1. 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

2. 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 over- consumption rather than deficiency in industrialized countries => Lifestyle Diseases

3. The dietary pattern approach – an example Has been found associated with a decreased risk of CVD, obesity, type 2 diabetes, cancer etc.

4. 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

5. Local diets…

6. Modern day Nordic Diet: Slimani et al, 2002, Public Health Nutrition

7. Healthy components of the traditional Nordic Diet Berries Cabbages Root vegetables Dark bread/Whole grain Fish/Shellfish Apples/Pears

8. 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, Beta- carotene 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

9. Nordic diet in the Swedish WLH cohort -Dietary composition and lifestyle

10. Nordic diet in the Swedish WLH cohort Objective: To investigate the adherence to a healthy Nordic Food Index, and compare dietary composition, nutrient intake, and lifestyle among adherence- groups Study cohort: Swedish women aged 30-49 years at recruitment (1991– 1992) Selected by random sampling using the individual, national registration number 96.000 women invited, 49.259 accepted. 45.277 women included in the present study based on information on the included variables

11. 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 8 th year by the Nordic Council of Ministers They are the main reference point for nutritional recommendations in the Nordic countries

12. The healthy Nordic Food Index in the present study 1 point for above-median intake of: Wholegrain bread Oatmeal Apples/pears Cabbages Root vegetables Fish/shellfish (Olsen et al, J Nutr, 2011) 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 Intake of the food components included in the healthy Nordic Food Index (g/day) in the cohort Median 25 th percentile 75 th percentile Whole grain bread 0024.6 Oatmeal0016.4 Apples and pears 35.217.661.5 Cabbage a 8.12.814.5 Root vegetables b 11.05.325.6 Fish and shellfish c 20.713.730.5 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

13. Participant characteristics Those with the highest score were: Older More educated Slightly higher mean BMI More physically active Less likely to smoke healthy Nordic food index score All n=45,277 0-1 n=9395 2-3 n=20,891 4-6 n=14,991 Mean age (SD)39.2(5.7)38.7 (5.9)39.2(5.7)39.4(5.7) Mean education, years (SD) 12.2(3.0)11.8 (2.9)12.2(3.0)12.6(3.0) Mean BMI (kg/m 2 ) (SD) 23.5(3.7)23.3 (3.7)23.5(3.7)23.6(3.6) Physical activity level, N (%) -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) Smoking status, N (%) -Never18692(41.3)3270(34.8)8408(40.3)7014(46.8) -Past13413(29.6)2540 (27.0)6167(29.5)4706(31.4) -Current13172(29.1)3585(38.2)6316(30.2)3271(21.8)

14. Intake of food groups and energy by Index score We found: A trend of increased intake of all components of the healthy Nordic Food Index with increasing score 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)

15. 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

16. 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 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

17. 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: 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 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 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

18. Discussion We found a direct association between adherence and dietary items with no or adverse health-effects: Potatoes Red/processed meats 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 high- adherers, given their higher level of physical activity Higher degree of underreporting among low-adheres Taken together, our results suggests that residual confounding could operate in studies on Nordic Diet and health outcomes, if not controlled properly 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.

19. Take home message In conclusion, a high score on the healthy Nordic Food Index was associated with being older, higher educated, non-smoking, and having a higher physical activity level, and higher intake of fibre and a higher micronutrient density 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. Given the increasing focus on Nordic diet, there is a need for further clarification of the association between adherence to such diet, dietary composition, and lifestyle, to allow causal interpretation of future studies on adherence and health outcomes

20. 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