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ORIGINAL ARTICLE
National nutrition surveys in Europe: a review on the current status in the 53 countries of the WHO European region Holly L. Rippin1*, Jayne Hutchinson1, Charlotte E. L. Evans1, Jo Jewell2, Joao J. Breda2 and Janet E. Cade1 Nutritional Epidemiology Group (NEG), School of Food Science and Nutrition, University of Leeds, Leeds, United Kingdom; 2Division of Noncommunicable Diseases and Promoting Health through the Life-Course, World Health Organization Regional Office for Europe, UN City, Marmorvej 51, 21000 Copenhagen, Denmark 1
Abstract Objectives: The objectives of this study were (1) to determine the coverage of national nutrition surveys in the 53 countries monitored by the World Health Organization (WHO) Regional Office for Europe and identify gaps in provision, (2) to describe relevant survey attributes and (3) to check whether energy and nutrients are reported with a view to providing information for evidence-based nutrition policy planning. Design: Dietary survey information was gathered using three methods: (1) direct email to survey authors and other relevant contacts, (2) systematic review of literature databases and (3) general web-based searches. Survey characteristics relating to time frame, sampling and dietary methodology and nutrients reported were tabled from all relevant surveys found since 1990. Setting: Fifty-three countries of the WHO Regional Office for Europe, which have need for an overview of dietary surveys across the life course. Subjects: European individuals (adults and children) in national diet surveys. Results: A total of 109 nationally representative dietary surveys undertaken post-1990 were found across 34 countries. Of these, 78 surveys from 33 countries were found post-2000, and of these, 48 surveys from 27 countries included children and 60 surveys from 30 countries included adults. No nationally representative surveys were found for 19 of 53 countries, mainly from Central and Eastern Europe. Multiple 24hr recall and food diaries were the most common dietary assessment methods. Only 22 countries reported energy and nutrient intakes from post-2000 surveys; macronutrients were more widely reported than micronutrients. Conclusions: Less than two-thirds of WHO Europe countries have nationally representative diet surveys, mainly collected post-2000. The main availability gaps lie in Central and Eastern European countries, where nutrition policies may therefore lack an appropriate evidence base. Dietary methodological differences may limit the scope for inter-country comparisons. Keywords: national diet surveys; WHO European region; dietary assessment methodologies; scoping review – gaps; multi- criteria analysis; nutritional epidemiology
Received: 8 May 2017; Revised: 16 March 2018; Accepted: 19 March 2018; Published: 16 April 2018
Graphical Abstract: National diet surveys identified
109 naonally representave surveys (34 countries; 16 with longrunning NDS with mulple collecon waves).
28 post-2000 naonally 78 post-2000 representave surveys naonally with latest energy and representave nutrient intakes reported surveys (33 countries). (22 countries).
19 countries with no naonally representave survey (mainly Central and Eastern European countries).
T
he World Health Organization (WHO) European Food and Nutrition Action Plan aims to ‘significantly reduce the burden of preventable diet-related noncommunicable diseases, obesity and all other forms of malnutrition still prevalent in the WHO European Region’ and improve diet and nutrition in the European population (1). An unhealthy diet is one of the four major behavioural risk factors for non-communicable diseases (NCDs) in all WHO regions (2), with the European region proportionately suffering the greatest NCD
Food & Nutrition Research 2018. © 2018 Holly L. Rippin et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. Citation: Food & Nutrition Research 2018, 62: 1362 - http://dx.doi.org/10.29219/fnr.v62.1362
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Holly L. Rippin et al.
burden. Other risk factors include alcohol, tobacco misuse and physical inactivity (2). In Europe, the four most common NCDs account for 77% of disease and almost 86% premature mortality (1). NCDs and related conditions, including overweight and obesity, have significant and growing economic and social costs (1), which traditional clinical approaches are increasingly unable to address (3). Mozaffarian et al. (3) call for a shift in emphasis from such pharmacological treatments to primary prevention through addressing lifestyle risk factors such as dietary patterns in order to reduce cardiovascular risk and NCD-associated problems. Dietary surveys thus have an important role in assessing dietary patterns in the whole population. Nutrition and health surveys formed the main source of information for dietary risk factors and physical inactivity in a systematic analysis of disease risk in 21 regions worldwide across two decades (4). Such surveys can provide a means of monitoring trends, identifying areas of concern and inequality and evaluating policy impact, thereby ultimately contributing to the promotion of best practice across the region (1). The WHO European Food and Nutrition Action Plan (1) explicitly encourages member states to ‘strengthen and expand nationally representative diet and nutrition surveys’. Many western European countries currently have established dietary surveys that assess food and nutrient intake. A global review of country-specific surveys from 1990 to 2010 only reported dietary fat and oil intake (5). A comprehensive, updated review of total nutrient and food intakes across different populations and subgroups in Europe is needed, the results of which could identify where in Europe there is a need to improve diets and whether inequalities exist. This paper makes the first step in this regard, establishing which countries have nationally representative dietary surveys and highlighting gaps in nutrition survey provision across Europe. This review aims to identify which of the 53 countries in the WHO European region have conducted nationally representative dietary surveys of whole diets at an individual level and those that have not. It identifies key characteristics, centred on time frame, sampling and dietary methodology, of known surveys undertaken since 1990 for adults and children and aims to lay the foundations in establishing a clear picture of the current situation. Following this, future papers will examine energy and nutrient intakes in different population groups across Europe to better assess where both gaps in knowledge and dietary inadequacies lie. Information from dietary surveys can be used as a means for governments and health bodies to monitor and reduce the diet-related risk of NCDs and related conditions across Europe, thereby contributing to the goals set out in the WHO action plan.
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Methods We used three key approaches to identifying national diet surveys: (1) contacting authors of surveys, (2) systematic literature review and (3) general web-based searches. Identifying authors of national diet surveys We identified authors of national surveys within the WHO Europe remit using listed contact names and other information from two main reports of national dietary surveys (5, 6). If no response was obtained from those authors, Internet searches of nutrition organisations by country and the survey titles listed in the review of 1990–2010 surveys (5) and the European Food Consumption Survey (6) were carried out to find other potentially useful contact details. For countries where this approach did not yield usable contact details, Internet searches using various search terms were performed on organisations specialising in nutrition, including known government and public health agencies. WHO also provided contact details for some of those countries for which they had relevant associates. Contacts identified were asked to complete a questionnaire (Appendix 1) to provide information on nationally representative dietary surveys conducted at an individual level since 1990, including links or references to relevant reports. Systematic database search For countries where no contact could be identified, systematic searches were undertaken across Web of Science, Medline and Scopus for nationally representative dietary surveys that collected data at an individual level from 1990 to June 2016. The following query terms were run without language restrictions: (survey* OR research* [TS]) AND (nutrition* OR diet* OR food* [TS]) AND (list of countries). The title of each paper generated by the database searches was screened for relevance according to the criteria in Table 1; those that are not relevant were excluded. The remaining papers were screened by title and abstract, and full article where available, and their appropriateness for inclusion was checked by a second reviewer. Further surveys, related papers and nutrition expert contact names were gathered by general Internet searching to capture any recently released information, targeting known government and public health agencies using various search term combinations in order to maximise returns. Although there were no language restrictions in the initial search, the WHO Regional Office for Europe, Division of Noncommunicable Diseases and Promoting Health through the Life-Course, conducted an additional database search of papers in the Russian language as an extra check to maximise returns in the 12 Central and Eastern European countries where Russian is an official or widely spoken language Citation: Food & Nutrition Research 2018, 62: 1362 - http://dx.doi.org/10.29219/fnr.v62.1362
National nutrition surveys in Europe
Table 1. Survey inclusion and exclusion criteria Included
Excluded
Surveys conducted at an individual level
Surveys collected at group, that is, household level
Nationally representative surveys
Non-nationally representative, regional only surveys
Results of surveys reported by published and unpublished reports, academic journals and websites
Surveys with data collected prior to 1990
Surveys that included individuals >2 years
Surveys with samples exclusively 10); 2×24hr 74 years food diary (age 2). Face-to-face electronic interview.
1–80
4–75
4–75
4–75
19–64
4–90
Sample age
Food Composition Database of CIQUAL of Afssa.
Fineli 7 Food Composition Database
Danish Food Composition Databank
Nutrient reference database†
Y
N
N
N
N
N
N
Y
N
N
N
N
N
Y
N
N
Energy intake graphed Y/N‡
Continued
(59)
(58)
Not yet available.
(57)
(56)
(55)
(53, 54)
(52)
(50, 51)
Not yet available.
(49)
(48)
(47)
(46)
(44, 45)
Reference
National nutrition surveys in Europe
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5
6 (page number not for citation purpose)
Hungary*
2014
2009
2009
Hungarian diet and nutritional status survey (OTÁP 2014)
Hungarian diet and nutritional status survey (OTÁP 2009)
Hungarian dietary survey 2009
2003–2004
Nutrient intakes of toddlers and pre-schoolers in Greece: The GENESIS study
German nutrition survey 1998 2013–14
1997–1999
Der Kinder- und Jugendgesundheitssurvey (KiGGS)
HYDRIA – Greek national diet and health survey
2003–2006
German national nutrition survey (Nationale Verzehrstudie) II (NVSII)
Greece
2005–2007
None found
1993–1994
National food consumption survey (ASPCC)
Germany
1997
Enquête Nutri-Bébé 1997
1998–1999
2005
Enquête Nutri-Bébé 2005
Individual national food consumption survey (INCA)
2006–2007
Survey year
Etude nationale nutrition sante (ENNS); National nutrition and health survey
Survey name
Georgia
Country*
Table 2. Continued
3
2
2
3
2
4/5
3
2/4
5
3
5
3
2/4
Source **
3,077
1,165
857
2,374
4,011
3,861
17,641
15,371
1,500
660
1,0181,985
706
4,780
Sample size
19–30, 31–60, 60+
18–34, 35–64, 64+
18–34, 35–64, 64+
1–5
18+
20–79
0–17
14–80
2–85
0–30 m
3–1415+
1–36 m
Children 3–17 1, 665; adults 18–74 3,115.
Sample age
3-day diary (non-consecutive), FFQ, self-completed.
3-day diary (non-consecutive), Self-completed.
3-day diary (non-consecutive). Self-completed.
3-day diary (includes nutrient data). Face-to-face interview.
2×24hr recall; food propensity questionnaire. Face-to-face interview.
FFQ
Questionnaire.
DISHES diet history interview, 24hr recall, diet weighing diary (2×4 days). Face-to-face electronic interview.
7-day diary.
3-day weighed diary. Face-to-face interview.
7-day diary.
3-day weighed diary (non-consecutive inc weekend). Face-to-face interview.
3×24hr recall (non-consecutive)
Dietary methodology
Új tápanyagtáblázat.
Nutricomp.
Bundeslebensmittelschlüssel (BLS)
Nutrient reference database†
Y
N
N
N
N
N
N
Y
N
N
N
N
N
Energy intake graphed Y/N‡
Continued
(73, 74)
(72)
Not yet available.
(71)
(69, 70)
(68)
(67)
(65, 66)
(64)
(63)
(62)
(61)
(60)
Reference
Holly L. Rippin et al.
Citation: Food & Nutrition Research 2018, 62: 1362 - http://dx.doi.org/10.29219/fnr.v62.1362
Ireland*
Iceland*
Country*
Citation: Food & Nutrition Research 2018, 62: 1362 - http://dx.doi.org/10.29219/fnr.v62.1362
2003–2004
2002 1998
National children’s food survey.
SLAN 2002
SLAN 1998
North-South food consump- 1998 tion survey 1990
5
2005–2006
National teens’ food survey
Irish national nutrition survey
3
2007
Survey of lifestyle, attitudes and nutrition in Ireland (SLAN), 2007
5
3
2
2
3/4
2
2008–2010
National adult nutrition survey 2011 (NANS)
2
2010–2011
1990
Dietary survey of the Icelanders
4/5
4
2
4/5
4
Source **
National pre-school nutrition survey
2002
The diet of Icelanders, dietary survey of the Icelandic nutrition council 2002
2010–2011
1992–1994
2nd National Hungarian survey
The diet of Icelanders – a national dietary survey 2010–2011
2003
Survey year
3rd National Hungarian survey
Survey name
Table 2. Continued
1,214
1,379
6,539
5,992
594
441
9,223
1,500
500
1,240
1,118
1,312
2,559
3,633
Sample size
8–18+
18–64
18+
18+
5–12
13–17
18+
18–90
1–4
15–80
15–80
18–80
18–100
18–100
Sample age
Icelandic Database of Food Ingredients (ÍSGEM); Public Health Institute for Raw Materials in the Icelandic Market.
Nutrient reference database†
Diet history.
7-day diary. Self-completed.
Semi-quantitative FFQ.
Semi-quantitative FFQ.
7-day weighed food diary (consecutive). Self-completed.
7-day semi-weighed food diary (consecutive). Self-completed.
FFQ. Face-to-face interview.
4-day semi-weighed food diary (consecutive). Self-completed.
McCance and Widdowson’s The Composition of Foods 5&6 editions
McCance and Widdowson’s The Composition of Foods 5&6 editions
McCance and Widdowson’s The Composition of Foods 5&6 editions
4-day weighed food diary (consec- McCance and Widdowutive). Self-completed (by carer). son’s The Composition of Foods 5&6 editions
Diet history.
Single dietary diary.
2×24hr recall + FFQ. Telephone interview.
3×24hr recall + FFQ
Multiple dietary diary.
Dietary methodology
N
N
N
N
Y
Y
N
Y
Y
N
N
Y
N
N
Energy intake graphed Y/N‡
Continued
(90)
(89)
(88)
(87)
(85, 86)
(83, 84)
(82)
(81)
(80)
(77–79)
(76)
(75)
Reference
National nutrition surveys in Europe
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7
8 (page number not for citation purpose)
National diet survey 2012–14
Latvia
None found
None found
None found
Dutch national food consumption survey 2012–2016 (DNFCS 2012–16)
Monaco
Montenegro
Netherlands*
2012–2016
2
1/4/5
Nutrition and lifestyle in the 1997 Baltic Republics
None found
1/2
Food consumption survey in 2007 adult Lithuanian population
Malta
2
1/4
2
2
6
4/5
3
4
4
Source **
Study of actual nutrition 2013–2014 and nutrition habits of Lithuanian adult population
Nutrition and lifestyle in the 1997 Baltic Republics
Latvian national food con2008 sumption survey 2007–2009
Luxembourg
Lithuania
None found
Kyrgyzstan 2012–2014
Nutritional and health status 2008 survey of the population in Kazakhstan
1994–1996
INN-CA 1994–1996
Kazakhstan
2005–2006
The third Italian national food consumption survey INRAN-SCAI 2005-2006
1999–2001
Mabat first Israeli national health and nutrition survey
Italy
2005–2006
Mabat national health and nutrition survey of the Elderly (Zahav)
Israel*
Survey year
Survey name
Country*
Table 2. Continued
4,340
2,094
1,936
2,513
2,299
1,949
3,418
3,526
2,734
3,323
3,240
1,782
Sample size
1–79
20–65
19–65
19–75
19–64
7–64
0–74
15–59
0–94
0.1–97.7
25–64
65–100
Sample age
2×24hr recall and 1-day food diary (some age groups), FFQ.
24hr recall + questionnaire
24hr recall.
24hr recall + questionnaire. Faceto-face interview,
24hr recall + questionnaire
2×24hr recall (non-consecutive), FFQ. Face-to-face interview.
2×24hr recall (non-consecutive), FFQ, dietary diary
2×24hr recall
7-day weighed diary. Self-completed.
3-day diary (consecutive). Self-completed.
Single dietary diary.
Single dietary diary.
Dietary methodology
N
N
Energy intake graphed Y/N‡
EuroFIR Food Classification
Latvian National Food Composition Data Base 2009
N
N
N
Y
N
Y
N
N
N
Banca Dati di Y Composizione degli Alimenti. INRAN-DIARIO 3.1
Nutrient reference database†
Continued
Not yet available: (97)
(50, 51)
(95, 96)
(94)
(50, 51)
(93)
Results not yet available
(92)
(91)
Reference
Holly L. Rippin et al.
Citation: Food & Nutrition Research 2018, 62: 1362 - http://dx.doi.org/10.29219/fnr.v62.1362
Citation: Food & Nutrition Research 2018, 62: 1362 - http://dx.doi.org/10.29219/fnr.v62.1362
Poland*
Norway*
Country*
2002 2000 1997 1993–1994
1993 1992
Sub-sample of NOWAC (component of EPIC)
UNGKOST-2000
Norwegian national dietary survey (NORKOST 1997)
Norwegian national diet survey (NORKOST 1993–1994).
UNGKOST-1993
Pilot study
2003–2005 2000
WOBASZ-national multicentre health survey
Sub-sample of the household food consumption and anthropometric survey
2013–2014
2010–2011
Norwegian national diet survey NORKOST3
WOBASZ II study
2015–2016
1992
Dutch national food consumption survey (DNFCS-2) 1992
UNGKOST 3
1997–1998
Dutch national food consumption survey (DNFCS-3) 1997–1998
4/5
4
3
1
5
1/5
4/5
3
1
3
2
2/4/5
2/4/5
2/4
2003
Dutch national food consumption survey (DNFCS 2003)
2/3
2
2007–2010
Dutch national food consumption survey 2007–2010 (DNFCS 2007–10)
Source **
Dutch national food 2005–2006 consumption survey – young children (DNFCS 2008)
Survey year
Survey name
Table 2. Continued
18–70
4–13
1–92
1–97
19–30
2–6
7–69
Sample age
4,200
6,661
6,170
1,200
1,7051,564
3,144
2,672
3948151,009
1–100
20–74
20+
16–79
1318
16–79
16–79
4, 9 and 13
2,000 (female) 46–75
1,787
1,721
6,218
6,250
750
1,279
3,819
Sample size
24hr recall, face-to-face interview.
Single dietary diary
24hr recall and FFQ. Face-to-face interview.
FFQ
FFQ
FFQ
FFQ
4-day diary, self-completed.
FFQ
2×24hr recall and FFQ. Telephone interview.
4-day online diary plus FFQ (consecutive). Self-completed via web.
2-day diary.
2-day diary.
2×24hr recall (non-consecutive, telephone).
2-day diary (non-consecutive). Self-completed (by adult), FFQ.
2×24hr recall. Telephone (adults)/face-to-face (children) interview, FFQ.
Dietary methodology
Energy intake graphed Y/N‡
The Norwegian Food Composition Tables
The Norwegian Food Composition Tables
N
N
N
N
N
N
N
N
N
Y
Y
N
N
N
Dutch Food Composition Y Database (NEVO)
Dutch Food Composition Y Database (NEVO)
Nutrient reference database†
Continued
(113)
(112)
(110)
(111)
(110)
(109)
(108)
(107)
(106)
(104, 105)
(103)
(103)
(102)
(101)
(98–100)
Reference
National nutrition surveys in Europe
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9
10 (page number not for citation purpose) 2012
Nutrient intake in children and adolescents in Slovakia
Dietary intake of macro – and micronutrients in Slovenian adolescents
Nutrient intake in the adult population of the Slovak Republic
Slovenia
1991–1999
None found
Slovakia‡‡
3
5
1991–1994 & 1 1995–1999
None found
2
Serbia
1994, 1995, 1996, 1998, 2000, 2001, 2002, 2003, 2004, 2005
The Russia longitudinal monitoring survey – higher school of economics (RLMS-HSE)
2/3
4
3
6
5
Source **
San Marino
2011–2012
The Russia longitudinal monitoring survey – higher school of economics (RLMS-HSE)
Russian federation*
2006
National synthesis, 2006
Romania
2002–2003
Dietary calcium and body mass index in Portuguese children
None found
2015–2016
1991–1994
Dietary habits and nutritional status of selected populations
National food and physical activity survey (IAN-AF)
Survey year
Survey name
Republic of Moldova
Portugal
Country*
Table 2. Continued
2,224
3,3374,556
4,018
1994–11,295, 1995–10,632, 1996–10,448, 1998–10,663, 2000–10,969, 2001–12,100, 2002–12,489, 2003–12,634, 2004–12,639, 2005–12,228.
21,686
1,036
4,511
4,221
1,1262, 1934,945
Sample size
Dietary methodology
24hr recall. Face-to-face interview.
24hr recall.
24hr recall.
FFQ
24hr recall, face-to–face interview.
2×24hr recall (non-consecutive) and FPQ (electronic interview), 2-day food diary for children 4 years, by adult 4 years.
4-day food diary (consecutive). Self-completed via web.
2×24hr recall.
24hr recall (×2 in 25% sample), face-to-face interview. FFQ.
2×24hr recall (non-consecutive), face-to-face interview, FFQ.
3-day diary + 24hr recall (consecutive). Interview and self-completed.
3-day diary + 24hr recall (consecutive). Face-to-face interview, telephone (interview), tablet and camera (self-report).
2×1-day diary (