To describe the intake of the fat-soluble nutrients retinol, β-carotene, vitamin E and vitamin D and their food sources among 27 redefined centres in 10 countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.
Between 1995 and 2000, 36 034 subjects (age range: 35–74 years) completed a single standardized 24-h dietary recall using a computerized interview software program (EPIC-SOFT). Intakes of the fat-soluble nutrients were estimated using the standardized EPIC Nutrient Database.
For all the nutrients, in most centres, men had a higher level of intake than did women, even after adjustments for total energy intake and anthropometric confounders. Distinct regional gradients from northern to southern European countries were observed for all nutrients. The level intake of β-carotene and vitamin E also showed some differences by level of education, smoking status and physical activity. No meaningful differences in the nutrient intake were observed by age range.
These results show differences by study centre, gender, age and various lifestyle variables in the intake of retinol, β-carotene, vitamin E and vitamin D between 10 European countries.
Vitamins A, D and E belong to the family of fat-soluble vitamins. Similar to their water-soluble counterparts, these fat-soluble vitamins have important metabolic and physiological roles (Debier and Larondelle, 2005; Holick, 2005). In addition, their intake may also be associated with reduced risk of several chronic diseases, particularly some cancers (Giovannucci, 2007, 2008; Constantinou et al., 2008) and heart disease (Fairfield and Fletcher, 2002; Singh et al., 2005; Voutilainen et al., 2006; Wallis et al., 2008). In contrast to water-soluble vitamins, fat-soluble vitamins are stored in the liver and fatty tissues and are only slowly excreted from the body. Thus, they may have deleterious or toxic consequences if consumed at very high levels. Although in well-fed populations serious deficiencies of these vitamins are rare, mild intake insufficiencies may be present, particularly in certain sub-populations, such as vegetarians, individuals consuming low-fat diets or those with fat absorption problems (Fairfield and Fletcher, 2002). These factors make the comparative assessment of the dietary intake levels of these nutrients in different European countries an important issue.
Vitamin A, also known as retinol, has essential roles in night vision and cell differentiation, particularly during embryological development, as well as in carcinogenesis, glycoprotein synthesis, epithelial cell integrity, immune cell maintenance and human growth hormone production (Love and Gudas, 1994; McCullough et al., 1999; Marceau et al., 2007; Sommer, 2008). In addition, some data suggest that, similar to vitamin E, vitamin A may also have an anti-oxidative function, but this remains to be better clarified (Palace et al., 1999). For the most part, dietary sources of vitamin A are of animal origin (e.g., dairy products, fatty fish, liver, eggs, etc.), and populations that do not consume many of these animal products may be at risk of insufficiency of these nutrients. Vitamin A may also be produced endogenously from dietary precursor pro-vitamin A carotenoids (α-carotene, β-carotene and β-cryptoxanthin; from plant origin). However, the efficiency of this conversion is rather low and these carotenoids have a lower bioavailability or efficiency of intestinal uptake than retinol itself. Vitamin A from animal products is mostly consumed as retinyl esters, which are easily hydrolysed endogenously to form retinol (Debier and Larondelle, 2005). There is strong interest in the disease-protective role of retinol (Goodman et al., 2008), and data obtained from the European Prospective Investigation into Cancer and Nutrition (EPIC) suggest that higher blood concentrations are associated with a reduced risk of gastric cancer (Jenab et al., 2006).
Vitamin E is a general term describing the α-, β-, δ- and γ-forms of the tocopherol and tocotrienol chemical classes, although the inclusion of various other isomers of tocopherols and tocotrienols into the definition of vitamin E is currently under debate. The main role of vitamin E in the body is as an anti-oxidant, and it is this role that has sparked interest in the potential of vitamin E in chronic disease prevention (Singh et al., 2005; Traber and Atkinson, 2007; Constantinou et al., 2008).
Vitamin D can be diet-derived or produced endogenously from sun exposure (Holick, 2007). The degree of endogenous production depends on several variables such as genetics, degree of sun exposure, geographical location, ethnicity, etc (Nesby-O'Dell et al., 2002; Kimlin, 2008). The dietary sources of vitamin D are limited, being found primarily in fatty fish (including cod liver oil), egg yolk and fortified dairy products. Vitamin D is essential for calcium/phosphorus metabolism and bone health (Holick, 2007), but more recent data suggest that it may also have a chronic disease-protective role (Zittermann et al., 2005; Ali and Vaidya, 2007; Wallis et al., 2008).
Very high levels of these nutrients, whether from dietary sources or by way of supplementation, may have a negative impact. For example, in a comprehensive review of randomized clinical trials, supplementation of β-carotene, vitamin A and vitamin E was associated with an increased risk of mortality (Miller III et al., 2005; Bjelakovic et al., 2008). In addition, very high daily supplementation of vitamin D can also lead to severe toxicity (Heaney, 2008). Indeed, safe tolerable upper intake limits have been established for many of these nutrients.
The objective of this study was to conduct a comparative analysis of the dietary intake levels of these nutrients with consideration of food sources, lifestyle confounders and seasonal variations, using data obtained from EPIC, a cohort of 10 European countries (Riboli and Kaaks, 1997; Bingham and Riboli, 2004). Consumption of these nutrients as food supplements is described elsewhere in this special issue (Skeie et al., in this supplement). The data to be presented in this study use the newly developed standardized EPIC Nutrient Database (ENDB) (Slimani et al., 2007) and are based on the EPIC calibration study subcohort (Slimani et al., 2002a). A better understanding of dietary exposures of these nutrients in various countries can provide further insight into potential aetiological links with chronic disease risk.
Materials and methods
Study population, design and dietary assessment
The rationale and methods of the EPIC study have been previously described in detail (Riboli and Kaaks, 1997; Riboli et al., 2002; Bingham and Riboli, 2004). The EPIC cohort consists of 23 subcohorts in 10 European countries (Denmark, France, Greece, Germany, Italy, the Netherlands, Norway, Spain, Sweden and the United Kingdom), providing a wide range of cancer occurrence rates, lifestyle and dietary habits. The EPIC subcohorts represent heterogeneous groups that were population based (Bilthoven centre of the Netherlands, Greece, Germany, Sweden, Denmark, Norway, Spain, Italy, Cambridge centre of the United Kingdom and part of the Oxford centre of the United Kingdom), health-conscious individuals (a majority of the Oxford centre of the United Kingdom), participants in breast-screening groups (Utrecht centre of the Netherlands) or teachers and school workers (France). In France, Norway, the Utrecht centre of the Netherlands and the Naples centre of Italy, all subjects were women. For this study, the initial 23 EPIC administrative centres have been redefined into 27 geographical regions relevant to the analysis of dietary consumption patterns (Slimani et al., 2002a). The EPIC study was approved by the ethics review boards of the IARC (International Agency for Research on Cancer) and all local EPIC centres. All EPIC participants provided informed consent.
Within the design of the EPIC study, a subsample of each study centre was randomly (age, sex stratified) chosen for the application of a standardized 24-h dietary recall (24-HDR) assessment gathered using computerized software (EPIC-SOFT) (Slimani et al., 1999, 2000). This subcohort is referred to as the EPIC Calibration Substudy and was undertaken between 1995 and 2000. Each participant provided a single 24-HDR in a face-to-face interview (Slimani et al., 1999), except in Norway where it was obtained by telephonic interview (Brustad et al., 2003). By design, the sampling procedures of the EPIC Calibration Substudy were defined to control for seasonal and day-of-the-week variations in dietary intake (Slimani et al., 2002a). In total, complete 24-HDR information exists on 36 994 subjects (13 486 men and 23 508 women), representing ∼8% of the entire EPIC cohort. A total of 36 034 subjects with 24-HDR data were included in this analysis, after exclusion of 960 subjects aged under 35 or over 74 years, because of low participation in these age categories. Using EPIC-SOFT, information on the intake of all foods and beverages was collected, described, quantified, entered and coded according to common rules. The classification of the EPIC-SOFT food groups and food subgroups used in the calibration study is derived from a system described in detail elsewhere (Slimani et al., 2002a).
Intakes of retinol, β-carotene, vitamin D and vitamin E were estimated using the ENDB project (Slimani et al., 2007). Although the ENDB values are obtained from country-specific food composition tables, they are standardized as much as possible across the EPIC countries by matching EPIC foods to the national databases, deriving the nutrient values of unavailable foods, and imputation of missing values using common procedures and algorithms (Slimani et al., 2007).
Data on other lifestyle factors, including education level, total physical activity and smoking history considered in this analysis, were collected at baseline through standardized questionnaires and clinical examinations, and have been described elsewhere (Riboli et al., 2002, Slimani et al., 2002a). Data on age as well as body weight and height were self-reported by the participants during the 24-HDR interview. The mean time interval between these baseline questionnaire measures and the 24-HDR interview varied by country, from 1 day to 3 years later (Slimani et al., 2002a).
Intakes of retinol, β-carotene, vitamin D and vitamin E were calculated as least square means and standard error (s.e.) by EPIC centre (ordered from southern to northern European centres), by age (10 year categories from 35 to 74), by gender, as well as by combined values for all centres and for men and women. The main food groups contributing to the intake levels of each of the above-mentioned nutrients were also determined. The statistical models were adjusted for age as well as a set of weights to control for the day of the week (Monday–Thursday; Friday–Sunday) and season (Spring, Summer, Autumn, Winter) of the 24-HDR collection (referred to as ‘minimally-adjusted model’). Models with further adjustments for height, weight and total energy intake were also run and are referred to as fully adjusted models in this text.
Differences in intake levels were compared according to categories of education level (none/primary, technical/secondary, university or higher), smoking status (smoker, former smoker, never smoker), level of physical activity (active, moderately active, moderately inactive, inactive), body mass index (BMI; <25, 25 to <30, ⩾30 kg/m2) and European region (South: all centres in Greece, Spain, Italy and the south of France; Central: all centres in the north-east and north-west of France, Germany, the Netherlands and the United Kingdom; North: all centres in Denmark, Sweden and Norway). P-values for trend across age categories were computed. Statistical significance of differences in intake levels by each of these stratifications was assessed and P-values <0.05 were considered as statistically significant. Statistical significance for differences by gender was also assessed.
Analyses were also carried out to determine the main food source of each of the four nutrients of interest, by study centre and gender. All analyses were conducted using the SAS statistical software (version 9.1, SAS Institute, Cary, NC, USA).
Table 1 shows the mean intakes and s.e.m. for retinol, β-carotene, vitamin D and vitamin E, presented for each centre by gender and also by age range at recruitment. These data are shown with further adjustments for height, weight and total energy intake (so-called ‘fully adjusted model’) in Table A1 in the Appendix. Table 2 shows the overall intake of each nutrient (for all centres combined) stratified by European region, as well as a number of important lifestyle variables that may potentially affect nutrient intake levels. Tables 3 and 4 show the percentage contribution of the main food groups to the intake of each nutrient in men and women, respectively. Table 5 shows the country-specific mean intakes of the nutrients by the season in which the 24-HDR was administered, stratified by gender. For all four nutrients, intakes by the day of the week in which the 24-HDR was administered were sporadic and no remarkable variation was observed (data not shown). In tables presenting information by EPIC centre, the data are arranged geographically from south to north.
Mean intakes of retinol
For men, the mean intake of retinol ranged from 422 (Granada, Spain) to 1715 μg/day (Malmö, Sweden), whereas for women the range was 241 (Ragusa, Italy) to 1219 μg/day (Umeå, Sweden) (Table 1 and Figures 1a and b). In all centres, except in the Florence centre of Italy, men had a higher mean intake than did women. The intakes for women ranged from 13.7 (Navarra, Spain) to 66.5% (Ragusa, Italy) and were lower than those for men. Overall, for all centres combined, men had a significantly higher consumption of retinol than did women (848 versus 600 μg/day, P difference by gender<0.01) (Table 1). Considering centre-specific data, no trends in retinol intake are apparent by age range for either men or women (Table 1). Further adjustments for age, height, weight and total energy intake did not meaningfully alter the observed intake values or patterns (Table A1 in the Appendix).
A clear and statistically significant regional gradient of increasing retinol intakes is apparent from Southern to Northern Europe in both men and women (Table 2). In men, but not in women, a statistically significant difference in intake was also observed by the level of physical activity, with active individuals consuming significantly more retinol than inactive subjects. In both men and women, former smokers had lower retinol intakes than did either never smokers or smokers (Table 2).
Overall, for men, it is clear that the major contributing food sources of retinol are meats/meat products (51.7%), added fats (18.5%) and dairy products (15.6%) with considerable variability between centres (Table 3). Compared with men, women appear to consume slightly less retinol from meats/meat products (44.9%), more from dairy products (20.9%) and a roughly similar amount from added fats (15.8%) (Table 4). For both genders, vegetables and fruits provide no retinol, whereas the other food groups appear to be very small yet consistent sources of this nutrient (Tables 3 and 4).
Mean intakes of retinol show little variation by season (Table 5).
Mean intakes of β-carotene
The intake of β-carotene ranged from 1901 (Umeå, Sweden) to 3907 μg/day (Health Conscious, UK) in men and from 1520 (Asturias, Spain) to 4590 μg/day (North-West, France) in women (Table 1 and Figures 1a and b). In most centres, men tended to have a higher intake of β-carotene than did women (range from 1.5% in Turin, Italy to 24.2% in Asturias, Spain), with the exception of centres in Germany, Denmark and Sweden where the intakes of β-carotene by women were higher (range from 7.0% in Malmo, Sweden to 29.4% in Aarhus, Denmark). However, for all centres combined, the intakes of β-carotene were relatively similar between men and women (2760 versus 2887 μg/day, P difference by gender=0.10; Table 1). No remarkable trends in β-carotene intake are apparent by age range (Table 1). Further adjustments for age, height, weight and total energy intake did not meaningfully alter the observed intake values or patterns (Table A1 in the Appendix).
Differences in the levels of β-carotene intake were apparent by European region in both men and women (Table 2). Men and women from Central European countries consumed a statistically significantly higher level of β-carotene than did those from Northern countries, whereas those from Southern countries had an intermediate intake level (Table 2). Subjects in the lowest category of schooling consumed significantly less β-carotene than did those with higher levels of education. This difference was particularly evident in women. Smokers showed a significantly lower intake of β-carotene than did either former smokers or never smokers. In terms of level of physical activity, active men showed a statistically higher level of β-carotene intake than did inactive men, whereas no differences of intake were apparent for women (Table 2).
In complete contrast to retinol, the major contributing food sources of β-carotene in both genders appear to be vegetables (men: 67.8%, women: 70.7%), fruits (men: 7.8%, women: 9.0%) and soups/bouillon (men: 6.6%, women: 7.8%) (Tables 3 and 4). These sources appear to be consistent between centres, with little regional variability.
In both men and women, the mean intakes of β-carotene show little variation by season (Table 5). Compared with the other seasons, the summer intakes of this nutrient are higher in men and women from Spain, Italy, Germany and Sweden. In the UK Health Conscious, intakes for men were highest in the winter and spring, whereas those for women were highest in the summer (Table 5).
Mean intakes of vitamin D
The highest mean intake of vitamin D was in Umeå (Sweden) for both men (9.1 μg/day) and women (6.1 μg/day). The lowest mean intakes were in Ragusa and Varese (Italy) for men (2.1 μg/day) and Florence and Turin (Italy) for women (1.7 μg/day) (Table 1 and Figures 2a and b). Men tended to have higher intakes of vitamin D than did women in most centres, ranging from 4.8% higher in Ragusa, Italy to 41.2% in Navarra, Spain (Table 1). For all centres combined, men consumed 4.9 μg/day compared with 3.4 μg/day for women (P difference by gender<0.01). No clear trends in intake were apparent by age range (Table 1). Further adjustments for age, height, weight and total energy intake did not meaningfully alter the observed intake values or patterns (Table A1 in the Appendix).
Subjects from Northern countries consumed significantly higher levels of vitamin D than did those from Southern countries, with intermediate levels in Central European countries (Table 2). However, for both men and women, no remarkable differences in intake levels were noted for any of the lifestyle variables (Table 2).
For men, the major contributing food group sources of vitamin D are fish/shellfish (41.9%), added fats (21.8%), meats/meat products (9.7%) and dairy products (9.6%) (Table 3). Similar to men, fish/shellfish are also the major sources of vitamin D in women (39.6%) followed by added fats (19.3%), dairy products (10.4%) and meat/meat products (9.4%) (Table 4). In both men and women, fish/shellfish appear to contribute to a greater percentage of vitamin D in Southern than in Central countries, and the reverse appears to be true for dairy products (Tables 3 and 4).
Intakes of vitamin D showed slight sporadic variation by season in most countries with the exception of Greece, Spain and Sweden where both men and women tended to have higher intakes in the summer, compared with the other seasons (Table 5).
Mean intakes of vitamin E
The lowest mean intake of vitamin E in men was in Malmo, Sweden (9.3 mg/day) and the highest in Greece (20.1 mg/day). In women, the mean intake of vitamin E ranged from a low of 7.7 mg/day (Malmo, Sweden and South and East Norway) to a high of 15.2 mg/day (San Sebastian, Spain) (Table 1 and Figures 3a and b). Similar to all the other nutrients, the intakes of vitamin E were higher in men than in women (range from 12.2% higher in Murcia, Spain to 28.4% higher in Bilthoven, the Netherlands). Overall, men consumed 14.5 mg/day, which was significantly (P difference by gender<0.01) higher than the 11.1 mg/day intake for women. For both men and women, no apparent trends in intake were apparent by age range (Table 1). Further adjustments for age, height, weight and total energy intake did not meaningfully alter the observed intake values or patterns (Table A1 in the Appendix).
Men in Southern and Central European regions consumed significantly higher levels of vitamin E than did those in Northern countries (Table 2). Although intakes for women in all three regions were lower than those for men, a clear and statistically significant south-to-north gradient of higher to lower intake was apparent (Table 2). In both men and women, smokers (as well as former smokers in the case of women) had significantly lower intakes of vitamin E than did never smokers. Men who were physically active showed a significantly higher level of vitamin E intake than did men who were inactive, whereas no differences in intake by level of physical activity were apparent for women. In both men and women, subjects in the lowest category of BMI (<25 kg/m2) had significantly higher vitamin E intake than did those in the highest category (⩾30).
In men, the major food group contributing to vitamin E intake is added fats (42.2%), whereas fruits (10.1%), vegetables (8.4%) and condiments/sauces (10.0%) appear to be important contributors as well (Table 3). This appears to be the case in most centres with little variability. In women, the major food group source of vitamin E is also added fats (31.2%), but compared with men a greater percentage is contributed by fruits (12.2%), vegetables (10.9%) and condiments/sauces (13.7%). Similar to men, women also show little variability between centres for food group sources of vitamin E.
In both men and women, there appeared to be little seasonal variation of vitamin E intake (Table 5).
Standardized data across different European countries on overall intake levels, major contributing food sources, lifestyle confounders and seasonal variation of nutrients are not only important for understanding dietary and nutrient patterns in different populations but they may also assist in devising policies pertaining to diet quality, nutritional intake levels and public health. This study has shown that the intake levels and food sources of the fat-soluble nutrients retinol, β-carotene, vitamin D and vitamin E vary to some extent by both gender and European region. This is more than likely a consequence of differences and heterogeneity of dietary patterns across Europe. The populations in this study range from southern European countries, where a diet rich in fruits and vegetables (rich sources of β-carotene and vitamin E) is consumed, to Central Europe, where meat and meat products (rich sources of retinol) are popular, to Northern Europe, where fish (rich sources of vitamin D) are more strongly consumed (Agudo et al., 2002; Welch et al., 2002; Linseisen et al., 2002b, 2006; Slimani et al., 2002b).
In this context, a contrast is apparent in the food sources as well as in the regional-specific intakes of retinol and β-carotene, both of which contribute to vitamin A status in the body. From these data, it is clear that the majority of retinol in both men and women comes from animal products, such as dairy products and meats/meat products. A remarkable regional gradient of retinol intake—lowest in the south and highest in the north––is very apparent in both men and women, suggesting large differences between these centres in the intakes of the main food sources of retinol and, possibly, variations in the nutrient content of specific foods across countries. It is also interesting to note that in the southern centres, dairy products appear to provide a greater proportion of retinol intake than they do in the northern centres. In contrast to retinol, β-carotene is almost exclusively derived from fruits and vegetables. Thus, it would be expected to have a regional gradient of intake somewhat opposite to that of retinol. Yet, although both men and women from the southern regions do have significantly higher β-carotene intakes than do subjects in the north, the subjects from the central region have a significantly higher intake than do those in the other two regions. This is suggestive of a very intricate heterogeneity of dietary patterns in these European regions that merits further insight in terms of the differing fruit and vegetable sources of β-carotene (Agudo et al., 2002) and may be of consequence in terms of associations with the risk of different chronic diseases.
It is also interesting to note that for all nutrients, except β-carotene, men had a higher intake than did women in most centres, and the differences were actually statistically significant when comparing men and women from all centres combined. To a large extent, the apparent gender differences in these non-energy adjusted data may be due to the fact that men consume more food than do women. When these data were adjusted for total energy intake (see Table A1), the gender differences were reduced but still apparent—likely because of the existence of gender-specific dietary patterns. For example, in the non-energy adjusted data, the gender difference was most striking for retinol, where women consumed ∼59% as much as men. This may be because men may consume a greater proportion of their overall diet as meats/meat products—which are the main food source of retinol—than women. Similarly, when considering data for all centres combined, women actually consume a higher amount of β-carotene than do men. This small difference is not statistically significant, but it is likely indicative that women may consume a higher proportion of their diet as fruits and vegetables, which are the main sources of this nutrient. It is interesting to note that in a subset of the population in this study, blood concentrations of β-carotene were also higher in women than in men (Al-Delaimy et al., 2004). Within the EPIC study, blood concentrations of various carotenoids have been identified as dietary biomarkers of the intake of specific fruits and vegetables at an ecological (Al-Delaimy et al., 2005b) and individual (Al-Delaimy et al., 2005a) level. The data also show that blood β-carotene levels follow the north–south European gradient, with the European region, BMI, gender and smoking status being the top predictors of concentration (Al-Delaimy et al., 2004). In our analysis, an inverse relationship was observed between overall dietary β-carotene intakes and BMI, particularly in women. With respect to smoking status, overall β-carotene intake was significantly lower in smokers than in former or never smokers and is probably indicative of different dietary patterns based on smoking status.
Another interesting component of these observations is the intake pattern of vitamin D. As is well known and also apparent from these data, the main food sources of vitamin D are fish/shellfish. In some centres, there was a small contribution of vegetables to overall vitamin D intake. This may be due to vitamin D from the intake of some mushrooms, or it may be as a result of mis-reporting of vegetable intake from mixed dishes that include vitamin D sources, such as eggs or milk. Interestingly, a non-negligible and relatively consistent contribution across centres was observed for meats and meat products to overall vitamin D intake. In fact, this food group has recently been suggested to provide more vitamin D than believed previously and a recent study shows that rickets and osteomalacia can be prevented by higher meat consumption, related in part to its vitamin D content (Dunnigan et al., 2005). The vitamin D contribution of added fats was high in northern EPIC regions, likely because of the high consumption of marine oils. However, dietary vitamin D is only a small component of body vitamin D status as the majority of body vitamin D is produced by sun exposure––that is, in populations with adequate access to sunlight (Holick, 2002). For this reason, higher dietary intake of vitamin D-rich foods to increase body vitamin D status has been recommended for some populations in very northern European regions (Brustad et al., 2004). In this study, perhaps as a conscious effort or as a consequence of supplementation of some food products, subjects in the northern European regions had significantly higher intakes of vitamin D than did those in either the central or southern regions. Similar geographic trends have been observed by some studies considering serum measures of body vitamin D status. A dated report shows higher mean serum vitamin D concentrations in Nordic countries compared with Mediterranean countries (van der Wielen et al., 1995), whereas a more recent systematic review of the European literature suggests a statistically significant positive association between latitude and body vitamin D status in subjects older than 65 years, but not in younger subjects (Mullie et al., 2008). Nevertheless, foods likely contribute little to overall vitamin D sufficiency (Harris, 2008).
Although some of the populations studied herein consume vitamin D in the form of multi-vitamin dietary supplements (Skeie et al., 2009), in other populations the contribution of supplemented vitamin D to overall serum vitamin D levels has been shown to be minimal (Yetley, 2008). On this latter point, it is important to note that the data presented in this study pertain only to intake from dietary sources and do not include supplement intake. The only exceptions are of course for foods that are directly supplemented with a nutrient, such as vitamin D in dairy products in some European countries. However, vitamin A (retinol), vitamin E and, more recently, vitamin D are very common as dietary supplements. Thus, the overall intakes of each of these nutrients may be higher in subgroups that regularly consumed dietary supplements containing these nutrients.
In both men and women, the overall intake of vitamin E showed an interesting difference by European region (higher intake in the south, lower in the north) and by BMI (higher intake with lower BMI). These observations may be related to the food sources of vitamin E, which is primarily derived from vegetable oils. Thus, the gradient of intake by European region may be due to the higher intake of vegetable oils in the south compared with the north, where butter and mixed fat margarines are consumed more than in the south (Linseisen et al., 2002a). The gradient of intake by BMI may be similarly related to varying dietary patterns of food sources vitamin E. For example, those with lower BMI may be consuming more fruits, vegetables and vegetable oils (all sources of vitamin E), whereas those with higher BMI may be consuming more butter and meats/meat products and less fruits and vegetables. Similar variations in dietary patterns may also explain differences in vitamin E intake by smoking status.
For all the nutrients presented in this study, very little variation in intake was observed by the day of the week (data not shown) or season in which the 24-HDR was administered. Intuitively, it is likely that there are some inter-individual differences in intake and dietary patterns from weekday to weekend and from season to season, but they are not being well observed herein at the population level because all these data are derived from a single 24-HDR. This limitation does not allow for any study at the individual level. On the topic of limitations, it must also be noted that although this is the largest study looking at the dietary intake levels of these nutrients, not all EPIC populations were population-based and hence these findings should not be extrapolated to general populations in each country or region.
The results presented in this study originate from the ENDB, a nutrient database that has been standardized across all the countries involved in the EPIC study. The lack of a standardized nutrient database has been a major obstacle to obtaining comparable nutrient intake data across Europe. The ENDB is the first initiative to take into account differences in the types of food available and methods for the calculation of micronutrient and macronutrient composition of foods across the different populations enrolled in the EPIC study.
In summary, the data presented in this study show some very interesting gender- and region-specific differences in the intakes of retinol, β-carotene, vitamin D and vitamin E in 10 European countries with great heterogeneity in dietary patterns as well as incidence of cancer and other chronic diseases. Given the essential metabolic roles of these fat-soluble nutrients, these observations may provide a basis for further studies exploring potential aetiological links between the intake of these nutrients and chronic disease risk in these countries.
Conflict of interest
M Jenab has received grant support from the World Cancer Research Fund. S Shakya-Shrestha received grants support from the British Heart Foundation. P Wallström received lecture fees from Prenet AB. S Bingham has received grant support from MRC Centre. The remaining authors have declared no financial interests.
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The work described in this paper was carried out with the financial support of the European Commission: Public Health and Consumer Protection Directorate 1993–2004; Research Directorate-General 2005; Ligue contre le Cancer (France); Société 3M (France); Mutuelle Générale de l’Education Nationale; Institut National de la Santé et de la Recherche Médicale (INSERM); Institut Gustave Roussy; German Cancer Aid; German Cancer Research Center; German Federal Ministry of Education and Research; Danish Cancer Society; Health Research Fund (FIS) of the Spanish Ministry of Health; Spanish Regional Governments of Andalucía, Asturias, Basque Country, Murcia and Navarra and the Catalan Institute of Oncology; and ISCIII RETIC (RD06/0020), Spain; Cancer Research UK; Medical Research Council, UK; the Stroke Association, UK; British Heart Foundation; Department of Health, UK; Food Standards Agency, UK; the Wellcome Trust, UK; Greek Ministry of Health; Hellenic Health Foundation; Italian Association for Research on Cancer; Italian National Research Council, Regione Sicilia (Sicilian government); Associazione Iblea per la Ricerca Epidemiologica - ONLUS (Hyblean association for epidemiological research, NPO); Dutch Ministry of Health, Welfare and Sport; Dutch Prevention Funds; LK Research Funds; Dutch ZON (Zorg Onderzoek Nederland); World Cancer Research Fund (WCRF); Swedish Cancer Society; Swedish Research Council; Regional Government of Skane and the County Council of Vasterbotten, Sweden; Norwegian Cancer Society; the Norwegian Research Council and the Norwegian Foundation for Health and Rehabilitation. We thank Sarah Somerville, Nicole Suty and Karima Abdedayem for their assistance with editing and Kimberley Bouckaert and Heinz Freisling for their technical assistance.
Guarantors: M Jenab.
Contributors: MJ carried out the statistical analysis, preparation of tables and figures, and wrote the paper, taking into account the comments from all co-authors. NS was the overall coordinator of this project and the EPIC Nutrient Database project. CB assisted in the statistical analysis and preparation of the tables and figures. SS, CHvG, MB, SS-S, BB, HV, MT, CB and PW were members of the writing group and gave inputs on the statistical analysis, drafting of the manuscript and interpretation of the results. EL, MW, NR, AMJ, JL, HB, EV, VD, SS, CS, PF, JM, SN, AAW, RT, MCB-R, MN, HBB-de-M, YTvdS, MJT, AB, ER and SB were local EPIC collaborators involved in the collection of dietary and other data, and contributed to the ENDB project. ER is the overall coordinator of the EPIC study. All co-authors provided comments and suggestions on the paper and approved the final version.
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Jenab, M., Salvini, S., van Gils, C. et al. Dietary intakes of retinol, β-carotene, vitamin D and vitamin E in the European Prospective Investigation into Cancer and Nutrition cohort. Eur J Clin Nutr 63, S150–S178 (2009). https://doi.org/10.1038/ejcn.2009.79
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