1. EUCCONET workshop, Bristol 2011 Michelle A. Mendez EARNEST Project Working Group on Comparative Analyses of Diet in Pregnancy Dietary intakes during pregnancy across Europe A collaborative multi-country analysis

2. Background Maternal diet may influence both maternal and child health even without marked deficiencies  e.g. possible effects on child neurodevelopment, asthma, allergy, bone mineralization Relatively little is known about prevailing patterns of intake across different countries and strata

3. Objectives Take advantage of existing data by developing methods to standardize food group intakes in studies including >200,000 women from across Europe  Dietary data collection costly, time-consuming, food-culture specific Specific aims:  Assess the feasibility of adequate standardization Estimates comparable to previous studies?  Conduct a comparative analysis of maternal diet disparities Smoking, weight status, age, education groups  Facilitate future pooled analyses on maternal diet and health

4. Methods Post hoc standardization methods were developed  Candidate food groups selected Meats, seafood, fruits & vegetables  Major contributors to key nutrients: bioavailable iron, docosahexanoic acid, folate  Standardized food group definitions derived Detailed description of items to include in each group/subgroup  Iterative process: initial definitions developed based on English- language translations of core partner FFQs  Within-country disparities in intake Maternal characteristics associated with diet

5. 1. Standardized definitions: Meats 1. Meats (excluding poultry/game birds) Total fresh, processed, organ & other meats (sum of subgroups) (a) Fresh red meatsInclude game meats & mixed dish content; exclude poultry, other white meats, & organ meats (reported separately) (b) Processed meatsInclude sausages, ham, tinned meats & similar items, incl. content of mixed dishes (c) Organ meatsLiver & other organs incl. content of mixed dishes (d) Other red meatsOther meats not included above 2. Poultry & game birdsTotal poultry & game birds, including mixed dish content

6. Standardized food groups/subgroups Fruits and vegetables: including/excluding juices  Whole fruit; fruit juices  Raw and cooked vegetables Meats  Red and processed meats; organ meats  Poultry/white meat Seafood (fresh and frozen/tinned)  Lean fish  Fatty fish (large and small species)  Shellfish

7. 2. Potential participants invited to collaborate Collaborators compiled own intake data, interpreting their local food culture  Detailed list of items included in each food group provided for review e.g. omission of sausages and other processed meats in one country  underestimated total meat intakes  Summary data to be provided: %iles 5, 25, 50, 75, 95; mean±sd Extremes often most relevant for health; distributions skewed

8. 3. Workshop to review preliminary data Standardized presentation format to ensure relevant issues discussed by each collaborator, including  (i) dietary assessment methods and timing  (ii) food item classification  (iii) mean intakes overall, across selected strata Inconsistencies in classification identified, e.g.  Meat/vegetable portions of mixed dishes not consistent  Varying ability to disaggregate subgroups Red/processed meats not readily separable due to differences in use of additives/fillers in items such as hamburgers  e.g. processed = 51% of total in Scotland vs. 18% Portugal

9. 4. Compilation and evaluation of intake disparities using revised food groups Comparisons with other studies to evaluate country intake disparities  EPIC multi-country study Health implications of disparities depend on intake levels Within-country intake disparities  (i) smoking, (ii) age, (iii) education, (iv) obesity Relevant for targetting nutrition policies/programs Confounding patterns? Insightful for joint analyses of health outcomes

10. Results

11. Participating studies Northern Europe (n=5)  Denmark – Danish National Birth Cohort (DNBC)  England – Avon Longitudinal Study (ALSPAC)  Norway – Mother & Child Study (MoBa)  Scotland – SEATON cohort  Sweden – ABIS study Southern Europe (n=4)  Greece – Rhea study  Italy – GEPSII study  Portugal- Generation XXI  Spain – INMA cohorts Western Europe (n=3)  France – EDEN cohort  Germany – LISA cohort  Netherlands – Generation R Central/Eastern Europe (n=3)  Poland - Lublin study  Poland - Krakow study  Austria - Vienna study

12. Varied design, sample size NEnrollment Period Dietary Assessment Northern Denmark: DNBC70,1331996-2002FFQ360 items England: ALSPAC11,8771991-2002FFQ50 items Norway: MoBa54,3501998-2008FFQ255 items Scotland: SEATON1,7101997-1999FFQ150 items Sweden: ABIS15,6591997-1999FFQ22 items† Western France: EDEN1,6102003-2005FFQ137 items Germany: LISA3,0391998-1999FFQ50 items Netherlands: Gen R1,2032002-2006FFQ293 items † Selected components of diet only.

13. Small influence of trimester of collection on overall energy intakes 3rd vs 1st trimester: modest diff in kcals Mendez et al, 2011 2 31 3 1 2 3312

14. Fruits & vegetables

15. Gradient in reported intake levels consistent with expectations Fruits & vegetables (g/day)

16. Levels of fruit intake similar in EARNEST vs. EPIC Mendez et al, AJCN 2011

17. Fruits & vegetables: (i) Smokers reported substantially lower intakes in most regions Northern Western Southern Eastern = disparity >100g (1 serving daily)

18. Fruits & vegetables: (ii) Younger women often reported substantially lower intakes Northern Western Southern Eastern = disparity >100g (1 serving daily)

19. Fruits & vegetables: (iii) More educated mothers had higher intakes in most regions Median intakes: 207–485 g/day Northern Western Eastern = disparity >100g (1 serving daily)

20. Fruit & vegetable intakes in the Mediterranean higher and not related to education Median intakes: 565–600 g/day Mediterranean/Southern

21. F&V: (iv) Overweight women had somewhat lower intakes, exceptions largely Mediterranean Overweight/obese=based on pre-pregnancy BMI Northern Western Southern Eastern

22. Red/processed meats

23. Similar levels of red/processed meat intake in EARNEST vs. EPIC Mendez et al, 2011

24. Red/processed meats: (i) Smokers consistently reported higher intakes Northern Western Southern Eastern =disparity ≈10-15 g/day, 1 serving/wk

25. Other red/processed meat intake disparities Younger women often reported higher intakes More educated women consistently reported lower intakes Overweight or obese women typically reported somewhat higher intakes

26. Seafood intakes Markedly higher in Spain and Portugal  Median intakes ≈ 65g/day, vs. 0–40g/d Substantial proportion exceed 3-4 servings/week  Consistent with expectations, e.g. similar to EPIC Intakes were related to maternal characteristics  Lower levels among smokers, younger, less educated and more obese women

27. Conclusions Feasible to harmonize food group intakes post hoc Widespread disparities in intakes of fruits & vegetables, but also of red & processed meats and seafood Disparities were associated with characteristics predictive of poorer pregnancy outcomes  Smoking in pregnancy, younger age, less education  Pre-pregnancy overweight and obesity: smaller disparities

28. Standardization challenges: food groups Group definitions not always straightforward  Fruit including juices?  Cooked vs. raw weight for vegetables?  Cereal products in servings vs. grams (bread vs pasta/rice cultures)?  Dairy products including cheeses, desserts? Absolute vs. energy-adjusted? Implausible reporters?

29. Harmonization challenges: nutrients Will FFQ food items yield sufficiently precise rankings?  e.g. seafood details may reduce misclassification of DHA intakes in some FFQs compared to others Fortification, supplement use, food varieties  New food products as well as shifting content existing products Food folate or dietary folate equivalents including folic acid? Incomplete or inconsistent food composition data  Definitions of available nutrients Fiber: non-starch polysaccharides or also lignin, resistant starch?  Details on specific fatty acids often lacking

30. Future directions Feasible to standardize/harmonize intakes though care is needed  Nutrients likely more time-consuming EPIC food table compilations for several European countries an important resource soon to be available Collaborative analyses of health effects  Sensitivity analyses to assess impact of variable FFQs