Dietary data in Europe European surveys

In Europe, there is a need for sources of dietary data that would provide a regular and comparable flow of information. A limited number of studies on documenting and monitoring the dietary intake in Europe have been conducted. The EPIC and SENECA projects are examples of studies that developed procedures to allow the collection of harmonised data across countries. DAFNE is an example of a European project that aimed at achieving post-harmonisation of data already collected.

2.5.1 The DAta Food NEtworking (DAFNE) initiative

The DAFNE initiative aims at exploiting the HBS-derived data for nutritional purposes and developing a cost-effective food databank, based on data collected in the European HBSs. The project has been successful in developing the methodology for harmonising food, demographic and socio-economic data collected in the HBSs of fourteen European countries (Belgium, Croatia, France, Germany, Greece, Hungary, Italy, Luxembourg, Norway, Poland, Portugal, the Republic of Ireland, Spain and the United Kingdom). The project is coordinated by the Department of Hygiene and Epidemiology of the Medical School, University of Athens, Greece.

The initial objective of the DAFNE project was the creation of comparable categories of food and socio-demographic information, allowing intra- and inter-country comparisons of nutritional habits and the identification of socio-demographic variables affecting them. Although several socio-demographic characteristics are recorded in the HBSs and many of them are included in the final roster of variables to be studied, the DAFNE team is currently focusing on locality (degree of urbanisation of the area where the household was situated), education and occupation of household head, as well as on household composition. These variables are used for the characterisation of the socio-demographic status of the household.

The development of a food classification system that would allow international comparisons of dietary patterns was a central element in the development of an HBS-based European food databank One of the intermediate results of the harmonisation procedure is the development of the DAFNE food classification system, which allows the categorisation of HBS-collected food data into 56 detailed subgroups. These subgroups can be aggregated at various levels ending up at 15 main food groups (Lagiou et al, 2001). The feasibility studies undertaken in the context of the DAFNE project demonstrated that the prospect of using HBSs for the assessment of dietary information is realistic and the potential considerable, assuming political will, administrative support and a minimal adjustment in infrastructure (Trichopoulou and Lagiou, 1997b, 1998).

In order to evaluate the nutritional information available in the DAFNE databank, a comparison of individualised HBS data with food consumption values derived from specially designed IDSs has recently been undertaken (Naska et al, 2001a, 2001b; Vasdekis et al, 2001). Preliminary results of this analysis show that there is considerable scope in using the DAFNE databank to achieve an average estimate of the populations' food habits, to run international comparisons and to complement with regular information the data collected in the specially designed individual dietary surveys.

2.5.2 The European Prospective Investigation into Cancer and Nutrition (the EPIC study)

The EPIC is a multi-centre prospective cohort study with the aim of investigating the complex relation between nutrition and other lifestyle and environmental factors in relation to the incidence of and mortality from cancer and other diseases (Riboli, 1992). The study is being undertaken in ten European countries (Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain,

Sweden and the United Kingdom) and is co-ordinated by the International Agency for Research on Cancer (IARC) in Lyon, France.

EPIC was initiated in 1990 with pilot and methodological studies to test the validity and feasibility of drawing, determining representative portions and storing biological samples, of taking anthropometric measurements and of collecting data through different types of questionnaires and from variable European populations (Riboli and Kaaks, 1997). Upon the finalisation and the standardisation of the study protocol, the fieldwork was undertaken from 1993 to 1998 and more than 480000 subjects were included in the cohort.

Eligible subjects were generally drawn from the general population, residing in a given geographical area. In some countries different sampling frames were used in order to ensure a good participation rate and complete follow-up; this did not seriously violate the sampling scheme of a cohort study. According to the study protocol, men over 40 years and women over 35 years of age were recruited. The lower age limit for women was selected to ensure a sufficient number of subjects for investigating risk factors for premenopausal cancers. The upper age limit of the cohort is less precisely defined and varies between 60 and 74 years, depending on the study centre.

Standardised protocols have been developed to collect data on the subjects' medical history, current medication, several lifestyle factors, anthropometry, diet and collection of blood samples. Sections of optional questions were added in some cases to address country-specific objectives. The questionnaire on physical activity was the same in the majority of the countries. A standard common protocol was used for the anthropometric measurements, allowing for tests of within-and between-observer variability.

For the dietary assessment, study subjects were requested to complete a centre-specific dietary questionnaire on their habitual food habits. In most countries a semi-quantitative, interviewer- or self-administered food frequency questionnaire was used. Preliminary analyses of the data colleted through the baseline questionnaire were undertaken in the coordinating center and included the estimation of the energy and selected nutrient intake and the daily consumption of major food groups.

Additionally, a random sample from each cohort selected on the basis of the number and age-gender distribution of expected cancer cases was interviewed by trained interviewers using a computerised software programme (the EPIC-SOFT) specially designed to collect standardised 24-hour recalls of foods consumed during the preceding day (Slimani et al, 1999).

In the field of collecting dietary data at a European level, the EPIC project contributed by developing methods for collecting comparable individual dietary intake data in culturally diverse populations. Although EPIC was not primarily aiming at documenting dietary patterns in Europe, the central database includes information on the habitual (using the food frequency method) and the sporadic (using one 24-hour recall) diet of more than 480000 Europeans with heterogeneous dietary habits, covering the diet of Mediterranean regions, the central European food patterns and the dietary habits of the Nordic populations.

2.5.3 MONItor trends in CArdiovascular diseases (the WHO-MONICA study)

The WHO-MONICA (The WHO MONICA Project, 1989; Tunstall-Pedoe et al, 2000) is a collaborative project designed to study the relationship between trends:

  1. In the main cardiovascular risk factors and CVD morbidity and mortality.
  2. In the acute medical care for CHD and the lethality of the disease.
  3. In the incidence of CHD and stroke.

To address the above research questions, data were collected in thirty nine centres in twenty six countries of four continents. Although the MONICA study was not solely undertaken in Europe, the majority of the MONICA populations were Europeans. Two types of databases were set up in each population, within a time period of ten years:

  • One, including cross-sectional data on the prevalence of cardiovascular risk factors in the general adult population, aged 35-64 years. The data collection was undertaken at least twice (one at the beginning and one at the end of the period) and preferably three times within the ten-year period.
  • The second, including longitudinal data on the incidence of CVD through a continuous registration of fatal and non-fatal coronary and/or stroke events.

The project started in the early 1980s and was concluded in the mid-1990s. The most essential criteria and procedures for recruitment and the standardisation of measurements, fieldwork, quality control and data storage are thoroughly described in the MONICA Manual (The WHO-MONICA Project, 1989-1999). A number of quality assessment reports and MONICA-related publications are available at the MONICA website (

The fieldwork for the core study included standardised questionnaires, anthropometric and biological measurements and study of medical records. Quality assurance in MONICA was based on several procedures described in the MONICA Manual, such as international training sessions, continuous internal and external quality control procedures, regular communication with the quality control and reference centres, and the elaboration and publication of several retrospective quality assessment reports. The core data were centralised in the MONICA Data Centre in Helsinki, Finland.

2.5.4 Nutrition and the elderly in Europe - the Euronut-SENECA study

In 1986 the Management Group of the Concerted Action on Nutrition and Health in the European Community (Euronut), decided to embark on a study of nutrition in the elderly. An international longitudinal study was thus initiated to study the effective use of food and food resources to enhance the quality of life in older persons, both in social and biological terms (de Groot et al, 1991). The first phase of the study was carried out in 19 centres of 12 European countries in 1988 and 1989. The follow-up study took place in 1993 in 9 out of the 19 centres. The first part was a cross-sectional study aiming at exploring the dietary patterns of elderly populations living in different European communities and at running international comparisons. The follow-up study provided the opportunity to analyse the effect of ageing and the relation of nutrition and health parameters with age.

Approximately 2600 individuals born between 1913 and 1918 were studied using strictly standardised methodology. The basic protocol was standardised and common to all participating groups. Data were collected on the dietary intake of the subjects, on their nutritional status (by collecting and analysing blood samples), on their anthropometric characteristics, physical activity, life-style, health and performance.

Food consumption data were collected during a personal interview, using a modified version of the dietary history method consisting of two parts: first, an estimated 3-day record including two weekdays and one weekend day, and secondly a checklist of foods. The food record was collected to assist the interviewer in having an idea of the subjects' eating pattern. In order to assess the habitual pattern of intake, subjects were questioned about their usual intake using the preceding month as the reference period. Portion sizes were recorded either by weighing, or were based on standardised household measures. Food consumption data were converted into energy and nutrients by using country-specific food composition tables (Euronut SENECA investigators, 1991).

2.5.5 International studies to address specific objectives

Apart from the four international projects described above, there are numerous other studies with European coverage, designed to address specific, nutrition-related research questions. Although some dietary information is recorded in these surveys, the data collected cannot be informative on the dietary patterns of the populations. Two European studies, with specific nutrition-related objectives, are indicatively presented below.

The calcium intake and peak bone mass (CALEUR) study is a European multicentre study undertaken from 1994 to 1997 in six European countries (Denmark, Finland, France, Italy, the Netherlands and Poland) and coordinated by the TNO-Nutrition and Food Research Institute (Zeist, the Netherlands). CALEUR was a cross-sectional study aiming at evaluating the association between the dietary calcium intake and the radial bone density in two age groups: adolescent girls aged 11-15 years and young women of 20-23 years of age (Kardinaal et al, 1999).

Another international study with specific objectives was the TRANSFAIR study, also coordinated by the TNO-Nutrition and Food Research Institute in the Netherlands. The TRANSFAIR study aimed at determining the trans-fatty acid content of 1299 food samples in fourteen European countries (Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden and the United Kingdom) (Van Poppel et al, 1998), at calculating the trans-fatty acid intake of the fourteen European populations, using data from representative food consumption surveys (Hulshof et al, 1999) and at studying in a cross-sectional design the relationship of

CVD risk factors and trans-fatty acid intake in eight of the above European populations.

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