Compliance with the European and national nutritional objectives in a Mediterranean population

Abstract

Objective:

To analyze compliance with the current European and Spanish nutritional objectives in a representative sample from Catalonia, a Spanish Mediterranean region; and to examine relationships between diet and plasma fatty acid composition.

Design:

Cross-sectional nutritional survey.

Setting:

Population based random sample derived from the Catalan Nutrition Survey.

Subjects:

A total of 516 healthy adult men (n=203) and women (n=313).

Methods:

Dietary habits were assessed by means of a quantitative food frequency questionnaire. A physical exam included height, weight, waist and hip circumferences, and a fasting blood draw.

Results:

Gender differences were observed in nutrient and energy intakes. Women showed a better compliance with the nutritional recommendations for monounsaturated fatty acid (MUFA) and polyunsaturated fatty acid (PUFA) than did men. Men showed a better compliance for saturated fatty acid (SFA) and carbohydrate than did women. However, the SFA:MUFA:PUFA ratio was similar in both gender (1.6:2.3:1.0 for men; 1.7:2.5:1.0 for women). The highest compliance was observed for nutritional goals of sodium, calcium and fruit and vegetable intakes for both genders. In addition, the present study showed that levels of certain fatty acids in plasma are clearly associated with dietary intake of foods rich in these components. The highest correlations were found for n-3 long chain polyunsaturated fatty acids with blue fish intake in both men and women (rmen=0.36 and rwomen=0.42; P<0.001).

Conclusions:

The diet followed in Catalonia seems to ensure compliance with most of the intermediate nutritional objectives for the Spanish population. However, a reduction in the SFA intake and an increase in the carbohydrate intake could be recommended in order to reduce the current prevalence of overweight and obesity in this Mediterranean region.

Sponsorship:

This study was supported by the Catalan Department of Health, the Nutrition Catalan Centre of the Institute of Catalan Studies, and Mercadona SA.

Introduction

Nutrition is recognized as one of the major health determinants. It is currently estimated in the scientific community that an unhealthy diet and a sedentary lifestyle may be responsible for up to one-third of the cases of cancers, and for premature deaths due to cardiovascular diseases (Kafatos and Codrington, 2003). Nutrition is also an important determinant for the prevalence of obesity, which continues to rise in the European community both among children and adults (Aranceta-Bartrina et al., 2003; York et al., 2004).

Promoting adequate eating habits, which follow healthy dietary models, constitutes one of the most important components within health promotion strategies (Tur et al., 2005). A clear example of a healthy dietary pattern is the ‘traditional’ Mediterranean diet, which has been shown to be protective against mortality for several causes and the development of coronary heart disease, stroke, hypertension and other chronic diseases (Martinez-Gonzalez et al., 2002; Psaltopoulou et al., 2004; Sanchez-Villegas et al., 2005; Trichopoulou et al., 2005). The nutritional objectives for the Spanish population are therefore based in the development of dietary guidelines within a Mediterranean context (Serra-Majem and Aranceta, 2001). However, the compliance with these nutritional goals should be periodically verified. Having in mind that Catalonia is one of the Spanish regions where the percentage of immigration is higher than the 10%, changes in eating habits and food consumption introduced by the increasing multicultural population could affect the Mediterranean dietary patterns in a near future.

Therefore, the main aim of the present work was to analyze compliance with the current European and Spanish nutritional objectives in a representative sample from Catalonia, a Spanish Mediterranean region. In addition, relationships between diet and plasma fatty acid composition were examined.

Subjects and methods

Subjects

The subjects were a subgroup of a larger sample (1600 subjects) randomly recruited in Catalonia, a Mediterranean region in north-western Spain, for a cross-sectional nutritional survey (Junca et al., 2003). The primary objective of the survey was to collect relevant information on the dietary habits of the Catalan population and assess their food consumption patterns. A third part of the participants agreed to have blood drawn and underwent physiological and anthropometric measurements in a clinical session after informed consent. Of these 533 Catalans, 17 did not fast for >12 h before blood sampling and were therefore excluded. The final sample consisted of 516 subjects, 203 men and 313 women. The study protocol was approved by the regional ethics committee, following the Declaration of Helsinki 1975 standards.

Anthropometric measurements

The anthropometric measures used in this study were: height (m), weight (kg), body mass index (BMI, calculated as weight in kg/height2 in m) waist and hip circumferences (HC), and waist–hip ratio (WHR).

Height was determined using a mobile anthropometer to the nearest millimeter. Body weight was determined to the nearest 100 g using a digital scale. Waist and HC were measured using a non-stretchable measuring tape. Waist circumference (WC) was measured at the navel in men, and midway between the bottom of the ribs and the top of the hip bone in women. HC was measured at the tip of the hip bone in men, and at the widest point between the hips and the buttocks in women. Prevalence of overweight and obesity was calculated according to previously described cutoff limits (Aranceta-Bartrina et al., 2005).

Nutrition data

Data on food intake were obtained with the use of a quantitative food-frequency questionnaire (FFQ), which was previously validated (Martín Moreno et al., 1993) and applied to other Spanish regions (Serra-Majem et al., 1994, 1999; Tur et al., 2004). The FFQ, which asked the subject to recall average use over the past years, consisted of 92 food items. The FFQ was arranged by food type and meal pattern. Frequency categories where based on the number of times that items were consumed per day, week or month. Consumption less than once a month was considered no consumption. Daily consumption in grams was determined by dividing the reported amount of the intake by the frequency in days. The relevant period of consumption of seasonal items was also taken into account. Edible fractions of foods were recorded in the database. Food values were converted into nutrient values by validated software developed by the Centre of Nutrition and Dietetics CESNID based on Spanish tables of food composition (Cervera, 2003).

Plasma fatty acid analysis

Blood samples were collected after fasting of the subjects for 12 h. Plasma was stored at −80°C before analyses. The fatty acid profile was determined by fast gas chromatography (fast GC) with a previous derivatization to their corresponding fatty acid methyl esters (Bondia-Pons et al., 2004). Briefly, 100 μl plasma samples containing a known amount of tridecanoic acid as an internal standard were saponified with sodium methylate. After esterification with borontrifluoride-methanol, the fatty acid profile was determined by capillary fast GC. Results were expressed as relative percentages of total fatty acids.

Statistical analysis

Analyses were performed with SPSS version 12.0. (SPSS Inc., Chicago, IL, USA). The unpaired Student's t-test was used to test differences between groups for variables following normality, and χ2 tests were performed for the rest of variables. Partial correlation coefficients between food groups and plasma fatty acids were calculated for each sex, adjusting by age. From the original correlation matrix that included all possible correlations between 50 food groups and the 29 fatty acid (25 individual fatty acids plus the four fatty groups saturated fatty acid (SFA), monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA) and long chain polyunsaturated fatty acids (LC-PUFA), food item correlations were not considered when at least three of the following conditions occurred: food group with very low fat content, very low intake of a particular food group, high heterogeneity (in terms of nutrient density and fat content) of foods within a group, correlation with P>0.01 and inconsistency between the results for the two sexes.

Results

Anthropometric characteristics of study participants are shown in Table 1. The high prevalence of overweight in men agreed with their average BMI, which was higher than the recommended value of 25 kg/m2. Prevalence of obesity was similar between genders. Women showed a higher prevalence of risk values for WC than men, whereas men showed a higher prevalence of risk values for WHR.

Table 1 Anthropometric characteristics and prevalence of obesity and overweight of study participants (mean±s.d.)

Table 2 shows daily intakes of energy and nutrients in men and women. Energy intake was significantly higher in male than in female subjects, but no significant difference was observed for energy intake per kg body weight. The contribution of carbohydrate to energy was higher in men, obtaining more energy from complex carbohydrate than did women. The percentage of energy intake from animal source protein was higher for women, oppositely to the protein energy intake from vegetable source, which was higher for men. The contribution of total fat and monounsaturated fat to energy was higher for women. No significant differences were observed in saturated and polyunsaturated fat. The mineral and vitamin intake was similar for both gender, with only significant higher intakes of iron and niacin in men.

Table 2 Daily intakes of energy and nutrients (mean±s.d.) in Catalan men and women

The population goals for nutrients consistent with prevention of major public health problems in the European countries (Kafatos and Codrington, 2003) and the intermediate nutritional objectives for the Spanish population (Serra-Majem and Aranceta, 2001) are shown in Table 3. The percentage of compliers in the Catalan sample with the former objectives can be seen in Table 4. Spanish intermediate objectives were chosen for this comparison as 25% of the Spanish population is already supposed to meet these goals (Tur et al., 2005). However, for carbohydrate and SFA, less than 25% of the subjects met the nutritional requirements. The European goals for total fat and carbohydrate intake were accomplished by less than a 10% of the Catalan sample. However, European goals for sodium and fruits and vegetables intakes were followed by more than the 75% of the Catalan participants. When comparing compliance between genders, women presented significant higher percentages of compliance for all components under study, except for the dietary fiber, total and saturated fat, carbohydrate and protein intake.

Table 3 Nutritional objectives for the European and Spanish populations
Table 4 Percentage of compliers in the Catalan sample with the nutritional objectives

In order to examine relationships between diet and plasma fatty acid composition, partial correlation coefficients between food groups and plasma fatty acids were calculated for each gender after adjustment by age. Tables 5 and 6 respectively show the significant correlations for men and women. The highest correlation was obtained for blue fish and the n-3 LC-PUFA (rmen=0.36 and rwomen=0.42; P<0.001).

Table 5 Partial correlation coefficients (r) between food groups and plasma fatty acids for men, adjusted by age
Table 6 Partial correlation coefficients (r) between food groups and plasma fatty acids for women, adjusted by age

Discussion

There are certain gender differences in the intake of energy and nutrients in the Catalan population according to the present study. Women showed a better compliance with the nutritional recommendations for MUFA and PUFA than did men. For MUFA, this could be attributed to the higher olive oil intake by women (median value: 24.2 vs 22.6 ml/day; P<0.01), which agreed with a higher oleic acid intake. The significantly higher white fish consumption (median value: 30.2 vs 28.3 g/day; P<0.01) could explain the higher n-3 LC-PUFA intake in women than in men. However, less than 20% of women accomplished the nutritional goals for SFA. This is probably due to the high dairy products intake in women (median value: 414 g/day (women) vs 369 g/day (men); P<0.01).

Nevertheless, the SFA:MUFA:PUFA ratio was similar for both gender (1.6:2.3:1.0 for men; 1.7:2.5:1.0 for women). Martinez-Gonzalez et al. (2002) considered a ratio of 1:2:1 as healthy (Capita and Alonso-Calleja, 2003). Our results suggest that a decrease in saturated fat should be recommended in the Catalan population. However, the 12% of energy derived from SFA found in the present study is still lower than the percentage found in other European populations (Slimani et al., 2002; Capita and Alonso-Calleja, 2003; Waijers et al., 2006) even in the Mediterranean region (Ferro-Luzzi et al., 2002).

The low compliance in the carbohydrate recommendations in the Catalan sample has also to be pointed out. Less than 1% women and less than 6% men accomplished the nutritional objective of obtaining more than the 55% of energy intake from carbohydrates. The higher percentages of fat-derived energy intake in Mediterranean countries than in the rest of Europe, mainly because of their olive oil culture, should not be a reason for reducing the intake of carbohydrate in the Mediterranean region. Even reducing the nutritional goals of carbohydrate to 50% of the energy intake, only 12% of the subjects accomplished them. Particular emphasis should be therefore be placed on reaching the intermediate objectives for this macronutrient. However, this objective must be accomplished without increasing the current high intake derived from sugar. More than 45% of the carbohydrate-derived energy comes from sugar and it should be balanced with higher intakes of complex carbohydrates and fiber.

Reducing the total SFA and sugar intake could help to reduce the high prevalence of overweight people in Catalonia.

It is well known that a healthy characteristic in the ‘traditional Mediterranean diet’ is the high consumption of fresh fruits and vegetables. The present study confirmed that more than 75% of the Catalan people accomplish the European nutritional goals for both fruits and vegetables. It is worth noting that the current average intake of 2–3 portions of fruit per day was not achieved by Catalan in the last decade (Serra-Majem et al., 1999; Cuco et al., 2002). The same fact occurs nowadays in other Mediterranean regions, where the compliance for the intake of fruits and vegetables does not even arrive to 20% (Tur et al., 2004).

The high compliance of the nutritional goals found in the Catalan sample encouraged us to look for possible relationships between food groups and plasma fatty acid composition. We are concerned that the fatty acids from plasma phospholipids have been reported to reflect dietary intake data over longer time than total plasma fatty acids do (Arab, 2003). However, in the recent years, some authors have successfully found correlations when analyzing total plasma fatty acids (Amiano et al., 2001, 2002; Wakai et al., 2005). The easiness of the selected method of analysis (Bondia-Pons et al., 2004), which combines no previous step of lipid extraction added to savings in the analysis time by fast GC, was the main reason to choose the determination of total fatty acids for our study. The coefficients of correlation (r) were not too high, but for many correlations the P-value was 0.001. Furthermore, the r-values were in the same range that those found by Fusconi et al. (2003) when studying the relationship between food and plasma phospholipid fatty acids in healthy Mediterranean subjects from Italy eating freely chosen diet.

Biomarkers such as plasma fatty acids can be directly influenced by the intake of certain dietary components, or there may be an indirect relationship between them because of the influence of lifestyle. Both types of association have different epidemiological and biological implications.

According to the present work, plasma MUFA levels in general, and oleic acid in particular, were significantly associated with olive oil consumption. The first time that these non-essential plasma fatty acids were related to their dietary source in a population eating a varied and freely chosen diet was observed in plasma phospholipid fatty acids in 2003 (Fusconi et al., 2003). Our study suggests a similar outcome when analyzing total plasma fatty acids. It is also interesting to point out a clear inverse relation between olive oil consumption and n-6 PUFA levels in plasma. This fact suggests that people eat olive oil or seed oils, but not both.

Long-chain n-3 fatty acids were associated with fish and seafood consumption. This correlation has been widely studied in phospholipid fatty acids (Dewailly et al., 2003; Laidlaw and Holub, 2003; Mozaffarian et al., 2005) but little information has still been reported for total fatty acids. A recent study conducted in Japan, one of the areas with the highest fish consumption in the world, examined the association between the intake frequency of fish with long-chain n-3 fatty acids in serum of 1257 subjects (Wakai et al., 2005) and the calculated coefficients of correlation were lower than the found in the present study. Other authors successfully examined correlations between fish intake and total fatty acids in plasma with coefficients of correlation in the range of those found in studies where phospholipid fatty acids were determined (Amiano et al., 2001).

Meat consumption was not clearly associated with plasma fatty acids. Nevertheless, some reported correlations were also observed in the present study, but all of them with levels of significance of P<0.05. They were beef and C20:4n-6 (Sinclair et al., 1994; Fusconi et al., 2003) and veal and C18:1 n-9 (Chajès et al., 2001).

Myristic acid (14:0) levels and cheese were as well correlated in women for a P<0.05. Myristic acid is a ubiquitous fatty acid that also constitutes more than 12% of cow's milk fat.

Alcohol intake was inversely correlated with levels of 17:0 and 18:0 fatty acids. C17:0 is not synthesized endogenously but comes from dairy products. The mutual exclusivity of wine and milk consumption has been previously observed (Fusconi et al., 2003) and the association is probably best explained by assuming that those who drink alcohol do not consume dairy products. No other significant correlations were obtained between plasma fatty acids and food groups.

To sum up, the diet followed in Catalonia seems to ensure compliance with most of the intermediate nutritional objectives for the Spanish population. However, it should be recommended a reduction in the SFA intake and an increase in the carbohydrate intake. These changes in the dietary habits, in addition to non-sedentary lifestyles, could positively influence the reduction of the prevalence of overweight and obese people in this Mediterranean region.

In addition, this study showed that levels of certain plasma fatty acids are clearly associated with dietary intake of foods rich in these components.

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Acknowledgements

We are grateful to the Public Health Division of the Department of Health of the Autonomous Government of Catalonia for providing the blood samples for the study. We thank Mr L Moshell for the English paper correction. We also thank the Spanish Ministry of Education for the FPU PhD-grant to Isabel Bondia-Pons.

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Correspondence to M C López-Sabater.

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Contributors: IB was responsible of the laboratory analysis, the interpretation of dietary and biochemical data, the statistical analysis, and the writing of the paper. SL participated in the study design, supervised the collection of dietary data and revised the paper providing expert advice on data interpretation. AIC supervised the laboratory analysis and quality control, and provided expert advice on data interpretation. MCL participated in the study concept and design and provided expert advice on data interpretation and in the discussion of the paper. None of the authors had any conflicts of interest in connection with this study.

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Bondia-Pons, I., Serra-Majem, L., Castellote, A. et al. Compliance with the European and national nutritional objectives in a Mediterranean population. Eur J Clin Nutr 61, 1345–1351 (2007). https://doi.org/10.1038/sj.ejcn.1602662

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Keywords

  • Spanish nutritional objectives
  • European nutritional objectives
  • plasma fatty acids
  • Mediterranean diet

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