National Adult Nutrition Survey - Doctoral Theses

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The role of micronutrients and impact of fortified foods in the diets of teenagers in Ireland
(University College Cork, 2024) Walsh, Niamh M.; Walton, Janette; Kehoe, Laura; Flynn, Albert; Cashman, Kevin; Coffey, Aidan; Department of Agriculture, Food and the Marine, Ireland
During the teenage years, adequate micronutrient intake is crucial for physical and cognitive development. Strategies to meet high nutritional needs can involve food based dietary guidelines (FBDG) or fortification of foods and recommendations for nutritional supplements. The aims of this thesis were to estimate current micronutrient intakes in the diets of teenagers in Ireland, investigate the dietary determinants of vitamin D and calcium and examine the role of fortified foods in teenagers. The analyses for this thesis were based on data from the National Teens’ Food Survey II (NTFS II), a nationally representative study which collected data on food and nutrient intakes of 428 teenagers (13-18y) in the Republic of Ireland between 2019-2020. Dietary data were collected using weighed food diaries and nutrient intakes were estimated using UK and Irish food composition data. Mean daily intakes (MDI) and usual intakes of food groups and nutrients were estimated using SPSS©. The prevalence of inadequate and excess intakes were estimated using estimated average requirements (EAR) and the tolerable upper intake level (UL). Dietary determinants of vitamin D and calcium intake were investigated by examining the food groups and consumption patterns which contributed to the difference in intakes between the high and low intake groups. A fortified food consumer was defined as someone who consumed fortified foods at least once during the recording period. A large proportion of teenagers in Ireland had inadequate intakes of micronutrients, particularly vitamin D (94%), calcium (51%), vitamin C (48%), and zinc (48%). There was little risk of excessive intakes with few exceeding the UL for folic acid (4%), copper (<1%), and zinc (<1%). The key sources of micronutrients included natural animal and plant sources and fortified foods, with supplements contributing to 0-6% of intakes. Considering the dietary determinants of vitamin D intake, 100% in the low intake group had intakes
The role of dietary fibre and plant-based foods in the diets of teenagers (13-18y) in Ireland
(University College Cork, 2024) McGowan, Clíodhna; Walton, Janette; Kehoe, Laura; Flynn, Albert; Cashman, Kevin; Coffey, Aidan; Department of Agriculture, Food and the Marine, Ireland
Background: Adequate nutrition during the teenage years is essential to support optimal growth and lay the foundations for long term health. This life stage is also characterised by social development, increasing autonomy and independence and is a critical stage for the optimisation of health and health-related behaviours as habits developed during this time often continue into adulthood. Dietary fibre is a nutrient of interest in public health due to its essential role in normal laxation and association with reduced incidence of non-communicable diseases. Plant-based foods such as ‘fruit & vegetables’ and ‘cereals, grains & potatoes’ are key sources of dietary fibre in the diet, and feature prominently in all food based dietary guidelines (FBDG) due to their nutrient density and association with a number of health benefits. Data from the National Teens’ Food Survey (NTFS) (2005-06) (a nationally representative survey of teenagers in Ireland) reported an intake of dietary fibre below recommendations, and a poor compliance with the Irish FBDG for ‘fruit & vegetables’ and ‘cereals, grains & potatoes’. There have been many changes in the environmental, social and cultural contexts which influence teenagers lifestyles including dietary choices since the NTFS, along with updated international recommendations for dietary fibre intake for teenagers and updated Irish FBDG. New detailed dietary data for teenagers has become available from the nationally representative National Teens’ Food Survey II (NTFS II) (2019-20). Aim: The overall aim of this PhD thesis was to use data from the NTFS II (2019-20) to examine intakes of dietary fibre and the role of plant-based foods such as ‘fruit & vegetables’ and ‘cereals, grains & potatoes’ in the diets of teenagers (13-18y) in Ireland. An additional aim of this thesis was to examine changes over time compared to the previous NTFS (2005-06). Methods: The analyses for this thesis were based on data from the NTFS II (13-18 years, n 428) and the NTFS (13-17 years, n 441). Dietary intake data was collected at brand level using a 4-day weighed food record (NTFS II) and a 7-day semi-weighed food record (NTFS). Energy and nutrient intakes were estimated using Nutritics© (NTFS II) and WISP© (NTFS) based on food composition data from McCance & Widdowson’s ‘The Composition of Foods’ 5th, 6th and 7th editions (plus all nine supplemental volumes). During both surveys, modifications were made to the food composition database to include recipes of composite dishes, fortified foods, generic Irish foods and new foods on the market. Usual intakes of energy and dietary fibre were estimated using the National Cancer Institute (NCI) method using SAS Enterprise Guide©. Dietary fibre intakes were compared to the adequate intake (AI) for normal laxation, proposed by EFSA for this age group (13-14y: 19g/d, 15-17y: 21g/d, 18y: 25g/d). All further analyses were conducted using SPSS© Version 29.0. The percent contribution of food groups to the mean daily intake (MDI) of dietary fibre were calculated by the mean proportion method. Differences in the intake of dietary fibre between sexes (boy, girl), age groups (13-14y, 15-18y) and surveys (NTFS II, NTFS) were calculated using independent sample t-tests. Dietary determinants of dietary fibre intake were investigated by splitting the population into low, medium and high dietary fibre intake groups and examining the key food groups which contributed to the difference in dietary fibre intake between the high and low intake groups and associated patterns of consumption of these food groups. Differences in the MDI of dietary fibre between the low, medium and high intake groups were assessed using ANOVA and Tuckey’s post-hoc analysis. The difference in the percentage of consumers of each food group identified as determinants of dietary fibre intake between dietary fibre intake groups (low, high) were assessed using the Chi-Square test for independence. The differences in consumption patterns between the low and high dietary fibre intake groups were assessed in consumers only using the Mann Whitney U test. To examine the role of ‘fruit & vegetables’ and ‘cereals, grains & potatoes’ in the diets of teenagers in Ireland, the MDI of each food group and subgroup was estimated by summing the weight of each food group consumed for each participant and dividing the total by the number of recording days (NTFS II: 4, NTFS: 7). The percent contribution of ‘fruit & vegetables’ and ‘cereals, grains & potatoes’ to energy, macro- and micro-nutrient intakes were calculated by the mean proportion method. Differences in the intake of ‘fruit & vegetables’ and ‘cereals, grains & potatoes’ between sexes (boy, girl), age groups (13-14y, 15-18y) and surveys (NTFS II, NTFS) were calculated using independent sample t-tests. Analyses to estimate intakes of fruit & vegetables included intake of fruit and/or vegetables from composite dishes and the calculation of inedible or unconsumed portions. To assess compliance with Irish FBDG, intakes of ‘fruit & vegetables’ and ‘cereals, grains & potatoes’ were converted to servings using the Irish FBDG recommendations and standard food portion sizes. Results: Teenagers in Ireland had a usual intake of dietary fibre of 16.9g/d, which was below the AI proposed by EFSA across all age groups examined (13-14y, 15-17y, 18y). Teenage boys had higher usual intakes of dietary fibre compared to girls, however, girls had higher energy adjusted intakes, indicating girls consume a more fibre dense diet. Older teenagers (18y) had higher absolute and energy adjusted intakes of dietary fibre than younger teenagers (13-14y, 15-17y), indicating that older teenagers consumed a more fibre dense diet. The key sources of dietary fibre were identified as ‘bread & rolls’ (19%) (‘white bread & rolls’, 10%), ‘grains, rice, pasta & savouries’ (14%), ‘potato & potato products’ (13%) (‘chipped, fried & roasted potatoes’, 8%), ‘breakfast cereals’ (12%) (RTEBC, 11%), ‘meat & meat products including dishes’ (9%), ‘vegetables & vegetable dishes’ (9%) and ‘fruit & fruit juices’ (7%). Intakes of dietary fibre have increased in teenagers in Ireland since the NTFS (2005-06) (16.9g/d vs 15.5g/d), albeit remain below the EFSA AI for all age groups examined. The increased intakes are due to a higher intake of dietary fibre from ‘grains, rice, pasta & savouries’ and ‘breakfast cereals’ in teenagers in the NTFS II compared to the NTFS. To identify the dietary determinants of dietary fibre intake, teenagers were split into low, medium and high dietary fibre intake groups based on their MDI of dietary fibre. Those in the high intake group had over double the intake of dietary fibre compared to those in the low intake group (24g/d vs 11g/d). The main food groups that contributed to the difference in dietary fibre intake between the high and the low intake groups were ‘high fibre RTEBC’ (17%), ‘wholemeal & brown bread & rolls’ (11%), ‘vegetables & vegetable dishes’ (14%), ‘grains, rice, pasta & savouries’ (10%) and ‘fruit’ (10%). For ‘high fibre RTEBC’ there were more consumers in the high intake group compared to the low intake group (53% vs 33%) and those in the high intake group consumed it more often over the 4 days (2.8 vs 2.0 times) and consumed more at each eating occasion (72g vs 47g). For ‘wholemeal & brown bread & rolls’ there were more consumers in the high intake group compared to the low intake group (63% vs 24%). For ‘grains, rice, pasta & savouries’ there was no difference in the number of consumers between the groups but those in the high intake group consumed it more often over the 4 days (3.2 vs 2.4 times). For ‘vegetables & vegetable dishes’ and ‘fruit’, both food groups were more likely to be consumed by teenagers in the high intake group compared to the low intake group (vegetables & vegetable dishes: 90% vs 75%, fruit: 89% vs 57%) and be consumed more frequently during the recording period (vegetables & vegetable dishes: 6.9 vs 3.4 times, fruit: 5.5 vs 2.4 times). ‘Fruit & vegetables’ were consumed by all teenagers in the NTFS II with an MDI of 218g/d (‘fruit & fruit juices’: 122g/d and ‘vegetables’: 96g/d). Teenagers in the NTFS II had lower intakes of fruit & vegetables compared to teenagers in the NTFS (NTFS II: 218g/d, NTFS: 240g/d). The MDI of 218g/d equated to approx. 2.7 servings of ‘fruit & vegetables’ per day. This is below the Irish FBDG recommendation of 5-7 servings/day, with the majority of teenagers (92%) not meeting the recommended 5-7 servings per day and 22% of teenagers consuming less than one serving (80g) of ‘fruit & vegetables’ per day. For ‘vegetables’, 50% of intakes were from ‘vegetables in composite dishes’, which highlights the important contribution of composite dishes to vegetable intakes in teenagers, and the importance of including fruit and vegetables in composite dishes in estimates of fruit and vegetable intake (particularly for vegetables). ‘Fruit & vegetables’ contributed a small proportion of energy (5%) in the diets of teenagers in Ireland and made important contributions to the intake of dietary fibre (16%) and several micronutrients which have been identified as low in this population, including vitamin C (42%), vitamin A (24%), potassium (14%), folate (DFE) (14%) and vitamin B6 (11%). ‘Fruit & vegetables’ also contributed to the intake of total sugars (20%), due to the natural sugars present in ‘fruit & fruit juices’ and a negligible amount to free sugars (2%) due to ‘fruit juices & smoothies’. ‘Cereals, grains & potatoes’ were consumed by all teenagers in the NTFS II with an MDI of 345g/d (‘grains, rice, pasta & savouries’:128g/d, ‘total bread’: 85g/d, ‘potato & potato products’:84g/d and ‘breakfast cereals’: 48g/d). The overall food group contributed 4.8 servings for boys and 3.8 servings for girls with 1.6 and 1.1 servings, respectively, from ‘wholemeal & brown breads, cereals, pasta and rice and unprocessed potatoes’. This is well below the recommended intake of 4-7 and 3-4 servings per day for boys and girls respectively of ‘wholemeal & brown breads, cereals, pasta and rice and unprocessed potatoes’ in the Irish FBDG. ‘Cereals, grains & potatoes’ contributed significantly to intakes of energy (39%), carbohydrate (55%), protein (30%) and dietary fibre (60%) and made important contributions to a number of micronutrients including B vitamins (15-50%), vitamin D (25%), vitamin C (21%), vitamin E (22%), calcium (35%), potassium (33%) and iron (22%) in the diets of teenagers in Ireland. ‘Cereals, grains & potatoes’ also contributed to intakes of saturated fat, sodium and free sugars, primarily due to specific subgroups including ‘pizza’, ‘savoury dishes & products’ and ‘chipped, fried & roasted potatoes’, ‘bread’ and ‘breakfast cereals’. Teenagers in the NTFS II had lower overall intakes of ‘cereals, grains & potatoes’ compared to teenagers in the previous NTFS (NTFS II: 345g/d, NTFS: 364g/d) with lower intakes of ‘potatoes & potato products’ and ‘low fibre RTEBC’ and higher intakes of ‘grains, rice, pasta & savouries’. Conclusion: In conclusion, the findings from this thesis indicate that overall, teenagers in Ireland are not meeting dietary guidelines for dietary fibre, fruit & vegetables and cereals, grains & potatoes. However, a positive finding was that there is a proportion of the teenage population that had intakes of dietary fibre that reached the AI proposed by EFSA based on existing dietary patterns, providing an evidence base to develop dietary strategies to improve dietary fibre intake in this population group. Based on this evidence, these strategies should focus on increasing intake of ‘fruit & vegetables’ and promoting a swap from refined grains to wholemeal & brown breads, cereals, pasta and rice and unprocessed potatoes which would improve intakes of dietary fibre in teenagers in Ireland and also support FBDG for ‘fruit & vegetables’ and ‘cereals, grains & potatoes’, which have a much wider nutritional role in the diet as evidenced in this thesis. Findings from this thesis may provide evidence to public health campaigns to improve dietary fibre intakes and promote the consumption of plant-based foods to increase compliance with the Irish FBDG in teenagers in Ireland. The findings from this thesis may also provide information to policy makers across various sectors of Irish society including education and health to gain a more comprehensive understanding of the plant-based foods influencing intakes of dietary fibre in teenagers in Ireland.
The role of plant-based foods and dietary fibre in school-aged children (5-12y) in Ireland
(University College Cork, 2020-05-01) McCarthy, Róisín; Flynn, Albert; Cashman, Kevin; Kehoe, Laura; Walton, Janette; Food Institutional Research Measure
The consumption of plant-based foods has been associated with a variety of health benefits and a more sustainable environment. Plant-based foods including wholegrains cereals, vegetables and fruit provide important nutrients in the diet and are particularly promoted in food based dietary guidelines (FBDG) for their high dietary fibre (DF) content. The aim of this thesis was to examine the role of ‘cereals, grains & potatoes’ and ‘fruit & vegetables’, and DF in the diets of school-aged children (5-12y) in Ireland. A further aim was to investigate any changes in the intakes of these food groups and DF in school-aged children between 2003-04 and 2017-18. The analyses for this thesis were based on data from the National Children’s Food Survey II (NCFS II) which was a nationally representative cross-sectional study that collected food and beverage consumption data from 600 children aged 5-12 years in the Republic of Ireland between 2017 and 2018. Findings from the NCFS II were compared to the previous NCFS (2003-04). For each survey, dietary data were collected (at brand level) using weighed food diaries and nutrient intakes were estimated using UK and Irish food composition data. Mean daily intakes (MDI) of ‘cereals, grains & potatoes’ and ‘fruit & vegetables’ were estimated using SPSS© and their contribution to energy and nutrient intakes were estimated using the mean proportion method. Usual DF intakes were estimated using the validated National Cancer Institute (NCI)-Method. Dietary determinants of DF intake were investigated using tertile analysis to determine the food-groups and patterns of consumption which contributed to higher intakes of DF. The MDI of ‘cereals, grains & potatoes’ was 271g/d (approx. 3.7 servings/day) of which 1.7 servings was wholemeal/brown or from unprocessed potatoes. This is below the recommendation of 3-5 servings of wholemeal cereals & breads, potatoes, pasta and rice daily. The MDI of ‘fruit & vegetables’ was 221g/d (approx. 2.8 servings/day) which is below the World Health Organisation recommendation of ≥ 400g of fruit & vegetables per day and the Irish FBDG of 5-7 servings of fruit & vegetables per day (≤ 150ml/day from unsweetened fruit juice or smoothies). Despite these low intakes, ‘cereals, grains & potatoes’ made an important contribution to intake of energy, carbohydrate, DF, B vitamins, vitamin D, iron and calcium but also contributed to intakes of saturated fat, free sugar and sodium. ‘Fruit & vegetables’ made important contributions to intakes of DF, vitamin A, vitamin C, B-vitamins, potassium and magnesium but also contributed to intakes of total and free sugars. While overall intakes of ‘cereals, grains & potatoes’ and ‘fruit & vegetables’ were similar to the previous NCFS (2003-04), intakes of wholemeal breads, high fibre ready-to-eat breakfast cereals (RTEBC), porridge, pasta, whole fruit and smoothies were higher and intakes of low fibre RTEBC, potatoes and fruit juice were lower. The intake of DF in school-aged children in Ireland was 14.4 g/d which is below the adequate intake for normal bowel function in children but higher than that reported in the previous NCFS (2003-04) (12.4g/d). Determinants of a higher DF intake were wholemeal/brown breads, high fibre RTEBC, fruit and vegetables. The consumption patterns associated with a higher DF intake were a higher proportion of children consuming these foods (except for vegetables), consuming these foods more frequently and having a higher intake per eating occasion (except for fruit). Findings from this thesis may provide evidence for public health campaigns to promote the consumption of plant-based foods to increase compliance with the food based dietary guidelines and to improve DF intakes in this population group.
Vitamin K in the diet of the Irish population (1-90 years)
(University College Cork, 2020-03-31) Kingston, Ciara; Flynn, Albert; Cashman, Kevin; Kehoe, Laura; Walton, Janette; Department of Agriculture, Food and the Marine, Ireland; Food Institutional Research Measure
Vitamin K is required to maintain normal blood coagulation and may also function in other areas including bone health and the inhibition of vascular calcification. The aim of this thesis was to estimate the intake, adequacy and dietary sources of vitamin K1 and vitamin K2 in the Irish population (1-90y) and to examine any changes in vitamin K1 or vitamin K2 intakes and sources in school-aged children (5-12y) between 2003-04 and 2017-18. This research was based on data from five nationally representative dietary surveys carried out by the Irish Universities Nutrition Alliance (www.iuna.net). These surveys included the National Children’s Food Survey (NCFS) (5-12y) (2003-04), the National Teens’ Food Survey (13-17y) (2005-06), the National Adult Nutrition Survey (18-90y) (2008-10), the National Pre-school Nutrition Survey (1-4y) (2010-11) and the NCFS II (5-12y) (2017-18). For each survey, dietary data were collected (at brand level) using weighed/semi-weighed food diaries. Each food, beverage and dietary supplement recorded was assigned a unique food code according to its food descriptor and nutritional profile. Using these food codes, the Irish Food Composition Database (IFCD) (2012) was updated to include food composition data for vitamin K1 and vitamin K2 (menaquinone-4 (MK-4) and menaquinones-5-10 (MK-5-10)). Vitamin K1 is typically found in green vegetables and certain plant oils. MK-4 is formed in mammals from the tissue specific conversion from vitamin K1 or from menadione (a synthetic form of vitamin K added to animal feed). The longer chained menaquinones, MK-5-10, are synthesized by bacteria capable of food fermentation and are found in fermented foods and foods of animal origin. As there are no analytical data available for vitamin K content of foods in Ireland, composition data for vitamin K1, MK-4 and MK-5-10 were assigned to each food code using published analytical values from the UK Composition of Foods Integrated Dataset, the United States Department of Agriculture National Nutrient Database or published papers, recipe calculation based on individual ingredients, and from nutritional information on product labels. In addition, foods that were either not fermented or of animal origin were assigned a composition value of 0µg for each menaquinone group. For a small number of food codes, vitamin K1 values were assigned based on the fat content of a similar product.. Overall, foods highest in vitamin K1 were herbs and ‘vegetable & vegetable dishes’. Foods highest in MK-4 and MK-5-10 were ‘meat & meat products’, ‘eggs & egg dishes’ and ‘cheese’. The distribution of vitamin K1 and vitamin K2 (MK-4 and MK-5-10) intakes in the Irish population were carried out using SPSS© for Windows™ Version 22.0. The mean intakes of vitamin K1 were above the European Food Safety Authority Adequate Intake (AI) of 1µg/kg/d (required to maintain normal blood coagulation) for children aged 1-12y. However, vitamin K1 intakes were below the same AI for teenagers aged 13-17y. ‘Vegetable & vegetable dishes’ (primarily green vegetables) was the key source of vitamin K1 for both children and teenagers. Mean intakes of MK-4 and MK-5-10 ranged from 8-13µg/d and 32-45µg/d in the Irish population aged 1-90y, respectively. The key dietary sources of MK-4 and MK-5-10 were ‘meat & meat products’, ‘milks’ and ‘cheese’. There was no difference in the intake and dietary sources of vitamin K1 or vitamin K2 in Irish children (5-12y) between 2003-04 and 2017-18. The data presented in this study will add to the small pool of data available on vitamin K intakes and sources in nationally representative samples of population groups. The Irish food composition database for vitamin K will support future researchers in the assessment of vitamin K intakes at individual or population level.
Nutritional status of older adults in Ireland
(University College Cork, 2018) Kehoe, Laura; Flynn, Albert; Walton, Janette; Department of Agriculture, Food and the Marine
Population ageing is rapidly progressing and it is estimated that by 2050, one in every five people globally will be aged 60 years or over. Adequate nutritional status can play a key role in preventing or delaying the progression of age related diseases. The aim of this thesis was to estimate usual macro- and micro-nutrient intakes, to determine the key sources, compliance with recommendations and to investigate the nutritional status of older Irish adults (≥65 years). This thesis also aimed to examine the impact of fortified foods and nutritional supplements on micronutrient intakes, prevalence of inadequate intakes and nutritional status of older adults. The analysis for this research was based on data from the subset of older adults aged ≥65 years (n 226) in the Irish National Adult Nutrition Survey (NANS) (2008-2010). Food and beverage intakes were estimated using a 4-day semi-weighed food record. Sixty-four per cent of older adults provided a blood sample (of which 79% were fasting) and 67% of older adults provided a morning first void urine sample for the analysis of nutritional biomarkers. Nutrient intakes were estimated using WISP® which estimates nutrient intake using data from ‘McCance and Widdowson’s The Composition of Foods’, Sixth Edition (plus all nine supplemental volumes). Usual intakes of macro- and micro- nutrients were calculated using the NCI-method implemented in SAS® macros. The prevalence of inadequate micronutrient intakes (% upper levels (UL)) was also calculated. The distribution of nutrient status was examined using SPSS® and the prevalence of deficiency was examined using published cut-off ranges. In summary, this study has highlighted unfavourable intakes of total and saturated fat, sugar, salt and dietary fibre together with low intakes and/or suboptimal status of key micronutrients such as vitamin D, riboflavin, vitamin B12, folate, calcium and magnesium in older Irish adults. Furthermore, the consumption of fortified foods and use of nutritional supplements make significant contributions to intakes and status of these micronutrients. Future strategies to address the nutritional issues identified in older adults could include the promotion of healthy food choices together with improvements of the food supply including reformulation (fat, sugar and salt), food fortification or supplementation to support successful ageing of our population. The data presented in this study will serve to inform policy makers in the development and implementation of updated dietary recommendations for older adults in Ireland. Furthermore, information about the relative contributions of specific foods to micronutrient intakes will be useful to both policy makers and the food industry to develop targeted dietary strategies to improve the diets of older Irish adults.

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