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Adherence to the healthy Nordic food
index, dietary composition and lifestyle
- A cross-sectional study in a cohort of Swedish women
Nina Roswall
Cand.Scient., PhD
Danish Cancer Society Research
Center
International Vitamin Conference,
Washington DC, May 2014
Nutrient or dietary pattern approach to diet research?
Nutrients:
• Nutrient specific recommendations (e.g. the Nordic Nutrition
Recommendation)
• Dietary supplements
• Fortification
=> Deficiency diseases
Dietary patterns:
• Nutrients interact with other nutrients and food compounds
• Present-day nutrition-related health problems are primarily related to overconsumption rather than deficiency in industrialized countries
=> Lifestyle Diseases
The dietary pattern approach – an example
Mediterranean diet - hits in Medline
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Has been found associated with a decreased risk of CVD,
obesity, type 2 diabetes, cancer etc.
Dissemination of dietary patterns
Questionable that such a regionally defined diet is
applicable universally:
• Adoption of unfamiliar foods may be difficult to implement in
other cultures – especially among those mostly in need of a
dietary change!
• It is easier to increase intake of well known foods
• Also: Locally grown foods are eco-friendly, sustainable and
economic
Local diets…
Modern day Nordic Diet:
Slimani et al, 2002, Public Health Nutrition
Healthy components of the traditional Nordic Diet
•
•
•
•
•
•
Berries
Cabbages
Root vegetables
Dark bread/Whole grain
Fish/Shellfish
Apples/Pears
Health effects of a Nordic diet
Vitamins, antioxidants,
N-3 fatty acids
CVD, inflamatory
markers
Phytochemicals,
Vitamin K, N-3 fatty
acids, Antioxidants,
Fiber, Carotenoids
Cancer
Dietary fiber, Betacarotene
Cancer
Phytoestrogens, Vitamins,
minerals, antioxidants
Diabetes, CVD, colorectal
cancer
N-3 fatty acids, Vitamin D,
Selenium
Prevention of stroke,
Reduced blood pressure,
Anti-inflammatory
Vitamins, Minerals,
Phytochemicals, Dietary
fibers, Polyphenols
CVD, to some extent
cancer
Nordic diet in the Swedish WLH cohort
-Dietary composition and lifestyle
Nordic diet in the Swedish WLH cohort
Objective:
Study cohort:
• To investigate the adherence to • Swedish women aged 30-49
a healthy Nordic Food Index,
years at recruitment (1991–
and compare dietary
1992)
composition, nutrient intake,
• Selected by random sampling
and lifestyle among adherenceusing the individual, national
groups
registration number
• 96.000 women invited, 49.259
accepted.
• 45.277 women included in the
present study based on
information on the included
variables
Nordic diet in the Swedish WLH cohort
• Six month recall FFQ administered,
including 80 food items
• Energy and nutrient intake was
calculated using nutrient
composition tables from the
Swedish National Food
Administration database
• These were compared to the Nordic
Nutrition Recommendations:
• Energy percentages (carbohydrates,
protein, fat alcohol)
• Absolute daily intakes (g/day) (fibre,
sodium)
• Nutrient density per MJ (Vitamin A, C, D, E,
folate and iron)
• The Nordic Nutrition
Recommendations are published
every 8th year by the Nordic Council
of Ministers
• They are the main reference point
for nutritional recommendations in
the Nordic countries
The healthy Nordic Food Index in the present study
1 point for above-median intake of:
• Wholegrain bread
• Oatmeal
• Apples/pears
Intake of the food components included in the healthy
Nordic Food Index (g/day) in the cohort
Median
25th
75th percentile
percentile
Whole
0
0
24.6
grain bread
• Cabbages
Oatmeal
0
0
16.4
• Root vegetables
Apples and
35.2
17.6
61.5
pears
Cabbagea
8.1
2.8
14.5
Root
11.0
5.3
25.6
20.7
13.7
30.5
• Fish/shellfish
(Olsen et al, J Nutr, 2011)
vegetablesb
Fish and
• When the median was 0, we gave 1
point for any intake of wholegrain
bread (42%) and oatmeal (40.3%)
• Score: 0-6 points
• Low adherence: 0-1, medium: 2-3,
High: 4-6 points
shellfishc
a
White and red cabbage, cauliflower, broccoli and
Brussels sprouts
b
Carrot, yellow turnip and beetroot
c
Atlantic herring, herring, mackerel, salmon, cod,
pollock, pike and seafood
Participant characteristics
healthy Nordic food index score
All
0-1
2-3
4-6
n=45,277
n=9395
n=20,891
n=14,991
Those with the
highest score were:
Mean age (SD)
39.2
(5.7)
38.7
(5.9)
39.2
(5.7)
39.4
(5.7)
• Older
Mean education,
12.2
(3.0)
11.8
(2.9)
12.2
(3.0)
12.6
(3.0)
23.5
(3.7)
23.3
(3.7)
23.5
(3.7)
23.6
(3.6)
• More educated
• Slightly higher
mean BMI
years (SD)
Mean BMI (kg/m2)
(SD)
Physical activity level, N (%)
• More physically
active
-1 (very low)
1805
(4.0)
608
(6.5)
842
(4.0)
355
(2.4)
-5 (very high)
3669
(8.1)
615
(6.6)
1627
(7.8)
1427
(9.5)
• Less likely to
smoke
Smoking status, N (%)
-Never
18692
(41.3)
3270
(34.8)
8408
(40.3)
7014
(46.8)
-Past
13413
(29.6)
2540
(27.0)
6167
(29.5)
4706
(31.4)
-Current
13172
(29.1)
3585
(38.2)
6316
(30.2)
3271
(21.8)
Intake of food groups and energy by Index score
We found:
90
• A trend of increased intake of all
components of the healthy Nordic
Food Index with increasing score
80
• But also with components not
included in the Index:
• Red meat (56 g/day in high-adherers vs.
46 g/day in low-adherers)
• Processed meat (32 vs. 26 g/day)
• Sweets (62 vs. 46 g/day)
• Potatoes (84 vs. 67 g/day)
• Total energy (7240 kJ (1730 kcal)/day vs.
5669 kJ (1354 kcal)/day)
70
60
50
40
30
20
10
0
HNFI 0-1
HNFI 2-3
HNFI 4-6
Dietary composition by adherence groups,
compared to NNR–recommendations
Those achieving a high score had:
• a higher carbohydrate intake
(52 vs. 50 E%)
• A lower intake of alcohol (1.4
vs. 2.0 E%), saturated (13 vs.
15 E%) and mono-saturated
fats (10 vs. 11 E%)
• A similar E% from protein and
polyunsaturated fat
• Compliance with the NNR was
similar across groups, but a bit
better among high-adherers
60
50
40
30
NNR low
HNFI 0-1
20
10
HNFI 2-3
HNFI 4-6
NNR high
0
Micronutrient density per MJ by adherence groups,
compared to Nordic Nutrition Recommendations
• Those achieving a high Index-score
had a higher micronutrient density
• Despite this, they only reached the
NNR for Vitamins A, C and iron,
whereas the low adherers reached
the recommendations for vitamin A
and iron only
25
20
15
NNR
HNFI 0-1
HNFI 2-3
10
• The proportion of micronutrients
coming from the healthy Nordic
Food Index was between 28.8%
(vitamin A) and 11.4% (iron)
among high-adherers, compared to
between 13.2% (vitamin C) and
6.0% (iron) among low-adherers
HNFI 4-6
5
0
Vitamin Vitamin Vitamin Vitamin Folate Iron (mg)
A
C (mg) D (µg) E (mg) (µg/10)
(RE/10)
Existing studies…
We have identified no previous
studies examining the dietary
composition in relation to adherence
to a healthy Nordic Diet Index.
But studies on adherence to the
Mediterranean Diet Score have found
similar results. High adherers had:
In relation to individual characteristics
of the adherers, they were:
• more physical activity
• Had a lower alcohol intake
• fewer were smokers
• On average older than non-adherers
• Less likely to be overweight
• Higher intake of carbohydrates, PUFA, n-3
fatty acids, fibre, folate, vitamin C, E and iron
• Similar protein intake
• Lower saturated fat intake
Suggesting that the mechanisms
through which the dietary patterns
assert their health-beneficial effects
could be similar
Patino-Alonso MC, J Acad Nutr Diet, 2013; Hu EA, PLoS One, 2013; Olmedo-Requena R, Public Health
Nutr, 2013; Sanchez-Villegas A, Eur J Clin Nutr, 2003; Filippidis FT, Public Health, 2011; Bonaccio M,
Appetite, 2013; Boghossian NS, Eur J Clin Nutr, 2013; Schroder H, J Nutr, 2004; Tyrovolas S, Int J
Food Sci Nutr, 2009; Romaguera D, J Nutr, 2009
Discussion
We found a direct association between • Taken together, our results
adherence and dietary items with no
suggests that residual confounding
or adverse health-effects:
could operate in studies on Nordic
• Potatoes
Diet and health outcomes, if not
• Red/processed meats
controlled properly
• Sweets.
• Included because they represent an
important part of total energy intake
We also found a direct association
with energy intake.
This may be explained by:
• Higher energy expenditure among highadherers, given their higher level of
physical activity
• Higher degree of underreporting among
low-adheres
• The fact that we see an association
with both a healthy lifestyle and
unhealthy dietary items not
included in the Index suggest that
residual confounding could operate
in both directions; both
strengthening and diluting
associations between the healthy
Nordic Food Index and outcome.
Take home message
• In conclusion, a high score on the
• Given the increasing focus on
healthy Nordic Food Index was
Nordic diet, there is a need for
associated with being older, higher
further clarification of the
educated, non-smoking, and having
association between adherence to
a higher physical activity level, and
such diet, dietary composition, and
higher intake of fibre and a higher
lifestyle, to allow causal
micronutrient density
interpretation of future studies on
adherence and health outcomes
• Despite this, high-adherers did not
reach the NNR for several
micronutrients
• High-adherers also had a higher
intake of more questionable dietary
items: Red/processed meats,
potatoes, and sweets.
Thank you!
Danish restaurant NOMA
(Short for ”Nordic food” in
Danish), serving only New
Nordic Cuisine, won the
title as the Worlds best
restaurant in 2010, 2011,
2012 and 2014