Mineral needs in Europe as compared to the global situation

Mineral needs in Europe as compared to the global situation Alexa L. Meyer; Ibrahim Elmadfa Department of Nutritional Sciences, University of Vienna, Austria

sefaoncul/istockphoto.com Europe a land of plenty?

Overweight and Obesity in EU- Adults Elmadfa et al. European Nutrition and Health Report 2009 3

Prevalence of overweight and obesity in European children (4-9 y)

Iron deficiency in overweight children (n=321) mean age: 11.3±3.6 y (range 3 19 y) Percentage of hypoferremic subjects (<8 µmol/l, <45 mcg/dl) Normal weight 4.4 Overweight 12.1 Obese 38.8 Pinhas-Hamiel et al. Int J Obes 2003, 27: 416 418

Prevalence of iron deficiency in 12- to 16-year-olds. Nead K G et al. Pediatrics 2004;114:104-108 2004 by American Academy of Pediatrics

Zinc status in obese children and adolescents from Southern Italy Serum Zn (µg/dl) Erythrocyte Zn (pg/10 6 RBC) Obese (n=96) 4-11y 11-16y Control (n=53) Obese (n=47) Control (n=111) 83±2* 93±5 86±4* 98±2 854±20 826±40 920±33 987±48 * significant difference between obese and normal age-matched subjects Obesity defined by a BMI 95th age percentile Modified from Perrone et al., Nutr Res 1998, 18 (2): 183-189.

Zinc status in obese children (11-14y) Reference: 75 110 μg/dl N=23 obese, 21 control Fig. 1. Percentage of distribution of plasma zinc concentration in obese individuals and control group. Marreiro et al. Biol Trace Elem Res 2002, 86: 107

Zinc status in obese children (11-14y) Reference: 40 44 μg/g Hb Reference: 300 600 μg Zn/24 h Fig. 2. Percentage of distribution of erythrocyte zinc concentration in obese individuals and control group. Fig. 3. Percentage of distribution of urine zinc concentration in obese individuals and control group. Marreiro et al. Biol Trace Elem Res 2002, 86: 107

Anaemia: also an issue in Europe WHO 2008: Worldwide prevalence of anaemia 1993 2005: WHO global database on anaemia.

de Benoist B et al., eds.: Iodine status worldwide. WHO Global Database on Iodine Deficiency. Geneva, World Health Organization, 2004

Region or country Selenium intake a Canada 98-224 United States, all China India New Zealand, low-selenium area 11 ± 3 Finland United Kingdom 60 (1974) 43 (1985) 32 (1994) 33 (1995) France 47 Italy 41 Sweden Germany 38-48 Slovakia 27 ± 8 80 ± 37 (all) 90 ± 14 (men) 74 ± 12 (women) 216 (seleniferous area) 3-11 (Keshan disease area) 2.6-50 (Kaschin-Beck disease area) 13.3± 3.1 (disease-free area) 1338 (seleniferous area) 27 (vegan low income) 48 (conventional diet) 26 (before Se fertilization) 56 (after Se fertilization) 40 ± 4 (conventional diet, South Sweden) 10 (vegan diet) Modified from FAO/WHO (2002). Human Vitamin and Mineral Requirements. Report of an expert consultation, Bangkok Thailand. Chapter 15 Selenium. Available at: http://www.fao.org/docrep/004/y2809e/y2809e0l.htm#bm21.1

European Nutrition and Health Report 2009: Nutrient Intake in the EU Summary (valid for all age groups) Level of recommendation Fat SFA Cholesterol Carbohydrates (esp. complex) Dietary fibers + Energy Balance Sodium Vitamin D Folate Calcium Iodine Iron (in women)

1200 1000 800 Calcium Intake of Ca, I, Fe in adults in Europe by region mg/d 600 400 200 0 North CEE West South men women Iron Iodine 25 µg/d 350 300 250 200 150 100 50 mg/d 20 15 10 5 0 North CEE West South 0 North CEE West men women men women Elmadfa et al. European Nutrition and Health Report 2009.

Intake of trace elements in adults IOM, 2000 and SCF, 1993 Elmadfa et al. European Nutrition and Health Report 2009.

Elmadfa et al. European Nutrition and Health Report 2009. Intake of trace elements in adults

Iron and Zn status in Spanish adults Intake <2/3 RDA Fe Zn Hb (men < 13, women < 12mg/dl) % of population with intakes and biochemical parameters below the respective reference levels Total Men Women 22.45 56.45 2.63 44.36 43.13 69.06 5.93 2.35 9.23 Iron deficiency a 12.7 10.3 14.5 Iron deficient anaemia b 2.1 0.8 3.0 Plasma Zn <70 µg/dl 17.80 17.06 18.48 a defined as the presence of at least 2 abnormal levels among 4 markers of Fe status (plasma Fe, total Fe binding capacity, transferrin saturation, MCV) b defined as levels below normal of Hb, MCV, MCH, MCHC Sánchez et al. J Nutr Biochem 2009, 20: 125-131.

Selenium status in Spanish adults 86.5% of participants had Se plasma levels < 125 µg/l, the threshold for maximal GSH Px activity. Maximization of plasma GPx and selenoprotein P Sánchez et al., Sci Total Environ 2010, 408: 1014-1020.

Fruit and vegetable consumption in Europe Elmadfa et al. European Nutrition and Health Report 2009. Using data from the EFSA Concise Food Consumption Database

Mineral content of plant foods in Germany over time German Nutrition Report 2004

POPULATION GROUPS REQUIRING SPECIAL ATTENTION

Life expectancy in Europe 2008 (EU-27) 76.4 82.4 Eurostat 2004, 2011

Europe: an ageing population Austria: 17.6 a 28.2 b The Statistical Handbook of Japan 2011, Chapter 2 Population. Statistics Bureau, Japan. www.stat.go.jp/english/data/handbook/index.htm a Statistik Austria; b Eurostat, EUROPOP2008 convergence scenario.

Mineral intake in elderly Europeans by region Elmadfa et al. European Nutrition and Health Report 2009.

Mineral intake in elderly Europeans by region Elmadfa et al. European Nutrition and Health Report 2009.

Elmadfa et al. European Nutrition and Health Report 2009. Intake of trace elements in elderly

Elmadfa et al. European Nutrition and Health Report 2009. Intake of trace elements in elderly

Mineral intakes in Viennese elderly ( 55 y) Elmadfa et al. Austrian Nutrition Report 2003.

Status of minerals in Viennese elderly aged 60 y (n=224, 87% women, 26% institutionalised) Elmadfa et al. 2 nd Viennese Nutrition Report 2004

Lower zinc absorption in elderly men N=9 young men 18-22y, 6 elderly men 67-83y N=6 young men 22-30y, 6 elderly men 65-74y Adapted from August et al. Am J Clin Nutr 1989, 50: 1457-1463. Turnlund et al. J Nutr 1986, 116: 1239-1247.

Zinc status in Spanish adults P<0.05 Sánchez et al., Sci Total Environ 2010, 408: 1014-1020.

Trace element status in Spanish adults Sánchez et al., Sci Total Environ 2010, 408: 1014-1020.

Mineral intake in Austrian pregnant women Data obtained from 24h recalls Elmadfa et al. Austrian Nutrition Report 2008.

Critical trace elements in pregnancy: Status in Austrian women % of pregnant women Markedly reduced marginally reduced normal Elmadfa et al.: Austrian Nutrition Report 2008

Nutritional status of Austrian pregnant women: Critical micronutrients Intake n=426 Austrian women Status n=113 Viennese women Ca I Fe Zn Elmadfa et al. Austrian Nutrition Report 2008.

EFFECTS OF NUTRITION TRENDS

Energy-reduced diets Polish RDA Grzybek et al. Eur J Clin Nutr 2002, 56: 1162 1168.

Iron in different meat types mg/100g fresh wt 5 4 3 2 1 0 0,77 2,63 0,8 0,73 0,24 0,39 0,28 0,45 Beef Pork Chicken Turkey It is often recommended to reduce red meat intake. However, red meat is a good source of iron, especially soluble haem iron that is best available, and thus, has its place in a well balanced diet. haem non-haem Modified from Lombardi-Boccia et al., J Food Sci 2002, 67(5): 1738-1741

Vegetarian lifestyle Corriere della sera, 2009 http://www.corriere.it/primo_piano/cronache/2009/02/12/pop_mappa.shtml

Intake of minerals and trace elements in Austrian adults by diet Elmadfa et al.: Austrian Nutrition Report 2008

Iron status of Austrian adults by diet Fe < 10.74 µmol/l (Sauberlich, 1999) Hb < 12g/l in women, <14g/l in men Glatzl, Master thesis at the Department of Nutritional Sciences, University of Vienna, 2004

Zinc status of Austrian adults by diet Reference (Sauberlich, 1999) deficient <11.5 µmol/l marginal 11.5-13 µmol/l sufficient 13-19 µmol/l Glatzl, Master thesis at the Department of Nutritional Sciences, University of Vienna, 2004

FOOD FORTIFICATION AND SUPPLEMENTATION THE SITUATION IN EUROPE

Fortification in some European countries Mandatory fortification is not widely practised. - UK: Fe, Ca, thiamin, niacin in white and brown (81% extraction) flour - Austria, Switzerland, Poland & Denmark: Salt iodisation - UK, Ireland, Belgium Poland Vit. A and D in margarine, voluntarily in many other countries Code of Practice of the International Margarine Association of the Countries of Europe (IMACE) Voluntary salt iodisation is common. - Germany, Italy, Spain, Finland, Netherlandsand: use of iodised salt by the food industry encouraged. Otherwise, voluntary fortification of some foods is more or less common, especially in breakfast cereals.

Estimated proportion of industrial-scale wheat flour being fortified in 2007 WHO, FAO, UNICEF, GAIN, MI, & FFI. Recommendations on wheat and maize flour fortification. Meeting Report: Interim Consensus Statement. Geneva, World Health Organization, 2009

Flour fortification with Iron in Denmark from 1954 to 1987 mandatory fortification of flour 30 mg elementary iron per kg flour after cessation of the national iron fortification program regular survey of iron status of the population prevalence of iron overload increased after cessation of fortification (BfR 2004)

Food fortification with iron in Germany Previously, only allowed for breakfast cereals: 8 mg iron-(iii)-diphosphate per 100 g cereals 14 mg elementary iron per 100 g Since 2006, fortification of food with iron allowed within EU legislation. However, the BfR (German institute for risk assessment) does not advise food fortification with iron unless there is medical need and the addition is adequatly controlled in light of potential adverse effects of chronic high iron intake (evidence of higher risk of coronary heart diseases and cancer) BfR Opinion, No. 016/2009, 2 March 2009 http://www.bfr.bund.de/cm/349/use_of_iron_in_food_supplements_and_for_the_forti fication_of_food.pdf

Flour fortification in Eastern Europe Many countries of Eastern Europe have a lower economic standard than the rest of the continent. Anemia in children and women is common. Mandatory flour fortification is envisaged in Romania, Bulgaria, Belarus, Ukraine, the Russian Federation, Moldavia, Georgia.

Frequency of fortified micronutrients in Austria Vitamins n Minerals/ trace elements C 342 (73 %) Ca 109 (23 %) B 1 218 (47 %) Fe 76 (16 %) B 6 203 (43 %) I 40 ( 9 %) Niacin 175 (37 %) Mg 33 ( 7 %) B 2 168 (36 %) P 33 ( 7 %) E 265 (35 %) Pantothenic Mn 2 (0,4 %) acid 144 (31 %) Cr 2 (0,4 %) D 27 ( 8 %) Se 2 (0,4 %) K 8 ( 2 %) F 2 (0,4 %) Mo 1 (0,2 %) n

Micronutrient Contribution of fortified foods to total intake of various micronutrients in Viennese adults (%) Vitamin C 28 Vitamin B6 26 Biotin 22 Vitamin B1 20 Pantothenic acid 19 Vitamin B12 16 Vitamin E 16 Vitamin B2 15 Folic acid 15 Niacin 13 Iron 9 Vitamin A 8 Calcium 8 Magnesium 7 Phosphorus 4 Zinc 4 Vitamin D 2 Elmadfa et al. Viennese Nutrition Report, 2004

Adapted from: Elmadfa et al.: Austrian Nutrition Report 2008 The impact of food diversity

Many of the minerals critical at a global level are so in Europe as well: iron, zinc, iodine Deficiency is rarely severe and mostly subclinical Intake does often not correlate with status importance of status assessment

Contributing to inadequate supply: Wide availability and low prices of highly refined energy-dense but nutrient-poor foods Low consumption of good food sources for instance fruit, vegetables, whole grain cereals, fish Reluctance to fortify food Special diets esp. for weight reduction Age-/disease-related malabsorption

From traditional to new concepts in nutrition: new frontiers in nutrition science Adequate nutrition Optimal nutrition Survival Hunger satisfaction Food quality/ safety Health promotion/disease prevention: Improving well-being Reducing the risk of chronic diseases

Thank you for your attention! Institute of Nutritional Sciences University of Vienna Althanstr. 14 A-1090 Vienna, Austria Tel.: +43 1 4277-54901 Fax.: +43 1 4277-9549 E-mail:nutrition@univie.ac.at Internet:http://www.univie.ac.at/nutrition/