 4017 participants from the Generation XXI birth cohort. Dietary data were collected from a 3-day food diary. Cardiometabolic clusters at 13 y were estimated by a probabilistic Gaussian mixture model (z-score of waist circumference [WC], HOMA-IR; HDL cholesterol, triglycerides, and systolic blood pressure [BP]). Multivariable linear and logistic regression models were used to estimate associations.

RESULTS

Calcium intake (/100 mg), after adjustment for confounders, was negatively and significantly associated with body mass index (BMI) (β = -0.02, 95% CI: -0.04; -0.01), WC (cm) (β = -0.23, 95% CI: -0.36; -0.11), and diastolic BP (mmHg) (β = -0.14, 95% CI: -0.26; -0.03). After additional adjustment for total energy intake, associations lose statistical significance. Calcium intake from milk at 7 y was inversely associated with WC (β = -0.25, 95% CI: -0.48; -0.03) and from yogurt at 10 y was associated with higher BMI (β = 0.08, 95% CI: 0.03; 0.13) and WC (β = 0.54, 95% CI: 0.12; 0.96). Calcium from vegetables at 4, 7, 10 y reduces later cardiometabolic risk (OR = 0.71; OR = 0.84; OR = 0.98, respectively).

CONCLUSIONS

This study supports a protective effect of calcium on adolescents' cardiometabolic health, especially from vegetables.

Combined mediterranean diet-based sustainable healthy diet and multicomponent training intervention impact on plasma biomarkers and metabolome in older adults

BACKGROUND AND AIMS

Healthy dietary patterns and exercise practices have been associated with improved metabolic and inflammatory profiles. However, studies regarding the combined effect of these interventions on plasma biomarkers and metabolome in older adults are sparser. The primary aim of this study was to investigate the impact of a combined Mediterranean Diet-based Sustainable Healthy Diet (SHD) and Multicomponent Training (MT) intervention on the plasma biomarkers and metabolome and how dietary intake and exercise could modulate these effects.

METHODS

SHD intervention included a weekly supply of Mediterranean Diet-based SHD food and four nutrition sessions involving a Mediterranean-Diet culinary workshop, and the exercise program included 50-min MT group sessions, held three times a week, lasting both 12 weeks. Plasma biomarkers were obtained through standard biochemical analysis. A proton (1H) nuclear magnetic resonance (NMR) spectroscopy-based metabolomics approach was used to study the metabolome in blood plasma. Repeated measures ANOVA were performed and adjusted for confounders.

RESULTS

SHD + MT intervention significantly decreased HDL-C and calcium. SHD + MT showed some changes in common with the SHD and MT group, namely a significant decrease in citrate levels (p = 0.009 for SHD + MT; p = 0.037 for SHDT) and an increase in pyruvate (p < 0.001 for MT and SHD + MT). The SHD + MT group also revealed specific changes in the levels of some amino acids (decrease in alanine, glutamine and lysine: p = 0.026; p < 0.001; p = 0.038, respectively). Increases in formate (p = 0.025) and unsaturated lipids (p = 0.011) are consistent with changes in energy and lipoprotein metabolism.

CONCLUSION

Our data show that a combined lifestyle intervention program, including a Mediterranean Diet-based SHD and MT, could modulate biomarker and metabolome and there seems to be a metabolic path associated to these interventions in older adults. Due to its wide-ranging relevance, it is pertinent to assess to what extent combined SHD and MT can contribute to better clinical profiles.

Inadequate intakes of fatty acids attributed to the ultra-processed foods consumed by Portuguese population: The upper project

BACKGROUND AND AIMS

Population-based studies suggest an inverse relationship between the dietary share of ultra-processed foods (UPF), as defined by NOVA classification, and the overall dietary nutritional quality. However, few studies have evaluated the impact of ultra-processed foods on the fatty acid profile of the diet. The aim of this study was to assess the association between consumption of UPF and the fatty acids profile of the diet in Portugal.

METHODS AND RESULTS

Cross-sectional data from IAN-AF 2015-2016 were used for this study. Food consumption data were collected through two 24-h food recalls, and food items were classified according to the NOVA system. For both adults and elderly, the contents of total fatty acids (TFA), saturated fatty acids (SFA) and trans fatty (TRFA) were higher in the fraction of UPF, compared to the other three NOVA groups, while [monounsaturated fatty acids (MUFA)+, polyunsaturated fatty acids (PUFA)/SFA] ratio was lower. The UPF population attributable fraction (PAF) demonstrated that if the dietary contribution of UPF was reduced to levels observed in the first quintile, statistically significant reductions in the prevalence of inadequate intakes of fatty acids would be observed for adults [TRFA (PAF 98.37%, 95% CI 87.27-99.79) and SFA (PAF 37.26%, 95% CI 25.46-47.19)] and for elderly [TRFA (PAF 94.61%, 95% CI 77.59-98.71) and PUFA (PAF 98.28, 95% CI 48.22-99.94)].

CONCLUSIONS

In this study the consumption of UPF was associated with a worse fatty acids profile in the Portuguese diet, adding evidence regarding the negative impact of UPF on diet quality.

Clean-label products: Factors affecting liking and acceptability by Portuguese older adults

Consumers are preferring more "natural" foods, made of "healthier" and "familiar" components - the "clean-label" trend. As the population ages, understanding the older adult consumer segment becomes increasingly important. This study aims to identify the factors influencing the acceptability and liking of clean-label products in older adults living in the community. A convenience sample of 100 older adults was used for this cross-sectional study. Socio-demographic data, health status, independence level, lifestyle characteristics, nutritional status, and food and nutrient intake data were collected. The acceptability and liking for clean-label products comprised two parts: Sensory analysis with overall liking evaluation of three pairs of products, using a 9-point hedonic scale and free comments; Willingness to eat and preference assessment of nine pairs of products using the Food Action scale and a simple preference test. The participants were 80% female with a mean age of 75 years old. The overall liking for clean-label versions of cookies and mayonnaise was lower than for traditional versions. However, participants were more willing to eat the clean-label versions of products, particularly ham and yogurt. Most of the participants would prefer buying the clean-label version of all nine pairs of products, especially for ham, loaf bread, sausages, and yogurt. In sum, older adults living in the community exhibit a lower liking but, a greater willingness to eat and a higher preference for buying clean-label products. Older adults who favor clean-label products have higher levels of education and are reported to have a more adequate diet.

Compliance with the 24-h Movement Guidelines for Portuguese children: differences between boys and girls

The 24-h Movement Guidelines for children recommend at least 60 min per day of moderate-to-vigorous intensity physical activity (PA), ≤ 2 h/day of screen time, and 9-11 h/day of sleep for children. Since little information is available on the 24-h Movement Guidelines in Portuguese children, this research attempts to know the proportion of Portuguese children meeting individual and combinations of these 24-h Movement Guidelines. Another aim of this study is to test sex differences in compliance with 24-h Movement Guidelines. A final sample of 1351 Portuguese children (51.4% girls, aged 7.65 ± 1.21) participated in this cross-sectional study. PA, screen time and sleep duration were parent-reported through a questionnaire. Only 3.7% of children met all three 24-h Movement Guidelines, whereas 11.9% met none. Although boys showed greater compliance with PA recommendations and girls with screen time recommendations, no significant sex differences were found in the compliance of all three 24-h Movement Guidelines. Given that 96.3% of Portuguese children did not meet 24-h Movement Guidelines, promoting these three movement behaviours in both boys and girls is crucial to encouraging positive consequences early.

Eating out of home in Portugal: characterisation and effects on dietary intake

This cross-sectional study aims to describe and compare energy, nutrient intake and food consumption according to eating location and by age groups using data from the National Food, Nutrition and Physical Activity Survey (IAN-AF 2015/2016). Dietary intake was estimated by two non-consecutive days of food diaries (children)/24-h recalls (other age groups), and four eating location categories were defined according to the proportion of meals consumed at out-of-home locations: Home (at least 80 % of meals at home), Other Homes, School or Work and Restaurants and Other Places. The majority of meals (69·1 %) were consumed at home. Meals were also often taken at school by children and adolescents and in restaurants and similar outlets by adults and elderly. Children and adolescents in the School or Work category ate more fruit, vegetables and pulses and cereals and starchy tubers, whereas adults in this category ate more red and processed meats, sugar-sweetened beverages and sweets. Compared with Home category, Restaurants and Other Places was associated with worse diet adequacies among children (β = -1·0; 95 % CI = -2·0, -0·04), adolescents: (β = -2·4; 95 % CI = -3·2, -1·5) and adults (β = -1·3; 95 % CI = -1·6, -1·0) reflecting higher intakes of energy, fat, trans-fatty acids and SFA, and Na. The elderly consumed more free sugars and fat when eating out of home in general. Overall, findings reflect important variation in nutrient profiles by eating location, with meals taken at school or work contributing to higher consumption of nutrient-dense foods and those taken in restaurants and other similar settings implying higher consumption of energy-dense foods.

Associations between chronotype, diet quality and timing of energy intake in Portuguese children and adolescents: The potential role of summer holidays

Later chronotypes may be associated with lower diet quality and later timing of energy intake in paediatric age. Period of data collection of these variables may affect these parameters and inter-relationship. We aimed to assess the cross-sectional association of chronotype with a diet quality score (HEI) and caloric midpoint (time of achieving 50% of total daily energy intake), considering summer holidays, using data from the National Food, Nutrition and Physical Activity Survey 2015-2016 for 578 participants (6-14 years of age). Chronotype was estimated by the midpoint of sleep and categorized as Early, Intermediate and Late, using physical activity diaries, while outcomes using two food diaries/24 h recalls. Associations of chronotype with outcomes were assessed by linear regressions adjusted for sex, age, parental education (model 1), BMI, sports practice (model 2), and summer holidays (no/yes) (model 3). In model 2, a Late vs. Early chronotype was negatively associated with HEI (β ˆ = -0.74; 95% CI: -1.47, -0.07) and positively with caloric midpoint (β ˆ = 0.35; 95% CI: 0.02, 0.69). However, associations lost significance in model 3. The association between chronotype and dietary habits may be benefit from being studied considering school terms and summer holidays. Future larger prospective studies are needed to clarify the role of summer holidays on this inter-relationship.

Cross-continental national nutrition surveys: a narrative review

Many countries use national nutrition surveys (NNSs) to assess their population's health and nutrition needs. However, NNS aims, approaches, tools, and measurements vary among countries. To date, there has been no review evaluating the NNSs and their practices worldwide to help conduct future NSSs. Therefore, this narrative review was conducted to 1) explore and tabulate current NNSs in five continents (Asia, Europe, Africa, North America, and Australia) and 2) help lay the foundation for establishing clear guidelines for future NNSs. The NNSs were identified using two approaches. First, an electronic database search was conducted with key terms in PubMed database. Second, a general web-based search on the survey webpages of governmental organizations was conducted using the same key terms to identify eligible surveys. The review included general adult population (≥ 18 years) with a cross-sectional design, excluding NNSs related to household-only surveys, specific age groups, or insufficient sample sizes. A total of 41 NNSs were identified in 37 countries across four continents: Asia (n = 15), Europe (n = 21), North America (n = 3), and Australia (n = 2). Broad differences between the surveys were identified, including survey purposes and designs, definitions of geographic areas and target groups, and dietary assessments. Currently, there are 26 ongoing NNSs, while 15 have ended. Among the ongoing NNSs, the cycles of the surveys were either at regular intervals (n = 8) or irregular intervals (n = 8). Of the 41 surveys, 24-h dietary recalls were used in 27 surveys, while only 6 surveys used diet diaries and 8 surveys relied on FFQs. Some surveys (n = 17) utilized multiple tools to assess dietary intake. Most of the surveys that assessed biochemical status (n = 12) focused on blood glucose, haemoglobin A1c (HbA1c), and lipid status, whereas some surveys (n = 6) tested for vitamin and mineral status in blood and/or urine samples. The review identified key characteristics, time frames, sampling methods, and dietary and physical assessment methods obtained from different surveys worldwide. The information organized in this review will be important for researchers, policymakers, and public health programme developers in developing and improving NNS.

Exploring tea and herbal infusions consumption patterns and behaviours: The case of Portuguese consumers

Consumption of tea and herbal infusions (THIs) have a long history in traditional medicine and cultural practices. The health-promoting benefits attributed to THIs are considered influential factors in consumer choices. However, there is limited data on consumer choices and attitudes that might interfere with the positive effects associated with THIs consumption. The aim of this study was to investigate the consumption pattern and behavior of THIs consumers in Portugal, assessing the influence of socio-demographic factors on the selection of THIs products and consumer practices related to these beverages. An online survey was conducted, and from the collected data, 720 responses met the aim of the study and were further analyzed. Most of the respondents were female, 74.4%, belonging to the 40-60 age group (40.6%) and were medium consumers of THIs (47.2%). Green tea was the most consumed type among participants, and its consumption was associated not only with age but also with the pattern of THIs consumption. Despite that, participants preferred herbal infusions, with citronella, chamomile, and lemon verbena being the most consumed types. For certain types of herbal infusions, consumption was associated with age, while other types were preferred by moderate or heavy consumers. Most participants purchased THIs in supermarkets, registered trademark and brand stores, in the form of THIs bag. Light consumers use only bag, while medium/heavy consumers indicated the use of other forms. Almost half of the respondents admitted to not reading the information on product labels before consumption and using THIs after the expiry date, while only one-third of them declared paying attention to the label instructions. This study revealed the impact of socio-demographic factors as age on the consumption patterns and preferences of THIs of consumers. Of concern is the neglect of label usage among Portuguese consumers. This emphasizes the urgency of implementing interventions to guide proper label use and promote good consumption practices to ensure the quality of THIs products.

Mediterranean Diet Favors Vitamin K Intake: A Descriptive Study in a Mediterranean Population

The Mediterranean diet (MD) is associated with improved longevity and the prevention and management of chronic inflammatory diseases (CIDs). Vitamin K, which is present in MD core components such as leafy green vegetables, is also known as a protective factor for CIDs. Estimates of vitamin K intake in Mediterranean settings are still scarce, and the association between MD and vitamin K intake is yet to be established. This study analyzed vitamin K intake and MD adherence in the Algarve region, in Portugal. We conducted a cross-sectional study in a nonrandom sample of adults using an online questionnaire which included a validated food-frequency questionnaire and a screener for MD adherence. A total of 238 participants were recruited (68% women and 32% men). Adherence to the MD was low (11%). Only 10% of the participants had vitamin K intake below the adequate intake. Adherence to the MD was positively correlated with vitamin K intake (r = 0.463; p < 0.001) and age (r = 0.223; p < 0.001). Our findings underscore the importance of promoting adherence to the MD for optimal vitamin K intake, and future research should focus on developing effective interventions to promote this dietary pattern, particularly among younger individuals and men.

Early feeding and nutritional status of Portuguese children in the first 36 months of life: EPACI Portugal 2012-a national representative cross-sectional study

Background

Early feeding practices have a critical role in the future not only in health but also in modulating eating habits. This study aimed to assess breastfeeding and complementary feeding practices and the nutritional status of Portuguese toddlers aged 0-36 months.

Methods

EPACI Portugal 2012 is a cross-sectional study of a national representative sample. Trained interviewers collected data about early feeding practices and anthropometrics. Body mass index was classified according to World Health Organization criteria. Frequencies and survival analysis were used to characterize variables.

Results

More than 90% of children were initiated breastfeeding, around 20% were exclusively breastfed for six months, and about 20% were breastfed at 12 months while complementary feeding was taking place. Exclusive breastfeeding was determined by maternal prepregnancy body mass index (HR 1.01; 95% CI 1.00, 1.03, P=.03) and low birth weight (HR 1.61; IC 95% 1.21, 2.15, P=.001) of the infants. About 90% were initiated complementary feeding between four and six months, and almost 10% were introduced to cow's milk before 12 months. In the second year of life, 83.2% and 61.6% of toddlers have already consumed nectars and sweet desserts, respectively. About one-third of Portuguese toddlers showed a body mass index z-score >1, and 6.6% were overweight/obese (z-score >2). No association was found between the duration of breastfeeding or timing of complementary feeding and the body mass index z-score in children.

Conclusions

Despite the low prevalence of exclusive breastfeeding at six months, Portuguese infants effectively comply with dietary recommendations during the first year of life. The transition to the family diet must be carefully made. There is a high prevalence of Portuguese toddlers at least at overweight risk. The duration of breastfeeding or timing of complementary feeding was not associated with the expression of overweight/obesity.

Consumer Knowledge about Dietary Relevance of Fruits and Vegetables: A Study Involving Participants from Portugal and France

Fruits and vegetables are recommended as low-calorie foods that contribute to the proper intake of necessary micronutrients, macronutrients, and bioactive compounds with health benefits. However, the recommendations for the dietary intake of these foods fail to be attained in most European countries. For this reason, promoting more knowledge about the health effects of fruits and vegetables is essential to decrease the incidence of chronic diseases. This study was conducted to investigate the knowledge of the health benefits of fruits and vegetables among the population of Portugal and France. The present work involved a questionnaire survey of 639 participants (257 from Portugal and 382 from France). The results revealed that most participants were young females (68.9%) with good education (76%) and an average weight range. They consumed a varied diet (57%) but had body dissatisfaction (63.2%). The respondents had good knowledge about the health effects of fruits and vegetables. However, the French population knew more about the theme than the Portuguese. Portuguese individuals were more likely to have incomplete information. Gender and education significantly influenced knowledge levels, with females and highly educated individuals demonstrating greater understanding. Dissatisfaction with body weight drives individuals to seek nutrition information. This investigation enhances our comprehension of the factors that affect knowledge of vegetable and fruit consumption among young adults in Portugal and France. Moreover, it highlights the importance of implementing focused educational programs to enhance nutrition literacy, particularly for less-aware demographic groups. Going forward, a more in-depth analysis of these factors could assist in creating more efficient strategies to encourage healthier dietary habits and improve nutrition literacy among these communities.

Empowering frail older adults: multicomponent elastic-band exercises and BCAA supplementation unleash physical health and preserve haematological biomarkers

The effectiveness of Branched Chain Amino Acids (BCAAs) supplementation on enhancing exercise performance in both young and older adults remains a topic of debate. Recent research suggests that BCAAs combined with regular exercise might have an impact on human erythropoiesis, blood dynamics, and iron homeostasis. Given the increasing longevity of the global population, it is crucial to investigate the potential benefits of BCAA supplementation and regular exercise as non-pharmacological interventions for improving the overall health of frail older adults. To assess the influence of a 40-week multicomponent exercise intervention (MEP) combined BCCA supplementation on the haematological indicators of frail older adults (83-93 years old) residing in nursing homes. A prospective, naturalistic, controlled clinical trial employing an intervention-washout-intervention was conducted for this purpose. The study included four experimental groups: MEP plus BCAA supplementation (MEP + BCAA, n = 8), MEP only (n = 7), BCAA supplementation only (n = 7), and control group non exercising (CG, n = 13). Fried's physical frailty (PF) protocol was employed to stratify the participants. Additionally, the assessment included the evaluation of nutritional status, comorbidities, and anthropometric measurements. Among the several haematological markers examined, only mean cellular Haemoglobin Concentration (MCH) [F = 4.09; p < 0.03] and Mean Cell haemoglobin Concentration (MCHC) [F = 10, 323; p < 0,0001] showed significant effects of time group. Our findings demonstrate that a long-term intervention with BCAA plus MEP did not lead to significant alterations in the haematological profile. An 8-week withdrawal from interventions did not affect the frailty status in the MEP and MEP + BCAA groups, whereas the control group exhibited an increase in PF status. The findings, demonstrating the potential pro-immune effect and maintenance of MCH and MCHC levels, highlight the relevance of incorporating exercise and nutritional strategies to promote healthy aging. This study contributes to the achievement of the United Nations Sustainable Development Goals 3 (good health and well-being) and 10 (reduced Inequalities) for all.

Food insecurity is associated with an unhealthy lifestyle score in middle- and older-aged adults: findings from the EPIPorto cohort

The association of food insecurity with the combined effect of lifestyles is still limited. This study evaluated the association between food insecurity and a lifestyle score in middle- and older-aged adults. A cross-sectional study (2013-2016) was performed among 595 individuals (≥ 50 years) from the EPIPorto cohort (Porto, Portugal). Food security status was assessed using the US Household Food Security Survey Module: Six-Item Short Form. Information on fruit and vegetable consumption (F&V), physical activity (PA) practice, tobacco smoking, and alcohol consumption were included in a lifestyle score. Those with F&V < five portions/day, < 150 min/week of moderate-intensity PA or < 75 min/week of vigorous-intensity PA, current smokers, consumers of > one drink of alcoholic beverages in women, and > two in men were assigned with one point; all the others had nil points. The score could range from 0 to 4, and was further categorised into three categories. Food insecurity was positively associated with an unhealthy lifestyle profile (OR = 2.272; 95%CI:1.079-4.782), independently of the adjustment variables. Analysing each lifestyle component, food insecurity was associated with low PA practice (OR = 2.365; 95%CI:1.020-5.485). Individuals from food insecure households were more likely to have an unhealthy lifestyle profile. Public health strategies should be developed among food insecure individuals to promote healthy lifestyles.

Ultra-processed food consumption deteriorates the profile of micronutrients consumed by Portuguese adults and elderly: the UPPER project

PURPOSE

This study aims to describe micronutrient intake according to food processing degree and to investigate the association between the dietary share of ultra-processed foods and micronutrient inadequacies in a representative sample of Portuguese adult and elderly individuals.

METHODS

Cross-sectional data from the National Food, Nutrition and Physical Activity Survey (2015/2016) were used. Food consumption data were collected through two 24-h food recalls, and food items were classified according to the NOVA system. Linear regression models were used to assess the association between the micronutrient density and the quintiles of ultra-processed food consumption-crude and adjusted. Negative Binomial regressions were performed to measure the prevalence ratio of micronutrient inadequacy according to ultra-processed food quintiles.

RESULTS

For adults, all evaluated vitamins had significantly lower content in the fraction of ultra-processed foods compared to unprocessed or minimally processed foods, except vitamin B2. For the elderly, out of ten evaluated vitamins, seven presented significantly less content in ultra-processed foods compared to non-processed ones. The higher energy contribution of ultra-processed foods in adults was associated with a lower density of vitamins and minerals. This association was not observed in the elderly. For adults, compared with the first quintile of ultra-processed food consumption, the fifth quintile was positively associated with inadequate intakes of vitamin B6 (PR 1.51), vitamin C (PR 1.32), folate (PR 1.14), magnesium (PR 1.21), zinc (PR 1.33), and potassium (PR 1.19).

CONCLUSION

Our results corroborate the importance of public health actions that promote a reduction in the consumption of ultra-processed foods.

Meat or meatless meals at lunch and dinner – exploring the associated factors and transition between meals

This study aimed to explore the factors associated with the consumption of meat vs. meatless meals and to assess the applicability of a multi-state model to describe transitions between lunch and dinner. Fifteen thousand four hundred and eight main meals (lunch and dinner) from a sample of adults (18-84 years, n = 3852) from the Portuguese Food, Nutrition and Physical Activity Survey (IAN-AF 2015-2016) were categorised as meat, fish, ovolactovegetarian or snack. Adjusted generalised-mixed-effects models were used to explore the associations and a time-homogeneous Markov-multi-state model was applied to study the transitions. Women, older and higher educated individuals presented higher odds of consuming meatless meals and lower hazard of transitioning to meat in the following main meal. Strategies for replacing meat with more sustainable foods should be specific towards different population groups. Studying transitions across main meals, using multi-state models, can support the development of feasible, realistic and group-specific strategies to replace meat and promote dietary variety.

Jordan's Population-Based Food Consumption Survey: Protocol for Design and Development

BACKGROUND

One of the factors influencing health and well-being is dietary patterns. Data on food consumption are necessary for evaluating and developing community nutrition policies. Few studies on Jordanians' food consumption and dietary habits at various ages have been conducted, despite the increased prevalence of overweight, obesity, and chronic diseases. This will be the first study focusing on Jordanians' food consumption patterns that includes children, adolescents, adults, and older adults.

OBJECTIVE

This cross-sectional study aims to describe the design and methodology of the Jordan's Population-based Food Consumption Survey, 2021-2022, which was developed to collect data on food consumption, including energy, nutrients, and food group intake, from a representative sample of Jordanians and to determine the prevalence of overweight and obesity and their relationship to food consumption.

METHODS

Participants were selected by stratified random sampling, using the Estimated Population of the Kingdom by Governorate, Locality, Sex, and Households, 2020 as the sampling frame. The food consumption survey sample was at the population level, representing gender and age classes (8-85 years old). The data collection period was 6 months. Food consumption was assessed using 24-hour dietary recall (2 nonconsecutive days, 1 week apart) interviews representing weekdays and weekends. In addition to data on food consumption, information on the use of food supplements, sociodemographic and socioeconomic status, and health was gathered. Weight, height, and waist circumference were all measured.

RESULTS

The survey included 632 households with 2145 participants, of which 243 (11.3%) were children, 374 (17.4%) were adolescents, 1428 (66.6%) were adults, and 99 (4.6%) were older adults. Three food consumption databases were used to stratify the mean 24-hour dietary recall food consumption into energy intake, carbohydrates, proteins, fats, fiber, vitamins and minerals, and food groups. BMI was calculated and classified as normal, overweight, or obese. Central obesity was classified as normal or abnormal based on the waist-to-height ratio. The survey results will be disseminated based on age, energy, nutrient, and food group consumption. The prevalence of overweight and obesity by age group will be presented, as well as a comparison to the situation in Eastern Mediterranean countries.

CONCLUSIONS

The survey data will be helpful in nutritional studies, assessing changes in dietary patterns, and developing and evaluating nutrition or health policies. It will be a solid base for developing a future national surveillance system on food consumption patterns with comprehensive food consumption, physical activity, biochemical, and blood pressure data.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41636.

Multidimensional Health Impact of Multicomponent Exercise and Sustainable Healthy Diet Interventions in the Elderly (MED-E): Study Protocol

Data concerning the combined effect of diet and exercise interventions on overall health in the elderly are scarce. The MED-E project's primary aim is to assess the effect of the different 3-month sustainable healthy diet (SHD) and multicomponent training (MT) interventions on several health outcomes in the elderly. A quasi-experimental study assigned older adults into four groups: (1) SHD, (2) MT, (3) SHD + MT, or (4) control group (CG). The SHD intervention included a weekly offer of a mixed food supply and individual and group nutritional sessions on the principles of an SHD. The MT groups were submitted to 50-min exercise sessions three times a week. The primary outcomes were blood biomarkers and metabolic profile alterations that were assessed pre- and post-intervention. Additionally, data on dietary intake and nutritional adequacy, physical fitness, body composition and anthropometry, cognitive function, quality of life, and geographical data were assessed at the same time points. The MED-E project's study protocol and future results will add to knowledge about the importance and beneficial contribution of combined SHD and MT interventions on healthy ageing policies.

Differential Patterns in Motivations for Practicing Sport and Their Effects on Physical Activity Engagement across the Lifespan

This study aims to report what motivates individuals to be physically active, to determine whether motivating factors influence physical activity (PA) levels, and whether this differs across the lifespan. This is a cross-sectional study with 498 individuals: 117 adolescents, 306 adults, and 75 older adults. PA was assessed using Baecke’s questionnaire, and motivating factors for practicing sports were investigated using a scale with twelve questions. The factor analysis identified three motivating factors for sports practice: psychosocial, bodily, and well-being. The scale’s overall reliability and internal consistency indicated a Cronbach’s alpha of 0.885. The analysis of covariance (ANCOVA) adjusted for sex indicated the three factors as having a significant effect on PA (p < 0.050); however, only the well-being factor showed a significant interaction with age groups (p = 0.023, ηp2 = 0.030). Subsequently, the effect of the well-being factor on PA scores in each age group was explored through regression analyses. Only older adults showed a significant association in the unadjusted [OR = 0.378, p = 0.001, R2 = 0.243] and the sex-adjusted analysis [OR = 0.377, p = 0.001, R2 = 0.288]. These results help us to better understand the underlying motivational reasons in different age groups for engaging in sports.

Secular trends in body image dissatisfaction and associated factors among adolescents (2007-2017/2018)

OBJECTIVE

To assess secular trends in body image dissatisfaction and associated factors among adolescents over a 10-year period (2007-2017/2018).

METHODS

The sample included 1,479 (2007, n = 531; 2017/2018, n = 948) high school adolescents of both sexes, aged 14 to 18 years, of schools in a city in southern Brazil, in 2007 and 2017/2018. Data were collected on sex, age, physical activity (IPAQ, short form), anthropometric measurements (body weight, height, and triceps and subscapular skinfolds), and body image dissatisfaction (figure rating scale). The variables were compared with Independent samples t-test and Mann-Whitney U-test. The associations between sex and other variables were examined with chi-square test, and the factors associated with body image were identified with multinomial logistic regression.

RESULTS

Most adolescents were dissatisfied with their body image in 2007 (65,2%) and 2017/2018 (71,1%). The prevalence of body dissatisfaction increased by 9.2% over the 10-year period, particularly dissatisfaction with thinness (21.3%). After stratification by sex, in 2017/2018 sample, dissatisfaction with overweight was 46.1% greater in boys, and dissatisfaction with thinness was 66.9% greater in girls. Factors found to be significantly associated with body image dissatisfaction were physical activity level, and body adiposity.

CONCLUSIONS

There was a secular trend toward increased body image dissatisfaction in both sexes. Future efforts should go beyond scientific production, in public and private environments aimed at increasing awareness of health issues related to body care in the physical, psychological, and environmental domains.

Quantitative risk-benefit assessment of Portuguese fish and other seafood species consumption scenarios

Portugal has high fish/seafood consumption, which may have both risks and benefits. This study aims to quantify the net health impact of hypothetical scenarios of fish/seafood consumption in the Portuguese population using a risk-benefit assessment methodology. Consumption data from the National Food, Nutrition and Physical Activity Survey 2015-2016 (n 5811) were used to estimate the mean exposure to methylmercury and EPA + DHA in the current and the alternative scenarios considered. Alternative scenarios (alt) were modelled using probabilistic approaches to reflect substitutions from the current consumption in the type of fish/seafood (alt1: excluding predatory fishes; alt2: including only methylmercury low-level fishes) or in the frequency of weekly fish/seafood consumption (alt3 to alt6: 1, 3, 5 or 7 times a week, replacing fish/seafood meals with meat or others). The overall health impact of these scenarios was quantified using disability-adjusted life years (DALY). In the Portuguese population, about 11 450 DALY could be prevented each year if the fish/seafood consumption increased to a daily basis. However, such a scenario would result in 1398 extra DALY considering the consumption by pregnant women and the respective risk on fetal neurodevelopment. Our findings support a recommendation to increase fish/seafood consumption up to 7 times/week. However, for pregnant women and children, special considerations must be proposed to avoid potential risks on fetal neurodevelopment due to methylmercury exposure.

Nutritional intake and malnutrition in institutionalised and non-institutionalised older adults

Malnutrition (synonym: undernutrition) is prevalent among older adults, which may be partly related to changes in dietary intake, but evidence on the link between malnutrition and diet is scarce. The aims of this study were to estimate the association between energy/nutrients intake and malnutrition, and to characterise nutritional inadequacy in institutionalised and non-institutionalised older adults. A national survey was conducted including a Portuguese representative sample of nursing home (NH) residents (n 563) and community-dwellers (n 837) aged ≥ 65 years. Data included socio-demographic characteristics, self-reported health, loneliness feelings, nutritional status (Mini Nutritional Assessment^®) and dietary intake (two non-consecutive 24-h recalls). A higher energy intake was associated with lower odds of malnutrition risk (being 'at risk of malnutrition' or 'malnourished') in both settings, but only significant among NH residents after adjusting for confounders (NH: OR = 0·66, 95 % CI 0·50, 0·86; community: OR = 0·64, 95 % CI 0·37, 1·10). The intake of carbohydrates, fat, fibre, vitamin C, Na, K and Mg was inversely associated with malnutrition risk in NH residents, and protein, fat, vitamin B₆, folates, Na, K, Ca and Mg intake in community-dwellers. After additional adjustment for total energy, only Na and Mg intake of community-dwellers remained significantly associated. The prevalence of inadequate nutrient intake was generally higher for the malnutrition risk group, which was particularly evident among community-dwellers. The effect of dietary intake on nutritional status seems more dependent on total energy and carbohydrates intake in institutionalised elders, whereas among community-dwellers protein and some micronutrients appear to have a greater impact.

Interaction effects of socio-economic position in the association between eating location and diet quality in Portuguese children and adolescents: results from the National Food, Nutrition and Physical Activity Survey 2015-2016

This study aims to evaluate the interaction effect of socio-economic environment (SEE) in the relationship between the eating location (EL) and diet quality, in children and adolescents. Data included Portuguese children and adolescents (3-17 years) from a National Dietary Survey Sample (IAN-AF 2015/2016, n 987). Dietary intake was obtained by 2-d food diaries (children) or 2-24-h-recall (adolescents). Participants were classified into four groups of EL: 'Home', 'Other homes', 'School' and 'Restaurants'. Diet quality was measured as a higher adherence to a healthy eating pattern. A previous developed socio-economic classification was used, and participants were grouped as belonging to a low socio-economic environment (LSE) or middle-high socio-economic environment (MHSE). Linear regression models were used to evaluate the association between EL and diet quality, stratified by the SEE. A statistically significant interaction effect was found (P < 0·01) for the SEE in the association between EL and diet quality. After adjustment for potential confounders, in LSE, participants belonging to 'Other homes' (β = -2·07; 95 % CI:-3·70, -0·44) and 'Restaurants' (β = -3·31; 95 % CI: -5·08, -1·54) had lower scores in the diet quality score, comparing to 'Home'. In MHSE, comparing with 'Home', 'Restaurants' showed lower diet quality (β = -1·56; 95 % CI:-2·65, -0·48), while the 'School' had better diet quality (β = 0·90; 95 % CI: 0·16, 1·64). The SEE influences the association between EL and diet quality and, belonging to more disadvantaged SEE, might represent a higher risk of unhealthy eating habits when eating out-of-home.

Modeling the health impact of legislation to limit the salt content of bread in Portugal: A macro simulation study

Background

Excessive salt consumption-associated with a range of adverse health outcomes-is very high in Portugal, and bread is the second largest source. Current Portuguese legislation sets a maximum limit of 1.4 g salt per 100 g bread, but imported and traditional breads are exempted. In 2017 the Ministry of Health proposed reducing the salt threshold to 1.0/100 g by 2022, however the legislation was vetoed by the European Commission on free-trade grounds.

Aims

To estimate the health impact of subjecting imported and traditional breads to the current 1.4 g threshold, and to model the potential health impact of implementing the proposed 1.0 g threshold.

Methods

We gathered bread sales, salt consumption, and epidemiological data from robust publicly available data sources. We used the open source WHO PRIME modeling tool to estimate the number of salt-related deaths that would have been averted in 2016 (the latest year for which all data were available) from; (1) Extending the 1.4 g threshold to all types of bread, and (2) Applying the 1.0 g threshold to all bread sold in Portugal. We used Monte Carlo simulations to generate confidence intervals.

Results

Applying the current 1.4 g threshold to imported and traditional bread would have averted 107 deaths in 2016 (95% CI: 43-172). Lowering the current threshold from 1.4 to 1.0 g and applying it to all bread products would reduce daily salt consumption by 3.6 tons per day, saving an estimated 286 lives a year (95% CI: 123-454).

Conclusions

Salt is an important risk factor in Portugal and bread is a major source. Lowering maximum permissible levels and removing exemptions would save lives. The European Commission should revisit its decision on the basis of this new evidence.

The influence of item order of the Household Food Security Survey Module on the assessment of food insecurity in households with children

OBJECTIVE

Changes in the item order of the US Household Food Security Survey Module (USHFSSM) were performed throughout time. This study aimed to compare the psychometric properties of the general and specific factors of the 2000 and 2012 versions of the USHFSSM to measure the construct of food insecurity in two Portuguese samples of households with children.

DESIGN

Cross-sectional.

SETTING

Portugal.

PARTICIPANTS

An adaptation of the 2000 version was applied to 839 adults (from households with children aged 7-17 years) from the National Food, Nutrition and Physical Activity Survey 2015-2016, while the 2012 version was used among 2855 families from the Generation XXI birth cohort.

RESULTS

The 2000 version showed to have a stronger ωh than the 2012 version (0·89 v. 0·78 for the general factor), as well as eigenvalues higher than 1 for the general factor (eigenvalues equal to 9·54, 0·97 and 0·80, for the general factor, specific factor 1 and specific factor 2, respectively), while the 2012 version had also the contribution of specific factors to explain food insecurity (eigenvalues equal to 9·40, 2·40 and 1·20, for general factor and specific factors 1 and 2, respectively). Good internal consistency (ωt = 0·99, for both versions) was obtained.

CONCLUSIONS

In conclusion, the 2000 and 2012 versions of the USHFSSM showed good psychometric properties; however, the 2000 version has stronger general factor, while the 2012 version also has the contribution of specific factors.

The effect of non-participation on the prevalence of food insecurity in a population-based cohort in Portugal

Non-participation can be a source of selection bias. We evaluated the effect of non-participation on food insecurity prevalence among 2942 young adults from the EPITeen cohort (Portugal), which we have followed since assembling the cohort in 2003-2004. We conducted a cross-sectional study when the cohort participants were 26 years old. To examine the effect of non-participation, we statistically imputed the missing data on food security status using multivariate imputation by chained equations based on characteristics associated with food insecurity, specifically household income perception, education and household structure from 21 or 24 years of age follow-ups. In our cohort, non-participation caused ~ 2% difference in the food insecurity prevalence: 11.0% (95% CI 9.0-13.0) for 954 participants and 12.6% (95% CI 11.1-14.1) after imputation. These estimates are close to evidence from other European countries and sustain the relevance of developing public health interventions to promote food security, especially considering the negative nutritional and health outcomes associated with food insecurity.

earlyMYCO: A Pilot Mother-Child Cohort Study to Assess Early-Life Exposure to Mycotoxins—Challenges and Lessons Learned

Early-life exposure occurs during gestation through transfer to the fetus and later, during lactation. Recent monitoring data revealed that the Portuguese population is exposed to mycotoxins, including young children. This study aimed to develop a pilot study to assess the early-life exposure to mycotoxins through a mother–child cohort, and to identify the associated challenges. Participants were recruited during pregnancy (1st trimester) and followed-up in three moments of observation: 2nd trimester of pregnancy (mother), and 1st and 6th month of the child’s life (mother and child), with the collection of biological samples and sociodemographic and food consumption data. The earlyMYCO pilot study enrolled 19 mother–child pairs. The analysis of biological samples from participants revealed the presence of 4 out of 15 and 5 out of 18 mycotoxins’ biomarkers of exposure in urine and breast milk samples, respectively. The main aspects identified as contributors for the successful development of the cohort were the multidisciplinary and dedicated team members in healthcare units, reduced burden of participation, and the availability of healthcare units for the implementation of the fieldwork. Challenges faced, lessons learned, and suggestions were discussed as a contribution for the development of further studies in this area.

Dietary exposure to artificial sweeteners and associated factors in the Portuguese population

This study aimed to evaluate the risk of the Portuguese population's exposure to six non-nutritive intense sweeteners (NNIS) and their main associated factors. A tiered approach was used to estimate the usual exposure to the NNIS obtained from two 1-day food diaries among children and two 24-hour recalls among adults in the Portuguese national dietary survey (IAN-AF 2015-2016; age: 3-84 y; n = 5005). The tiers considered were the following: Tier 2.1 represents the most conservative tier, in which all foods reported were matched with the respective maximum permitted levels (MPLs); in Tier 2.2, the MPLs were attributed only to the foods for which the brand's label information identified the presence of an added NNIS; finally, Tier 3 was identical to Tier 2.2, but analytical NNIS occurrence data were used, instead of MPLs. The usual exposure of the Portuguese population to each NNIS was very low in all tiers across all age groups, as was the estimated prevalence of exposure above the acceptable daily intake. Soft drinks were the main source of exposure for most sweeteners, and acesulfame K and aspartame were the most consumed NNIS. The odds of exposure to at least one NNIS were higher in more highly educated adults and elderly, obese elderly, women, and people with lower healthy diet scores. The estimated risk of exceeding the safety levels of NNIS intake was very low in all evaluated population groups, even when considering the most conservative approach.

A review of harmonization methods for studying dietary patterns

Data harmonization is the process by which each of the variables from different research studies are standardized to similar units resulting in comparable datasets. These data may be integrated for more powerful and accurate examination and prediction of outcomes for use in the intelligent and smart electronic health software programs and systems. Prospective harmonization is performed when researchers create guidelines for gathering and managing the data before data collection begins. In contrast, retrospective harmonization is performed by pooling previously collected data from various studies using expert domain knowledge to identify and translate variables. In nutritional epidemiology, dietary data harmonization is often necessary to construct the nutrient and food databases necessary to answer complex research questions and develop effective public health policy. In this paper, we review methods for effective data harmonization, including developing a harmonization plan, which common standards already exist for harmonization, and defining variables needed to harmonize datasets. Currently, several large-scale studies maintain harmonized nutrient databases, especially in Europe, and steps have been proposed to inform the retrospective harmonization process. As an example, data harmonization methods are applied to several U.S longitudinal diet datasets. Based on our review, considerations for future dietary data harmonization include user agreements for sharing private data among participating studies, defining variables and data dictionaries that accurately map variables among studies, and the use of secure data storage servers to maintain privacy. These considerations establish necessary components of harmonized data for smart health applications which can promote healthier eating and provide greater insights into the effect of dietary patterns on health.

Sugar-sweetened beverages, effects on appetite and public health strategies to reduce the consumption among children: a review

Sugar-sweetened beverages (SSBs) consumption have been of public health concern and a target of interventions due to their high consumption and burden in health-related consequences, particularly in children and adolescents. SSBs provide high energy intake with low nutritional value and are a major contributor for added and free sugars intake of Portuguese in all age-groups, especially adolescents. Despite its recognized effect on weight gain, it might also disrupt appetite regulation. Research on the effect of SSBs on appetitive traits is still scarce and unclear, and the current knowledge of these potential effects will be discussed in this review. This review also aims to describe public health strategies implemented to decrease SSBs consumption among children, particularly in Portugal, such as: (i) implemented taxation measures and its impact in sales and in preventable cases of disease and death, (ii) marketing regulations applied to children and adolescents, and ultimately (iii) the intention of application of a single Front-of-Package labeling system in all countries, aiming to increase consumers’ food literacy.

Active and sedentary behaviors in youth (6–14 years old): Data from the IAN-AF survey (2015–2016)

Background:

Strategic health interventions must be guided by effective surveillance systems that monitor population trends and patterns, therefore we aimed to provide youth's (6–14 years) national prevalence estimates of physical activity (PA), active outdoor play (AOP), sedentary behaviur (SB), and structured PA (SPA).

Methods:

Measures of moderate-to-vigorous PA, SB, AOP, and SPA, were obtained for 719 participants in 2 groups (6–9 and 10–14 years) using diaries and questionnaires. National estimates were calculated, by sex, region, and parental education.

Results:

While 54% (95%CI: 47.4–61.3) of youth meet PA recommendations, the prevalence is lower for the older group (P = .034). Similarly, AOP decreases with age both on weekends, from 94.3% (95%CI: 90.8–97.8) to 68.7% (95%CI: 62.2–75.1), and on weekdays from 84% (95%CI: 76.5–91.5) to 64.8% (95%CI: 59–70.6). Watching TV for ≥2 h/day is extremely high on weekends [71.3% (95%CI: 65.4–77.2)] and more prevalent in boys than girls on weekdays (P = .043). Higher parental education significantly increased SPA and active time. Time in SB was greater in boys [7.26 h (95%CI: 6.87–7.65)] than girls [6.48 h (95%CI: 6.09–6.87)] and increased with age (P < .001).

Conclusions:

Almost half of the youth failed to achieve PA guidelines, whereas 71% exceeded recommended TV time on weekends, suggesting the urgency of intervention measures.

Increasing Seaweed Consumption in the Netherlands and Portugal and the Consequences for the Intake of Iodine, Sodium, and Exposure to Chemical Contaminants: A Risk-Benefit Study

Background: Seaweed has a high potential for nourishing the future planet. However, besides being beneficial, it also contains adverse components; this poses the question whether consumption of seaweed foods overall contributes beneficially or detrimentally to human health, and hence if their consumption should be promoted or restricted. Methods: This study evaluated the impact of substituting regular foods with seaweed foods in the diet, both in terms of nutritional quality (via iodine and sodium) and food safety (via arsenic, cadmium, lead, and mercury). Food consumption data from the Netherlands and Portugal (adults aged >18 years) were used, in which 10% of the amounts of pasta, bacon, and lettuce consumed were replaced by seaweed-derived products made from kelp (Saccharina latissima). Using Monte Carlo Risk Assessment software (MCRA), long-term nutrient intake and exposure to contaminants were assessed. The results obtained for the Netherlands and Portugal were compared with data from Japan, a country that has a high natural consumption of seaweed. Results: This low-tier risk-benefit study reveals that an increased seaweed consumption (as assessed by the 10% replacement with seaweed products) has no consequences in terms of intake of sodium and exposure to cadmium, lead, and mercury, and the associated (absence of) adverse health aspects. The alternative scenario almost doubled the mean iodine intake in the Netherlands (to 300 μg/day) and Portugal (to 208 μg/day) and increased the average exposure to arsenic levels in the Netherlands (to 1.02 μg/kg bw/day) and Portugal (to 1.67 μg/kg bw/day). Conclusion: The intake of iodine and exposure to arsenic in the Netherland and Portugal were certainly higher due to the modeled increase of seaweed foods. If seaweed consumption increases close to the 10% substitution, the public health consequences thereof may trigger further research.

Dietary glycemic load and its association with glucose metabolism and lipid profile in young adults

BACKGROUND AND AIM

To evaluate the association of Glycemic Load (GL) with glucose metabolism and blood lipids among young adults.

METHODS AND RESULTS

This study included 1538 participants (51% females), evaluated at 21 years of age as part of the EPITeen cohort. The GL of each individual was obtained from the assessment of their dietary intake by using a 86-item semi-quantitative food frequency questionnaire. The evaluation included anthropometric measurements and a fasting blood sample was used to measure glucose, insulin, triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Insulin resistance was calculated based on the homeostasis model method (HOMA-IR). The association between the GL and the biochemical parameters was evaluated by linear regression models using β and 95% confidence intervals (95% CI), stratified by sex and adjusted for body mass index (BMI), energy and fiber intake, and self-perceived social class. No association was found between GL and the glucose metabolism parameters after adjustment. Regarding blood lipids, a positive association was found with LDL-C (β = 1.507, 95% CI 0.454; 2.561 for females; β = 0.216, 95% CI -0.587; 1.020 for males) and a negative association with HDL-C (β = -0.647, 95% CI -1.112; -0.181 for females; β = -0.131, 95% CI -0.422; 0.160 for males).

CONCLUSIONS

Our results suggest that, in healthy young subjects, a high GL diet may have a negative impact on lipid profile.

Energy intake misreport: how different methods affect its prevalence and nutrient intake estimates

BACKGROUND

Although different methods for the evaluation of energy intake (EI) misreport have been described, it is unclear which one is the most appropriate.

AIM

To assess the performance of these methods in the prevalence of EI misreports and accuracy of nutrient intake estimates.

METHODS

Reports of 3,639 adults from the Portuguese National Food, Nutrition and Physical Activity Survey 2015-2016 were classified using univariate (Willett; interquartile range) and multivariate (Goldberg; predicted total energy expenditure [pTEE], testing different standard deviations [SD]) methods. Self-reported intakes were compared to their respective estimates by urinary excretion in a sub-sample of 80. The effect of the exclusion of misreporters on nutrient estimates was assessed by the differences in linear regression coefficients between plausible and total sample.

RESULTS

The highest prevalence of EI misreport was observed using pTEE 1SD (63.9%). Differences in the associations between nutrient self-reported intake and estimated intake using urinary biomarkers were verified with misreporters' exclusion by pTEE 1SD method (β-protein = 0.209; 95% CI = 0.074-0.529; β-potassium = 0.276; 95% CI = 0.060-0.560) and Goldberg 2SD (β-protein = 0.080; 95% CI = 0.025-0.235; β-potassium = 0.106; 95% CI = -0.048-0.246).

CONCLUSIONS

Multivariate methods lead to a higher prevalence of misreports and larger differences in nutrient estimates. The application of the pTEE 1SD and Goldberg 2SD methods resulted in more accurate nutrient estimates.

An Ultra-Processed Food Dietary Pattern Is Associated with Lower Diet Quality in Portuguese Adults and the Elderly: The UPPER Project

This study aimed to identify dietary patterns (DPs) and their associations with sociodemographic factors and diet quality in Portuguese adults and the elderly. Cross-sectional data were obtained from the National Food, Nutrition and Physical Activity Survey (2015-2016), with two non-consecutive dietary 24 h recalls. Food items were classified according to the NOVA system and its proportion (in grams) in the total daily diet was considered to identify DPs by latent class analysis, using age and sex as concomitant variables. Multinomial logistic and linear regressions were performed to test associations of DPs with sociodemographic characteristics and diet quality, respectively. Three DPs were identified: "Traditional" (higher vegetables, fish, olive oil, breads, beer and wine intake), "Unhealthy" (higher pasta, sugar-sweetened beverages, confectionery and sausages intake) and "Diet concerns" (lower intake of cereals, red meat, sugar-sweetened and alcoholic beverages). "Unhealthy" was associated with being younger and lower intake of dietary fiber and vitamins and the highest free sugars and ultra-processed foods (UPF). "Diet concerns" was associated with being female and a more favorable nutrient profile, but both DPs presented a higher contribution of UPF than the "Traditional" DP. These findings should be considered for the design of food-based interventions and public policies for these age groups in Portugal.

Associated factors to the consumption of ultra-processed foods and its relation with dietary sources in Portugal

Ultra-processed foods (UPFs) are common worldwide and associated with poorer health outcomes. This work aimed to explore the UPF consumption associated factors and its main dietary sources, by sex, in Portugal. Participants from the National Food, Nutrition and Physical Activity Survey (IAN-AF) 2015-2016, aged 3-84 years, were included (n 5005). Dietary intake was assessed through two 1-day food diaries/24 h recalls. UPFs were identified using the NOVA classification. Associations were evaluated through linear regression models. Median UPF consumption was 257 g/d (10⋅6 % of total quantity; 23⋅8 % of total energy). Adolescents were those with higher consumption (490 g/d). Compared to adults, younger ages were positively associated with UPF consumption (e.g. adolescents (-females: 192, 95 % confidence interval (CI): 135, 249; -males: 327, 95 % CI: 277, 377)). A lower educational level was associated with lower UPF consumption (-females: -63; 95 % CI: -91, -34; -males: -68; 95 % CI: -124, -12). Also, a lower UPF consumption was observed in married males/couples compared to singles (: -48, 95 % CI: -96, -1). Furthermore, female current/former smokers were associated with a higher UPF consumption v. never smokers (: 79, 95 % CI: 41, 118; : 42, 95 % CI: 8, 75, respectively). Main UPF sources were yoghurts, soft drinks and cold meats/sausages differing strongly by sex, age and education level. Yoghurts containing additives were the main contributors to the UPF consumption in children and adult females from all education (~20 %). Soft drinks were leaders in adolescents (females: 26⋅0 %; males: 31⋅6 %) and young male adults (24⋅4 %). Cold meats/sausages stood out among low-educated males (20⋅5 %). Males, younger age groups, higher education, children with less-educated parents, married/couple males and smoking females were positively associated with UPF consumption.

Dietary Patterns in Portuguese Children and Adolescent Population: The UPPER Project

Considering the nature, extent, and purpose of food processing, this study aims to identify dietary patterns (DPs) and their associations with sociodemographic factors and diet quality in Portuguese children and adolescents. Cross-sectional data were obtained from the National Food, Nutrition and Physical Activity Survey (2015-2016) of the Portuguese population. Dietary intake was obtained from two non-consecutive days and food items were classified according to the NOVA system. The proportion (in grams) of foods in the total daily diet was considered to identify DPs by latent class analysis, with age and sex as concomitant variables. Associations of DPs with sociodemographic characteristics were assessed using multinomial logistic regression. Linear regressions adjusted by sociodemographic characteristics tested associations of DPs with diet quality. DPs identified were: "Unhealthy" (higher sugar-sweetened beverages, industrial breads, and sausages intake), "Traditional" (higher vegetables, fish, olive oil, breads, ultra-processed yogurts, and sausages intake), and "Dairy" (higher intake of milk, yogurt, and milk-based beverages). "Unhealthy" was associated with older ages and lower intake of dietary fibre and vitamins and the highest free sugars and ultra-processed foods (UPF), although all DPs presented significant consumption of UPF. These findings should be considered for the design of food-based interventions and school-feeding policies in Portugal.

Risk-Benefit Assessment of Cereal-Based Foods Consumed by Portuguese Children Aged 6 to 36 Months-A Case Study under the RiskBenefit4EU Project

Cereal-based foods, including breakfast (BC) and infant cereals (IC), are among the first solid foods introduced to infants. BC and IC are sources of macro and micronutrients that have beneficial effects on health, but can also be sources of harmful chemical and microbiological contaminants and nutrients that may lead to adverse health effects at high consumption levels. This study was performed under the RiskBenefit4EU project with the aim of assessing the health impact associated with consumption of BC and IC by Portuguese children under 35 months. Adverse effects associated with the presence of aflatoxins, Bacillus cereus, sodium and free sugars were assessed against the benefits of fiber intake. We applied a risk-benefit assessment approach, and quantified the health impact of changes in consumption of BC and IC from current to various alternative consumption scenarios. Health impact was assessed in terms of disability-adjusted life years. Results showed that moving from the current consumption scenario to considered alternative scenarios results in a gain of healthy life years. Portuguese children can benefit from exchanging intake of IC to BC, if the BC consumed has an adequate nutritional profile in terms of fiber, sodium and free sugars, with levels of aflatoxins reduced as much as possible.

Breakfast Cereals Intended for Children: Opportunities for Reformulation and Potential Impact on Nutrient Intake

Ready-to-eat cereals (RTECs) have become a popular breakfast option claiming to provide important nutrients to children's diets, despite being a source of excess sugar and, therefore, a health concern. Thus, food reformulation constitutes an important public health strategy that could benefit from inputs provided by nutrient profiling. This study aimed to assess the adequacy of the RTECs for children available in Portuguese supermarkets, applying three nutrient profile models (NPMs)-the nutrient profile model of the World Health Organization's Regional Office for Europe (WHO-EURO), the profile of the private-sector EU Pledge (EU-Pledge), and the national model developed by the Directorate-General of Health (NPM-PT)-in order to explore the potential for reformulation of the RTECs identified as not adequate and evaluate the impact of RTECs' reformulation on the nutritional quality of Portuguese children's diets. In total, 78 RTECs intended for children were assessed and two scenarios-current (not considering reformulation) and alternative (considering reformulation to accomplish the nutrient profile requirements)-were considered to assess the impact of reformulation on nutritional quality. Across all RTECs, only 5.1% could be promoted to children according to the considered NPMs. The most common nutrients requiring reformulation were sugar, saturated fatty acids (SFA), salt, and dietary fiber. The scenarios of reformulation considered could reduce the RTECs average content of total sugars, SFA, and salt by 43%, 8.7%, and 1.1%, respectively, and dietary fiber intake could be increased by 34%. Thus, these results support policies to implement reformulation strategies for developing healthier food products to be promoted to children.

Adhering to a Mediterranean diet in a Mediterranean country: an excess cost for families?

BACKGROUND

Adherence to the Mediterranean diet has been decreasing in southern Europe, which could be linked to several cultural or educational factors. Our aim is to evaluate the extent to which economic aspects may also play a role, exploring the relationship between food prices in Portugal and adherence to the Mediterranean diet.

METHODS

We evaluated data from the Portuguese National Food, Nutrition, and Physical Activity Survey (IAN-AF 2015-2016) (n=3,591). Diet expenditures were estimated by attributing a retail price to each food group and the diet was transposed into the Mediterranean Diet Score used in the literature. Prices were gathered from five supermarket chains (65% of the Portuguese market share). Linear regression models were used to assess the association between different adherence levels to the MD levels and dietary costs.

RESULTS

Greater adherence to the MD was associated with a 21.2% (p< 0.05) rise in total dietary cost, which accounts for more 0.59€ in mean daily costs when compared with low adherence. High adherence individuals (vs. low adherence) had higher absolute mean daily costs with fish (0.62€/+285.8%; p< 0.05), fruits (0.26€/+115.8%; p< 0.05), and vegetables (0.10€/+100.9%; p< 0.05). The analysis stratified by education and income level showed significantly higher mean daily diet cost only amongst higher income groups.

CONCLUSIONS

Our findings suggest that greater adherence to the MD was positively and significantly associated with higher total dietary cost. Policies to improve population's diet should take into consideration the cost of healthy foods, especially for large low- and middle-income families.

The first harmonised total diet study in Portugal: Planning, sample collection and sample preparation

The first Total Diet Study (TDS) was carried out in Portugal using harmonised procedures developed under the TDS-Exposure project. This publication describes in detail the TDS planning, sample collection and preparation, filling a gap found in literature. TDS food list (1070 items) by food group for 18-74 years olds was derived using 24 h recall food consumption survey data. Of the 164 TDS samples defined based on FoodEx2, the most represented belonged to 'Composite dishes' (21%) and 'Fish and Fish products' (15%). A total of 227 TDS samples (12 subsamples each), were collected (2014-2016) in Greater Lisbon region as 126 'national', 17 'regional non-seasonal' and 21 'regional seasonal'. Seasonal samples were mostly fruits, vegetables and some fish. Subsamples were prepared as consumed, pooled, homogenised and stored at -18 °C. The harmonised procedures used allow comparison of exposure assessment with other countries and evaluation of exposure trends if TDS are used.

Application of a Latent Transition Model to Estimate the Usual Prevalence of Dietary Patterns

Background: This study aims to derive habitual dietary patterns of the Portuguese adult population by applying two methodological approaches: a latent class model and a latent transition model. The novel application of the latent transition model allows us to determine the day-to-day variability of diet and to calculate the usual prevalence of dietary patterns. Methods: Participants are from the National Food, Nutrition and Physical Activity Survey of the Portuguese population, 2015–2016 (2029 women; 1820 men, aged ≥18 years). Diet was collected by two 24 h dietary recalls (8–15 days apart). Dietary patterns were derived by: (1) a latent class model using the arithmetic mean of food weigh intake, with concomitant variables (age and sex); (2) a latent transition model allowing the transition from one pattern to another, with the same concomitant variables. Results: Six dietary patterns were identified by a latent class model. By using a latent transition model, three dietary patterns were identified: “In-transition to Western” (higher red meat and alcohol intake; followed by middle-aged men), “Western” (higher meats/eggs and energy-dense foods intake; followed by younger men), and “Traditional-Healthier” (higher intake of fruit, vegetables and fish, characteristic of older women). Most individuals followed the same pattern on both days, but around 26% transited between “In-transition to Western” and “Western”. The prevalence of the dietary patterns using a single recall day (40%, 27%, 33%, respectively) is different from the usual prevalence obtained by the latent transition probabilities (48%, 36%, 16%). Conclusion: Three dietary patterns, largely dependent on age and sex, were identified for the Portuguese adult population: “In-transition to Western” (48%), “Western” (36%), and “Traditional-Healthier” (16%), but 26% were transient between patterns. Dietary patterns are, in general, deviating from traditional habits.

Challenges Associated With the Design and Deployment of Food Intake Urine Biomarker Technology for Assessment of Habitual Diet in Free-Living Individuals and Populations-A Perspective

Improvement of diet at the population level is a cornerstone of national and international strategies for reducing chronic disease burden. A critical challenge in generating robust data on habitual dietary intake is accurate exposure assessment. Self-reporting instruments (e.g., food frequency questionnaires, dietary recall) are subject to reporting bias and serving size perceptions, while weighed dietary assessments are unfeasible in large-scale studies. However, secondary metabolites derived from individual foods/food groups and present in urine provide an opportunity to develop potential biomarkers of food intake (BFIs). Habitual dietary intake assessment in population surveys using biomarkers presents several challenges, including the need to develop affordable biofluid collection methods, acceptable to participants that allow collection of informative samples. Monitoring diet comprehensively using biomarkers requires analytical methods to quantify the structurally diverse mixture of target biomarkers, at a range of concentrations within urine. The present article provides a perspective on the challenges associated with the development of urine biomarker technology for monitoring diet exposure in free-living individuals with a view to its future deployment in "real world" situations. An observational study (n = 95), as part of a national survey on eating habits, provided an opportunity to explore biomarker measurement in a free-living population. In a second food intervention study (n = 15), individuals consumed a wide range of foods as a series of menus designed specifically to achieve exposure reflecting a diversity of foods commonly consumed in the UK, emulating normal eating patterns. First Morning Void urines were shown to be suitable samples for biomarker measurement. Triple quadrupole mass spectrometry, coupled with liquid chromatography, was used to assess simultaneously the behavior of a panel of 54 potential BFIs. This panel of chemically diverse biomarkers, reporting intake of a wide range of commonly-consumed foods, can be extended successfully as new biomarker leads are discovered. Towards validation, we demonstrate excellent discrimination of eating patterns and quantitative relationships between biomarker concentrations in urine and the intake of several foods. In conclusion, we believe that the integration of information from BFI technology and dietary self-reporting tools will expedite research on the complex interactions between dietary choices and health.

Deoxynivalenol exposure assessment through a modelling approach of food intake and biomonitoring data - A contribution to the risk assessment of an enteropathogenic mycotoxin

Deoxynivalenol (DON), an enteropathogenic mycotoxin produced by Fusarium species, is usually associated with adverse health outcomes such as gastrointestinal diseases and immunotoxicity. To estimate DON exposure of the Portuguese population at national level, a modelling approach, based on data from 94 Portuguese volunteers, was developed considering the inputs of the food consumption data generated within the National Food and Physical Activity Survey and the human biomonitoring data used to assess the exposure to DON. Ten models of association between DON urinary biomarkers and food items (pasta, cookies, biscuits, sweets, bread, rusks, nuts, oilseeds, beer, meat, milk) were established. Applying the most adequate model to the consumption data (n = 5811) of the general population, the exposure estimates of the Probable Daily Intake revealed that a fraction (0.1%) of the Portuguese population might exceed the Tolerable Daily Intake defined for DON. The analysis stratified by age revealed children (3.2%) and adolescents (6.0%) are more likely to exceed the Tolerable Daily Intake for DON. Although the unavoidable uncertainties, these results are important contributions to understand the exposure to this mycotoxin in Portugal, to assess the associated risk and the potential public health consequences.

Calystegines are Potential Urine Biomarkers for Dietary Exposure to Potato Products

SCOPE

Metabolites derived from specific foods present in urine samples can provide objective biomarkers of food intake (BFIs). This study investigated the possibility that calystegines (a class of iminosugars) may provide BIFs for potato (Solanum tuberosum L.) product exposure.

METHODS AND RESULTS

Calystegine content is examined in published data covering a wide range of potato cultivars. Rapid methods are developed for the quantification of calystegines in cooked potato products and human urine using triple quadrupole mass spectrometry. The potential of calystegines as BFIs for potato consumption is assessed in a controlled food intervention study in the United Kingdom and validated in an epidemiological study in Portugal. Calystegine concentrations are reproducibly above the quantification limit in first morning void urines the day after potato consumption, showing a good dose-response relationship, particularly for calystegine A₃ . The design of the controlled intervention mimicks exposure to a typical UK diet and showed that neither differences in preparation/cooking method or influence of other foods in the diet has significant impact on biomarker performance. Calystegine biomarkers also perform well in the independent validation study.

CONCLUSION

It is concluded that calystegines have many of the characteristics needed to be considered as specific BFIs for potato product intake.

The role of socio-economic factors in food consumption of Portuguese children and adolescents: results from the National Food, Nutrition and Physical Activity Survey 2015-2016

This study aimed to evaluate the association between socio-economic factors and the food consumption of a young population. Participants were from the Portuguese National Food, Nutrition and Physical Activity Survey (IAN-AF 2015-2016) aged from 3 to 17 years (n 1153). Food consumption was assessed using two non-consecutive days of food diaries in children and two 24-h recalls for adolescents. A latent class analysis (LCA) was used to classify children's socio-economic status (socio-economic composite classification (SCC)), categorised in low, middle or high. The associations between socio-economic variables and food consumption were evaluated through linear or logistic regression models, weighted for the Portuguese population distribution. A positive association was found between belonging to a higher level of SCC and consumption of fruits and vegetables (FV), by children (β = 2·4, 95 % CI 1·1, 3·8) and by adolescents (β = 52·4, 95 % CI 9·6, 95·3). A higher SCC, but particularly higher maternal education, was positively associated with consumption of 'white meat, fish and eggs'. Both higher SCC and parental education were positively associated with salty snack consumption in the adolescents' group. In conclusion, children and adolescents with higher educated parents and belonging to a high socio-economic level have a higher daily intake of FV and white meat, fish and eggs. Socio-economic factors play an important role in justifying differences in the food consumption of children and adolescents and must be considered in future interventions. The relationship between higher socio-economic position and salty snack consumption in adolescents needs to be further explored in other populations.

The association between dietary patterns and nutritional status in community-dwelling older adults-the PEN-3S study

BACKGROUND

Diet plays a key role in the ageing process. Despite this, little is known about the effect of dietary patterns on older adults' nutritional status. The main aim of this study was to analyse the association between a posteriori derived dietary patterns (DPs) and nutritional status among community dwellers aged ≥65.

METHODS

Cross-sectional study including a representative sample of the community-dwelling Portuguese population aged ≥65 (n = 849, mean age 74.1 years old). Data were collected through computer-assisted, face-to-face interviews. Dietary patterns were derived a posteriori based on two 24-h recalls by a latent class transition model. Nutritional status was assessed by the Mini Nutritional Assessment (MNA^®) and measured body mass index (BMI). Associations were estimated by regression models. MNA score was reversed and log-transformed considering its skewed distribution.

RESULTS

Two DPs were identified: 22.0% of the studied population followed a 'Protein-based foods' DP (highest consumption of legumes, meats and sweets), and 59.1% followed a 'Mediterranean' DP (highest consumption of vegetables, fruits, dairy, cereals/tubers, bread, fishery and olive oil). Moreover, 18.9% switched between those patterns ('In-between' DP). After adjustment, the 'Protein-based foods' DP was associated with better MNA score (EXP(β) = 0.716, 95% CI 0.533, 0.962), compared to the 'Mediterranean' DP, particularly for total energy intake up to 2200 kcal/day. No significant associations were found between DPs and BMI.

CONCLUSIONS

A protein-based pattern is associated with lower malnutrition risk in older adults, when considering an adequate energy intake. This should be taken into account when designing and disseminating food-based guidelines for healthy ageing.