What's behind the Nutritional Recommendations provided to Nordic populations?

1. The evidence behind our dietary
guidelines
Gianluca Tognon
Department of Public Health and Community Medicine
www.gianlucatognon.it

2. Dietary habits in Nordic countries:
common features
• High intake of milk and dairy products, moderate to high
consumption of meat and a moderate consumption of
vegetables and fruit
• A moderate to high intake of fish (lower in Denmark)
• Potatoes and cereal products constitute as major staple
foods
• Common trends in the last 2-3 decades: increased
consumption of low-fat milks and spreads, decreased total
consumption of edible fats, and increased consumption of
cheese, fruit and vegetables
• Cultural and culinary traditions differ among countries

3. Nordic Nutrition
Recommendations (NNR)
• NNR give values for the intake of and balance
between, individual nutrients which are adequate
for development and function as well as
contributing to the risk-reduction in certain diet-
associated diseases
• Food-based dietary guidelines represent a
”translation” of the recommendations on energy
and nutrients to foods and may include
recommendations or advice on food choice,
amounts, frequencies and eating pattern

4. NNR revision
• The last NNR edition (4th) was released in 2004
• A revision is ongoing, with the aim of including new
concepts from areas where new scientific knowledge
has emerged
• Nutrition in specific groups (e.g. children, elderly,
overweight subjects) will be also covered
• Systematic Literature Reviews (SLRs) will be performed
• Established criteria for evaluating the methodological
quality of the included studies and the overall strength
of the scientific evidence will be used and the work
process will include several stakeholders
• The SLRs will be evaluated by external reviewers

5. The choice of studies to be
included into SLRs
• Controlled intervention studies, prospective cohort
studies, case-control studies and systematic reviews
will be included
• Retrospective case-control studies where the
measure of exposure occurred after or concurrent
with the outcome will only be used when results
from other study types won’t be available
• Cross-sectional studies will primarily be used for
describing prevalence and animal studies will not be
used apart from describing mechanisms

6. Target population
• The primary target population for NNR5 is
defined as the general healthy population
• This means that studies focusing on treatment
of patients with overt disease will be excluded
• Studies involving subjects with increased
metabolic risks or pre-disease states, e.g. with
established risk factors,
will be considered

7. Literature search
• The search strategy will be documented, so
that the systematic reviews can be reproduced
and compared with other review as well as
updated as long as new findings emerge
• Preference should be for data published in
peer-reviewed journals, but other sources
such as official or expert reports and
government funded research, may provide
some valuable information

8. Evidence from systematic
reviews and meta-analysis
• Meta-analysis uses statistical methods to
combine multiple studies addressing the same
research question in order to get an overall
estimate
• Meta-analyses can sometimes shed new
insights that individual studies failed to reveal
because of power limitations

9. Forest plots

10. Advantages and
disadvantages
• Potential advantages of meta-analyses include an
increase in power, an improvement in precision,
the ability to answer questions not posed by
invidividual studies, and the opportunity to settle
controversies arising from conflicting claims
• However, they also have the potential to mislead
seriosly, particularly if specific study designs,
within-study biases, variation across studies, and
reporting biases are not carefully considered

12. Present Nordic
Recommendations
(NNR4)

13. Fruit and vegetables
• Important sources of several nutrients (vitamin C, folate,
potassium, fibre, carotenoids and flavonoids) associated to a
low energy density
• A large body of evidence supports the hypothesis that
vegetables and fruit protect from chronic disease such as
cancer (lung, gastrointestinal and hormone-related),
cardiovascular disease and type 2 diabetes and reduce risk
factors (blood pressure, LDL-C)
• Hypothesized mechanisms include: antioxidant activity,
modulation of detoxifying enzymes, stimulation of the immune
system, decrease in platelet aggregation, alteration in
cholesterol metabolism, modulation of steroid hormone
metabolism, blood pressure reduction and even antibacterial
and antiviral activity

14. • In addition to the contribution of these foods
to nutrient intake, they may play a role in
improving the dietary pattern by replacing
other, less favourable foods in the diet
• An increase in vegetables and fruit
consumption to at least 400 g/d would reduce
the cancer incidence by 20% in Sweden
• An increase in the vegetable and fruit
consumption level to 600 g/d has been
estimated to be associated with a 10-20%
reduction in cardiovascular disease incidence

15. Potatoes
• Common staple food in Nordic countries
contributing starch as well as several nutrients
(potassium, vitamin B6, vitamin C and fibre)
• Boiled generally have a high glycaemic index,
but also a high satiating effect
• Based on the glycaemic properties of potatoes
and the lack of data of a protective effect of
potatoe consumption on chronic disease risk,
a restricted consumption of potatoes has been
recommended by some researchers

16. • In some epidemiological studies, dietary patterns
including a high consumption of potatoes have been
associated with increased risk of T2D, CHD and weight
gain
• However, in many of these studies potatoes were
reported as fried and were generally associated with a
dietary pattern characterized by a high consumption of
meat and high-fat and high-sugar foods and a low
consumption of fruit, vegetables and fibre-rich cereals
• In other studies based on dietary patterns,
consumption of e.g. baked potatoes and sweet
potatoes was more frequent in healthy eating patterns
(high consumption of fruit and vegetables, low-fat
dairy products and whole grains) and was associated
with a lower mortality (e.g. Mediterranean diet)

17. Cereals
• A major source of carbohydrate and dietary fibre
in the Nordic diet
• Wholegrain products in particular, provide nutrients such as K, Mg,
vitamin E, folate and antioxidants
• Several observational studies support the beneficial role of
wholegrain consumption or cereal fibre in reducing the risk of CVD
and total mortality
• High wholegrain consumption has also been inversely associated
with chronic disease risk
• The phytochemicals of wholegrain cereals may serve as both
antioxidants and phytoestrogens
• The potential beneficial effects of wholegrain food include lowering
of serum total and LDL-cholesterol, in some cases also
hypotriglyceridaemic effects, antioxidant properties and possibly
also antithrombotic and decreased platelet-aggregating effects

18. Fish and seafood
• Regular fish intake, both fatty and lean, contributes to
iodine, selenium, vitamin D and n-3 fatty acids intake,
and is recommended as part of a balanced diet
• Fatty fish, is a major source of long-chain n-3 fatty acids
• A moderate amounts of fish or n-3 fatty acids from fish is
associated with a lower risk of fatal CHD and in particular
sudden cardiac death, probably via anti-arrhythmic
effects
• The protective effect of fish intake against CHD and
related diseases could also be attributable to
constituents other than n-3 fatty acids such as proteins

19. Milk and dairy
products
• Milk, fermented milks and cheese are traditional
foods in the Nordic diet
• Milk provides several nutrients e.g. calcium,
potassium, riboflavin and selenium
• Cheese contains largely similar amounts of
nutrients on an energy basis, except for e.g.
lactose and potassium, which are concentrated in
the whey
• Dairy fats are rich in saturated fatty acids, a good
reason for recommending low-fat products

20. • Milk or fermented milk product intake has in some
earlier studies been shown to have less pronounced
effects on serum lipids than expected from their fat
content
• Many of the studies included very large amounts of
milk, which could have affected the general dietary
composition
• More recent intervention studies in humans including
mainly fermented milk products containing different
bacteria strains have shown varying results
• Due to their high content of calcium, dairies have been
promoted for adequate bone formation during
childhood and the prevention of post-menopausal
osteoporosis
• Adequate or high intakes of calcium seem to increase
bone density in adolescence and supplementation with
calcium or milk has similar effects in older women

21. Meat and meat
products
• Traditional foods in the Nordic diet contributing
protein, readily available iron, selenium, zinc and a
range of B vitamins
• Due to the relatively high proportion of SAFA, high
consumption of fatty meat and meat products can
contribute to increased LDL-C levels
• Processed meat products usually contain relatively
high amounts of sodium (salt)
• Inclusion of lean meat into the diet improves iron
availability and status without providing too many
fats

22. • High consumption of meat, especially red (beef, pork,
sausages) and processed meat (cold cuts) has been
regarded as risk factor for colorectal cancer
• Meat may contain harmful components formed during
cooking (heterocyclic amines and polycyclic aromatic
hydrocarbons), processing (nitrates and nitrites) or during
intestinal metabolism (N-nitroso compounds)
• The carcinogenic potential of these compounds may be
dimished by avoiding exposure of meat surfaces to flames
and high temperatures and also by increasing dietary
intake of protective constituents derived from plant foods
• Meat and meat products provide a wide range of
nutrients and consumption of moderate amounts of meat,
preferably lean, is recommended as part of a balanced
and varied diet

23. Edible fats
• Edible fats, e.g. butter, margarines and vegetable oils,
are the major sources of fat in the Nordic diet
• The recommendations on choice of fats emphasise a
limitation of saturated and trans fatty acids, and an
increase in n-3 fatty acids but not of n-6 fatty acids
• Soft or fluid vegetable fats, low in saturated and trans
fats, should primarily be chosen
• A good n-3/n-6 proportion can be achieved using
rapeseed oil and rapeseed oil based fats, in addition
to other good sources such as fish and seafood

24. Energy-dense and
sugar-rich foods
• Foods rich in fat and/or refined sugars, such as
soft drinks, sweets, snacks and sweet bakery
products, mainly contribute ”empty calories”
• A frequent consumption decreases the
nutrient density and increases the risk of
nutritional imbalance and inadequacy and
also dental caries
• A high intake of refined sugars in
fluid form, e.g. soft drinks, may
increase the risk of overweight

25. Salt intake
• The recommendation on sodium (salt) is
mainly based on effects on blood pressure
• A major factor in order to achieve the
recommended salt intake is a reduction in the
sodium levels in many processed foods
• In addition, household and
individual use of table salt need
to be moderated

27. Key recommendations
Foods and components to reduce
• < 2,300 mg/day of sodium and < 1,500 mg/day
among persons who are 51 and older and those of any age who
have hypertension, diabetes, or chronic kidney disease
• < 10% of calories from saturated fatty acids by replacing them with
unsaturated fatty acids
• < 300 mg/day of dietary cholesterol
• trans fatty acid consumption as low as possible by limiting
hydrogenated oils and other solid fats
• Reduce the intake of calories from solid fats and added sugars
• Limit the consumption of foods that contain refined grains,
especially if they also contain solid fats, added sugars, and sodium
• If alcohol is consumed, it should be consumed in moderation: up to
one drink per day for women and two drinks per day for men

28. Foods and nutrients to increase
• Increase vegetable and fruit intake
• Eat a variety of vegetables, especially dark-green and red and
orange vegetables and beans and peas
• Consume at least half of all grains as whole grains
• Increase intake of fat-free or low-fat milk and milk products
• Choose a variety of protein foods, including seafood, lean
meat and poultry, eggs, beans and peas, soy products, and
unsalted nuts and seeds
• Replace some meat and poultry with seafood
• Use oils instead of solid fats where possible
• Choose foods that provide more potassium, dietary fiber,
calcium, and vitamin D, such as vegetables, fruits, whole
grains, and milk and milk products

29. Healthy eating patterns

30. The DASH Diet
• The DASH eating pattern and its variations
have been tested in several clinical trials
• DASH emphasizes vegetables, fruits, and low-fat milk and milk
products; includes whole grains, poultry, seafood, nuts and is lower
in sodium, red and processed meats, sweets, and sugar-containing
beverages
• Modifications containing higher levels of either unsaturated fatty
acids or protein have been tested
• In research studies, each of these DASH-style patterns lowered
blood pressure, improved blood lipids, and reduced cardiovascular
disease risk as well as mortality compared to diets that were
designed to resemble a typical American diet
• The DASH-Sodium study on hypertension also reduced sodium, and
resulted in lower blood pressure in comparison to the same eating
pattern, but with a higher sodium intake

31. The Mediterranean diet
• The first evidence of the beneficial effects of the
Mediterranean diet came years ago from the Seven Country
Study (Keys, 1980)
• The general features of this pattern are a high or moderately
high intake of:
– cereals (that in the past were largely unrefined)
– olive oil (and therefore MUFA)
– fruit, vegetables and legumes
– nuts and seeds
– fish (according to the proximity of the sea, and therefore PUFA)
– alcoholic beverages, but mostly red wine, generally during meals
(Willett et al., 1995)
• And a low or moderately low intake of
– dairy products (mostly in the form of cheese and yogurt)
– meat and meat products (and therefore SAFA)

32. Mediterranean diet and mortality
• The Mediterranean diet was first considered protective against
CHD (de Lorgeril et al., 1999)
• Recently a longitudinal study showed that MD was associated
with a higher preservation of ventricular function and a more
favourable prognosis after an acute coronary event
(Chrysohoou, et al., 2010)
• In other studies, beneficial effects on total mortality have been
discovered (Trichopoulou et al., 2005)
• A Mediterranean dietary pattern has also been shown to
increase longevity among European elderly of the HALE
project (Knoops et al., 2004)
• In addition, a recent paper on the Swedish population showed
a reduction in total mortality among young women (Lagiou et
al., 2006)

33. Mean and median intakes of different food
groups in the H70 elderly study in Gothenburg
Overall mean Median intakes and p for trend across
Food groups (g/day)
(N = 1,037) 95% CLs (g/day) birth cohorts
: 209.5 (99.6; 406.3)
Vegetables and potatoes 237.6 98.7 < 0.0001
: 239.0 (120.1; 432.2)
: 176.4 (22.3; 527.7) < 0.0001
Fruit 196.6 146.3
: 155.5 (14.0; 456.0)
: 2.0 (0; 40.0) < 0.0001
Legumes nuts and seeds 15.2 20.2
: 13.3 (0; 60.0)
: 165.0 (68.2; 383.0) (-) < 0.0001
Total cereals 207.4 104.0
: 213.0 (98.3; 442.1)
: 74.2 (0; 298.5)
- Wholegrain cereals 107.9 95.6 (-) < 0.0001
: 92.8 (0; 322.0)
: 45.2 (12.8; 105.3)
Fish and fish products 53.8 35.8 < 0.0001
: 53.7 (13.8; 129.5)
: 373.3 (127.9; 829.5)
Dairy products 445.1 251.7 0.41
: 446.0 (74.0; 1061.9)
: 110.1 (47.9; 187.3)
Meat, meat products, eggs 129.5 55.3 < 0.001
: 137.7 (66.3; 251.1)
: 89.7 (38.4; 168.8)
- Meat and meat products 105.4 47.9 < 0.0001
: 109.1 (52.5; 204.9)
: 0 (0; 9.8)
Red wine 2.0 4.7 < 0.001
: 0 (0; 10.7)

34. Mediterranean diet score across
birth cohorts
1901 1911 1922 1930 Overall p for
(N = 323) (N = 214) (N = 88) (N = 412) (N = 1,037) trend
Refined mMDS
4.3 1.6 4.0 1.6 4.8 1.5 4.8 1.8 4.5 1.7
(mean SD)
< 0.001
Medians
4 (2; 7) 4 (1; 7) 5 (2; 7) 5 (2; 8) 4 (2; 7)
(5th;95th perc)
HALE mMDS
4.1 1.5 3.6 1.4 4.1 1.4 4.1 1.6 4.0 1.5
(mean SD)
0.02
Medians
4 (2; 6) 4 (1; 6) 4 (2; 6) 4 (1; 7) 4 (2; 6)
(5th;95th perc)

35. Mediterranean diet and mortality
Mediterranean diet score (MDS) HR 95% CLs
MDS 0.93 (0.89; 0.98)
- Crude estimate 0.92 (0.88; 0.97)
- Highest 4 levels vs the others 0.82 (0.67; 0.99)
- Crude estimate 0.81 (0.67; 0.99)

36. Food groups
High intake/level of: HR 95% CLs
- Vegetables and potatoes 1.06 (0.90; 1.24)
- Fruit 1.03 (0.87; 1.21)
- Legumes, nuts and seeds 0.98 (0.83; 1.16)
- Cereals 1.01 (0.86; 1.19)
- Wholegrain cereals 0.85 (0.73; 1.00)
- Fish 0.96 (0.82; 1.13)
- Alcohol 0.77 (0.61; 0.97)
- MUFA/SAFA ratio 0.98 (0.84; 1.15)
- (MUFA + PUFA)/SAFA ratio 0.96 (0.82; 1.13)
Low intake of:
- Dairy products 0.82 (0.70; 0.96)
- Meat and meat products 0.89 (0.76; 1.05)
- Meat, meat products and eggs 0.84 (0.71; 0.98)

37. Final considerations
• Studies of dietary patterns are inherently
complex
• However, there is a convergence of evidence on
the fact that dietary patterns associated with
longevity emphasize fruits and vegetables and
are reduced in saturated fat, meats, refined
grains, sweets, and full-fat dairy products
• We hope is that the results of the present
research will stimulate a productive discussion
on these issues and be considered in updated
food- and nutrient-level guidelines for the
Swedish population

38. THANKS FOR YOUR
ATTENTION!