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Public Health Nutrition: page 1 of 17 doi:10.1017/S1368980012004077
Micronutrient intake and status in Central and Eastern Europe
compared with other European countries, results from the
EURRECA network
Romana Novakovic
´
1,
*, Adrienne EJM Cavelaars
2
, Geertruida E Bekkering
3
,
Blanca Roman-Vin
˜as
4
, Joy Ngo
4
, Mirjana Gurinovic
´
1
,MariaGlibetic
´
1
, Marina Nikolic
´
1
,
Mana Golesorkhi
5
, Marisol Warthon Medina
6
,ZvonimirS
ˇatalic
´
7
,AnoukGeelen
2
,
Lluis Serra Majem
4,8
, Pieter van’t Veer
2
and Lisette CPGM de Groot
2
1
Institute for Medical Research, Centre of Research Excellence in Nutrition and Metabolism, University of
Belgrade, Tadeusa Koscuska 1, Belgrade 11000, Serbia:
2
Division of Human Nutrition, Wageningen University
and Research Centre, Wageningen, The Netherlands:
3
Catholic University of Leuven, Maurits Sabbe Library,
Leuven, Belgium:
4
Community Nutrition Research Centre, Nutrition Research Foundation, Barcelona, Spain:
5
Department of Sport and Health Sciences, Oxford Brookes University, Oxford, UK:
6
International Institute of
Nutritional Sciences and Food Safety Studies, Division of Sport Exercise & Nutritional Sciences (SENS),
University of Central Lancashire, Preston, UK:
7
Faculty of Food Technology and Biotechnology, University of
Zagreb, Zagreb, Croatia:
8
Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Las
Palmas de Gran Canaria, Spain
Submitted 26 September 2011: Final revision received 28 June 2012: Accepted 1 August 2012
Abstract
Objective: To compare micronutrient intakes and status in Central and Eastern
Europe (CEE) with those in other European countries and with reference values.
Design: Review of the micronutrient intake/status data from open access and grey
literature sources from CEE.
Setting: Micronutrients studied were folate, iodine, Fe, vitamin B
12
and Zn
(for intake and status) and Ca, Cu, Se, vitamin C and vitamin D (for intake).
Intake data were based on validated dietary assessment methods; mean intakes
were compared with average nutrient requirements set by the Nordic countries or
the US Institute of Medicine. Nutritional status was assessed using the status
biomarkers and cut-off levels recommended primarily by the WHO.
Subjects: For all population groups in CEE, the mean intake and mean/median
status levels were compared between countries and regions: CEE, Scandinavia,
Western Europe and Mediterranean.
Results: Mean micronutrient intakes of adults in the CEE region were in the
same range as those from other European regions, with exception of Ca (lower in
CEE). CEE children and adolescents had poorer iodine status, and intakes of Ca,
folate and vitamin D were below the reference values.
Conclusions: CEE countries are lacking comparable studies on micronutrient intake/
status across all age ranges, especially in children. Available evidence showed no
differences in micronutrient intake/status in CEE populations in comparison with
other European regions, except for Ca intake in adults and iodine and Fe status in
children. The identified knowledge gaps urge further research on micronutrient
intake/status of CEE populations to make a basis for evidence-based nutrition policy.
Keywords
Micronutrient
Intake
Status
Central and Eastern Europe
Epidemiological research has shown socio-economic
differences in health at all ages throughout Europe
(1)
.
These inequalities in health have been reported to vary
between countries and between socio-economic indica-
tors
(2,3)
. A possible explanation for these inequalities is a
less optimal nutritional status in disadvantaged groups.
For example, those with lower income suffer from higher
rates of obesity, CVD and certain cancers that are linked
to nutrition and diet
(3,4)
. This may be due to the fact that
groups with limited economic means consume unhealthy
foods that are cheap, energy-dense and nutrient-poor.
Socio-economic position, as measured by income for
instance, has been found to be one of the most important
predictors of diet quality
(4)
.
Since the proportion of (economically) disadvantaged
populations is higher in Central and Eastern European
Public Health Nutrition
*Corresponding author: Email romanabgd@yahoo.com rThe Authors 2012
(CEE) countries
(5–9)
it is highly relevant to evaluate
whether differences in nutritional status may contribute to
higher morbidity and mortality in CEE as compared with
other European countries.
Assessment of dietary intake and nutritional status for
European populations has been an emerging focus for
the last two decades. However, current nutritional data
are lacking for CEE populations
(10,11)
. This hinders
research on nutritional health, which is needed to
underpin nutrition policies for CEE populations with
sizeable disadvantaged groups.
To fill the knowledge gap mentioned above, an addi-
tional approach is needed to deal with the standard
searches conducted in known (open access) literature
databases, i.e. the identification of commonly overlooked
grey literature sources from CEE countries. So far, avail-
able nutritional data in CEE have often only been used
for local health policies and have remained largely
unexploited because they are either not published in an
accessible manner or not available in English
(1,12,13)
.
In the present study, we compare micronutrient intakes
and status in CEE with those in other European countries
using both open access sources and grey literature sour-
ces. A better use of the latter data from CEE and its further
exploitation will enable evaluation of the current nutri-
tional situation of CEE populations to enhance regional
policy making.
Methods
EURRECA
The present study was carried out within the context of the
EURRECA (EURopean micronutrient RECommendations
Aligned) Network of Excellence (http://www.eurreca.org).
This network aims to advance methodology for setting
micronutrient requirements and recommendations, and to
identify vulnerable groups regarding micronutrient intake
and status
(14,15)
. To answer our research question, we
used the standardized dietary intake/status methodology
recommended by EURRECA (more details are below).
We focused on the EURRECA top ten micronutrients,
prioritized on the basis of the amount of new scientific
evidence, their relevance to public health and the varia-
tions in current micronutrient recommendations (vitamin
B
12
, folate, Fe, Zn and iodine (intake and status) and
vitamin C, vitamin D, Ca, Se and Cu (intake only))
(14)
.
Search methodology
Data on CEE countries were collected from PubMed
and grey literature for intake and status, and from the
WHO Vitamin and Mineral Nutrition Information System
(VMNIS) database (http://www.who.int/vmnis/database/
en/) for status. For other European countries, we used
available comprehensive reviews, primarily the European
Nutrition and Health Report 2009 (ENHR II) for intake
(16)
and PubMed and WHO VMNIS for status only. Review of
the EFSA (European Food Safety Authority) Concise and
Comprehensive European Food Consumption Databases
did not result in additional data.
We searched for studies on intake and/or status
in PubMed published from January 1990 until April 2010
using common medical subject headings (MeSH) and free
text search terms: Micronutrients (listed) OR Biomarkers
of status (listed) AND General intake/status terms with
terms for adequacy, i.e. intake/status (requirement* or
recommend*oradequacyorinadequacyoradequateor
inadequate or cut point or threshold – in title and abstract)
AND Country (CEE and non-CEE countries, listed).
The WHO Global Micronutrient Databases on Iodine
Deficiency and Anaemia were used to collate information
on iodine and Fe status.
To collect grey literature data on intake and or status
from CEE countries, we cooperated with the United Nations
University/Standing Committee on Nutrition Network for
Capacity Development in Nutrition in Central and Eastern
Europe (NCDN CEE)
(17)
. This network gathers nutritional
researchers and public health specialists from all CEE
countries, whose representatives were introduced to the
purpose of the present study and with the search criteria
for collection of grey literature at their NCDN annual
meeting in November 2008. They were asked to identify
potentially relevant data from their countries, translate
the data to English if necessary and send them to us for
further screening.
Titles and abstracts from every source were screened,
and for potentially relevant papers and reports, full
texts were retrieved. Subsequently, we assessed which
studies were eligible for our study using the following
inclusion criteria.
1. The population studied should be representative for
the country and apparently healthy, and data gathered
should have had a sample size of at least 100 per
gender group
(18)
.
2. The study should include information on mean usual
micronutrient intake and apply one of the following
dietary intake methods (EURRECA best practice dietary
intake methods): a validated FFQ or validated diet
history; a food diary/register with at least 7d; three or
more 24 h recalls or registers; or three or fewer
24 h recalls with an adjustment for intra-individual
variability
(19)
. Initially, these criteria were applied to
both CEE and non-CEE data; however, keeping this
condition for CEE data would have resulted in very few
studies for assessment. For this reason, CEE studies on
intake that used one or more 24h recalls (with no
adjustments for intra-individual variability) or other
dietary assessment methods were included as well.
If more than one country-representative study that
fulfilled the inclusion criteria were available, the choice
of the study to be presented graphically was made by
Public Health Nutrition
2 R Novakovic
´et al.
giving preference to the one that was most recently
published.
3. Regarding nutritional status, data gathered should
include information on mean or median status using
best practice biomarkers defined in the context of
EURRECA: Hb, serum/plasma ferritin or serum/plasma
transferrin receptor for Fe; erythrocyte (red cell) folate,
serum/plasma folate or serum/plasma homocysteine
for folate; serum/plasma total B
12
, serum/plasma
methylmalonic acid or serum/plasma holotranscoba-
lamin for vitamin B
12
; serum/plasma Zn for Zn; and
urinary iodine (24 h or spot), serum or dried whole
blood spot thyroglobulin or serum thyroid-stimulating
hormone for iodine
(20–27)
.
Data analyses
We compared mean intakes and median (or mean) status
levels between countries, between regions and with
external reference values to evaluate differences between
countries and indications for inadequacies. When several
studies were available for one country, studies were
ranked for their eligibility considering representativeness
of the sample for the country, dietary assessment method
used and year of the study (most recent were given
preference).
To study regional variations in micronutrient intake
and/or status, Europe was divided into four geographical
regions: (i) CEE (Albania, Bosnia-Herzegovina, Bulgaria,
Croatia, Czech Republic, Estonia, Latvia, Lithuania, Hungary,
Macedonia, Montenegro, Poland, Romania, Serbia, Slovakia
and Slovenia); (ii) Mediterranean (Greece, Italy, Portugal
and Spain); (iii) Western Europe (Austria, Belgium, France,
Germany, Ireland, The Netherlands, Switzerland and the
UK); and (iv) Scandinavia (Denmark, Finland, Iceland,
Norway and Sweden).
Regional comparisons were made when data for a
specific micronutrient and population group were avail-
able for at least three CEE countries. This comparison
included the calculation of weighed mean regional
intakes and median status levels, plotting of country
means (medians) and subsequently the description of:
(i) differences in intake and/or status across European
regions and (ii) observed mean intake and/or status in
CEE countries in contrast to nutritional reference values.
Variables considered in the description were differences
in dietary assessment method (checked also by differ-
ences in mean daily energy consumption) and study
population. In cases where data were available for fewer
than three CEE countries, data from CEE countries were
compared with the data from other European countries
published in ENHR II
(16)
or from single studies, selecting
those with the most comparable data (regarding age
group, status biomarker, dietary assessment method and
year of the study).
To evaluate whether there is an indication for inade-
quacy in micronutrient intake, the mean usual intake was
compared with the ANR (Average Nutrient Requirement;
amount of nutrient which is sufficient for 50 % of the
apparently healthy population) derived for the Nordic
countries (Nordic Nutrition Recommendations, NNR)
(28,29)
,
as these are the most recent reference values set for a series
of European countries.* If an ANR for a micronutrient
was not set by NNR (Ca and vitamin D in adults, all
micronutrients in children), the ANR published for the
USA/Canada by the US Institute of Medicine was used
(22)
.
Relevant ANR are given in the figure captions. To assess
adequacy of levels of status markers, we used guidance on
cut-off values from EURRECA experts
(30–33)
. These cut-off
values were based on key references mostly published
by the WHO in cooperation with other institutions
(20–27)
.
The specific values used are added to figure captions,
table footnotes or text where applicable.
Results
Literature search and data availability
The search on micronutrient intake/status for all age
ranges in CEE in the PubMed database resulted in 1949
titles and abstracts, out of which 121 were left after
screening for potential relevance. The key reason for
exclusion was that studies did not report mean intake or
status. For one hundred and thirteen, full manuscripts
were obtained and checked for compliance with the
inclusion criteria; eight studies were inaccessible. Finally,
thirty-eight studies were kept for further analysis, of
which the grey literature added nine studies in total and
contributed primarily data on micronutrient intake in
adults. The WHO VMNIS database provided thirty-four
studies on iodine and Fe status. A detailed overview of
the study characteristics is given in Table 1.
Comparison of micronutrient intakes
Micronutrient intake data were most abundant for Ca,
folate, Fe, vitamin B
12
, vitamin C and vitamin D in adults.
Figures 1 to 6 plot the mean micronutrient intakes (with
95 % confidence intervals) geographically (by country in
four regions) and information is given on the dietary
assessment method, age range of the study population,
number of subjects and mean energy intake for males
and females.
Observed mean Ca intake (Fig. 1) among females in
CEE countries (pooled estimated mean: 869 mg/d) was in
general lower than those in other European countries.
The pooled means were 978, 1006 and 881 mg/d for
Scandinavian, Western European and Mediterranean
countries, respectively. The observed mean intake among
Public Health Nutrition
* Although more sophisticated methods are available for assessment of
inadequacy such as the EAR (Estimated Average Requirement) cut-point
method
(27)
, we only compared mean levels with a reference value, as the
more advanced methods use standard deviations. Standard deviations
vary considerably by assessment method and request a higher compar-
ability of measurement between countries.
Micronutrient intake/status in CEE 3
Public Health Nutrition
Table 1 Characteristics of studies included in the present review*
Country Study name Study year Population group No. of subjects; sex
Food intake method
or Status measure
Micronutrients
included in the study
Albania Iodine treatment in children with subclinical hypothyroidism
due to chronic iodine deficiency decreases thyrotropin and
C-peptide concentrations and improves the lipid profile
(46)
2009 Children aged
10 62 years
133 M&F Urinary iodine Iodine
Iodine supplementation improves cognition in iodine-deficient
school children in Albania: a randomized, controlled,
double-blind study
(47)
2006 Children aged
10–12 years
303 M&F Urinary iodine Iodine
Bosnia Thyroid volume and urinary iodine excretion in school children
in North-Eastern Bosnia
(48)
2008 Children aged 7–14
years
513 M&F Urinary iodine Iodine
Bulgaria Evaluation of endemic goiter prevalence in Bulgarian 2007 Boys and girls aged 274 M Urinary iodine Iodine
schoolchildren results from national strategies for
prevention and control of iodine-deficiency disorders
(49)
8–15 years 209 F
-AgeingNutrition
(50)
2006 .55 years 186 M 24hR Vitamin C
194 F
-National study of urinary iodine excretion – biomarker of 2003 Children aged 7–11 809 M&F; Urinary iodine Iodine
Iodine nutrition
(51)
years; pregnant
women
355 F
Croatia Diet quality in Croatian university students: energy, 2007 Males and females 183 M FFQ quantified Ca, Cu, folate, Fe,
macronutrient intakes according to gender
(52)
aged 18–30 years 480 F Se, vitamin B
12
,
vitamin C, Zn
Dietary habits and folate status in women of childbearing age
in Croatia
(53)
2006 Females aged
20–30 years
100 F 2324hR; serum
folate
Folate
Calcium intake, food sources and seasonal variations in 2005 Males and females 46 M FFQ Ca
Eastern Croatia
(54)
aged 18–55 years 115 F
Comparison of dietary habits in the urban and rural Croatian 2004 Children aged 8–16 315 (urban) FFQ quantified Ca, folate, Fe,
schoolchildren
(55)
years 163 (rural) Se, vitamin B
12
,
vitamin C,
vitamin D, Zn
Ultrasound bone measurement in children and adolescents: 2003 Boys and girls aged 120 M Semi-quantitative Ca
correlation with nutrition, puberty, anthropometry, and 7–10 years; boys 122 F; FFQ
physical activity
(56)
and girls aged 112 M
15–17 years 147 F
Czech Dietary habits in three Central and Eastern European 2009 Males and females 3690 M FFQ validated Ca, folate, Fe,
Republic countries: the HAPIEE study
(57)
aged 45–69 years 4223 F vitamin C
Health behaviors, nutritional status, and anthropometric
parameters of Roma and non-Roma mothers and their
infants in the Czech Republic
(58)
2009 Lactating women 151 F Serum folate Folate
Iodine in early pregnancy – is there enough?
(59)
2008 Pregnant women
aged 17–41 years
168 F Urinary iodine Iodine
Actual levels of soy phytoestrogens in children correlate with 2006 Boys and girls aged 129 M Urinary iodine Iodine
thyroid laboratory parameters
(60)
8–15 years 139 F
Mild hyperhomocysteinaemia is associated with increased 2006 Males and females 126 M Homocysteine; Folate, vitamin B
12
aortic stiffness in general population
(61)
aged 25–65 years 125 F serum folate;
serum vitamin B
12
4 R Novakovic
´et al.
Public Health Nutrition
Table 1 Continued
Country Study name Study year Population group No. of subjects; sex
Food intake method
or Status measure
Micronutrients
included in the study
Genetic determinants of folate status in Central Bohemia
(62)
2005 Males and females 250 M Serum folate; serum Folate, vitamin B
12
aged 18–65 years 261 F homocysteine;
erythrocyte folate;
serum vitamin B
12
INAA of serum zinc of inhabitants in five regions of the Czech 1999 Boys and girls aged 90 M Serum zinc Zinc
Republic
(63)
10 years; males 104 F;
aged 36–49 118 M;
years; females 118 F
aged 36–49 years
and 50–65 years
106 F
Estonia The reference limits and cut-off value for serum soluble
transferrin receptors for diagnosing iron deficiency in
infants
(64)
2008 9–12 months 146 M&F Serum transferrin Fe
Prevalence and causes of iron deficiency anemias in infants
aged 9 to 12 months in Estonia
(65)
2007 9–12 months 171 M&F Hb; serum
transferrin; serum
ferritin
Fe
-AgeingNutrition
(50)
2006 .55 years 126 M 24hR Folate, vitamin B
12
,
190F vitamin D
-Nutrition and Lifestyle in the Baltic Republics – Summary 1999 Males and females 900 M 24hR Ca, vitamin C, Fe,
Report
(66)
aged 19–64 years 1115 F folate
Hungary Dietary habits of schoolchildren: representative survey in 2007 Boys and girls aged 124 M 3dDR Ca, Cu, folate, Fe,
metropolitan elementary schools: Part 2
(67)
11–14 years 111 F vitamin B
12
,
vitamin C, vitamin
D, Zn
-Report on Periconceptional Folic Acid Supplementation for
Hungary
(68)
2007 Females aged
18–59 years
352 F 3324hR Folate
-AgeingNutrition
(50)
2006 .55 years 93 M 24hR Vitamin B
12
,
159 F vitamin C
Dietary survey in Hungary, 2003–2004
(69)
2005 Males and females 473 M 24hR Ca, Cu, folate, Fe,
aged 18–601
years
706 F vitamin B
12
,
vitamin C,
vitamin D, Zn
Prevalence and seasonal variation of hypovitaminosis D and
its relationship to bone metabolism in community dwelling
postmenopausal Hungarian women
(70)
2003 Females aged
41–91 years
319 F FFQ validated Ca
-Nutrition survey of the Hungarian population in a randomized 1996 Males aged 338 M 24hR; Hb; serum Ca, Cu, folate, Fe,
trial between 1992–1994
(71)
18–34 years and 730 M; folate; serum Zn vitamin C, Zn
35–59 years; 343 F
females aged 938 F
18–34 years,
35–54 years and
.55 years
105 F
Latvia -Nutrition and Lifestyle in the Baltic Republics – Summary 1999 Males and females 1065 M 24hR Ca, Fe, vitamin C
Report
(66)
aged 19–64 years 1235 F
Lithuania Prognostic value of reticulocyte haemoglobin content to
diagnose iron deficiency in 6–24-month-old children
(72)
2008 6–24 months 180 M&F Hb Fe
Micronutrient intake/status in CEE 5
Public Health Nutrition
Table 1 Continued
Country Study name Study year Population group No. of subjects; sex
Food intake method
or Status measure
Micronutrients
included in the study
-Nutrition and Lifestyle in the Baltic Republics – Summary 1999 Males and females 2606 M 24hR Ca, Fe, vitamin C
Report
(66)
aged 20–65 years 1132 F
Poland Iodine excretion with urine and thyrotrophic hormone
concentration in normal and complicated pregnancies in the
industrial region of iodine deficiency
(73)
2006 Pregnant women
aged 28?266?4
years
104 F Urinary iodine Iodine
-Food consumption of low income groups in Poland and
Belgium
(74)
2007 Males and females
aged 19–59 years
240 M&F 24hR and FFQ Ca, Cu, Fe, vitamin
B
12
, vitamin C, Zn
-Wartos
´c
´energetyczna i odz
˙ywcza diety doros"ych 2010 Males and females 3132 M 24hR; homocysteine Ca, Cu, folate, Fe,
mieszkan
´co
´w Polski. Wyniki programu WOBASZ
(unpublished results, obtained by personal correspondence
with Dr Elzbieta Sygnowska, 10 November 2010)
(75)
aged 20–74 years 3529 F vitamin B
12
,
vitamin C,
vitamin D, Zn
Dietary habits in three Central and Eastern European 2009 Males and females 4815 M FFQ validated Ca, folate, Fe,
countries: the HAPIEE study
(57)
aged 45–69 years 5044 F vitamin C
Polish Food Consumption and Anthropometric Survey 2000:
comparison between household budget survey and 24-h
recall data in a nationally representative sample of Polish
households
(76)
2005 All age groups
(0–96 years)
3716 M&F 24hR Ca, Cu, Fe, vitamin
C, Zn
Effectiveness of the iodine prophylaxis model adopted in 2008 Boys and girls aged 1450 M Urinary iodine Iodine
Poland
(77)
6–12 years 1563 F
Increased prevalence of hyperthyroidism as an early and 2007 Males and females 491 M Urinary iodine Iodine
transient side-effect of implementing iodine prophylaxis
(78)
aged .16 years 933 F
Comparative analysis of zinc status, food products’ frequency
intake and food habits of 11-year-old healthy children
(79)
2002 Children aged
11 years
157 M&F Serum Zn Zn
Serbia -National Survey of the Biological Impact of Universal Salt
Iodisation in the Population of Serbia 2007
(80)
2007 Children aged
6–14 years
1745 M&F Urinary iodine Iodine
-Yugoslav study of atherosclerosis precursors in 2003 Boys and girls aged 1984 M HFCS (7 d record); Ca, Cu, folate,
schoolchildren in Serbia from 1998–2003
(36)
15 years; males 1859 F; Hb Iodine, Fe,
and females aged 1225 M vitamin B
12
,
10–15 years, 1173 M vitamin C,
30–59 years and 147 M vitamin D, Zn
60–75 years 1228 F
1227 F
246 F
Slovakia Vitamin C protective plasma value
(81)
2007 Males and females 78 M FFQ Vitamin C
aged 19–68 years 109 F
The Republic The Republic of Srpska Iodine Deficiency Survey 2006
(82)
2008 Boys and girls aged 599 M Urinary iodine Iodine
of Srpska 7–10 years 592 F
M, males; F, females; 24hR, 24 h recall; 3dDR, 3 d diet record; HFCS, household food consumption survey.
*For all studies: supplements are not included in the assessment.
-Grey literature.
6 R Novakovic
´et al.
females in Estonia, Hungary and Lithuania was below the
ANR (source: NNR), which indicates that there is a risk
of inadequacy. Similar results were observed for CEE
males (pooled estimated mean: 862 mg/d); the pooled
mean Ca intakes for Scandinavian, Western European and
Mediterranean countries were 1130, 1129 and 885 mg/d,
respectively. In CEE, four out of eight countries had a
mean intake below the ANR among males, and in three
countries among females. Within CEE, relatively high
levels of Ca intake were observed for Croatia and Serbia.
This can likely be explained by the different age range of
the study population in the Croatian study (university
students, 18–30 years) and the different dietary assess-
ment method used in the Serbian study (intake data were
collected per household and calculated per person using
the consumption units). This explanation is supported by
the fact that mean energy intakes in these studies are also
relatively high. This remark also holds for the levels of
intake of other micronutrients from these two studies.
Figure 2 shows the observed mean intakes for folate.
In CEE the mean pooled intake (307 mg/d) was slightly
higher than in the other regions (Scandinavia: 235 mg/d,
Western Europe: 278 mg/d, Mediterranean: 275 mg/d), which
was due to the relatively high value for Croatia. In CEE,
Hungarian and Estonian females had mean intake below
the ANR, indicating a risk of inadequacy. Among CEE males,
the estimated mean intake (302 mg/d) was in the same range
as those in other regions (Scandinavia: 268 mg/d, Western
Europe: 322 mg/d, Mediterranean: 287 mg/d). Hungarian
males had folate intake below the ANR.
These results correspond with the previous publication
by de Bree et al.
(34)
which indicated that mean dietary
folate intake in Europe is in line with recommendations.
The observed mean Fe intakes are shown in Fig. 3. The
pooled mean intake among females from CEE (13 mg/d)
was similar to those from the other European regions
(range: 11–13 mg/d). For all CEE countries the mean
intake of females was above the ANR with the exception
of Hungary. For males, the mean estimated intake in CEE
(16 mg/d) was slightly higher than that in other regions
(range: 13–15 mg/d); all countries reported an observed
mean intake higher than the average daily requirements.
The mean intakes of vitamin B
12
are shown in Fig. 4.
The pooled levels for both females and males in CEE
(4 and 7 mg/d, respectively) were similar to the pooled
means for Scandinavia and Western Europe, whereas the
highest means were observed in the Mediterranean
countries (7 mg/d in females, 8 mg/d in males). For both
genders in all countries, mean intake values were above
the ANR.
The mean observed vitamin C intake (Fig. 5) in CEE
females (pooled estimate: 134 mg/d) was similar to that in
Public Health Nutrition
Dietary
intake
method
No. of
subjects;
sex
Age
range
(years)
Mean
(mg/d) SD SD
500 M
500 F
1069
922
395
300
9933
7841
730 M
846 F
1202
1007
592
450
9265
6804
2960
2028
1055
990
448
389
10 638
8232
2910
2209
354
299
11 033
7623
3108
2007
558
389
11 041
8131
4112
2511
325
339
NA
200
170
8925
7047
354
359
9937
8731
2305
2108
700 M
700 F
309
264
10 336
8433
1906
1604
1173 M
1227 F
1426
1105
643
501
11 415 (M&F)
425
438
9529
8727
2910
2608
858
782
468
420
10 945
8202
4317
3494
1065 M
1235 F
742
855
456
547
10 848
7522
5023
3355
717
656
319
276
11 734
9227
900 M
115 F
716
589
544
362
9567
6888
4804
3217
3690 M
4223 F
721
835
362
411
8727
4867
3007
3007
183 M
480 F
1711
1444
965
740
15 955
11 982
7534
5720
Sweden
Finland
Denmark
Ireland
Germany
France
Spain
Portugal
Italy
Serbia
Poland
Lithuania
Latvia
Hungary
Estonia
Czech
Croatia
400 600 800 1000 1200
Mean Ca intake (mg/d)
1400 1600 1800 2000
Country
Energy
(kJ/d)
EFR
24hR
EFR 300 M
300 F
EFR 650 M
650 F
DH 5000 M
5000 F
EFR 954 M
800 F
2x24hR 750 M
750 F
FFQ 1200 M
1200 F
EFR
HFCS
FFQ 4815 M
5044 F
24hR 2606 M
1132 F
24hR
24hR 473 M
706 F
24hR
FFQ
Republic
FFQ
19–64
19–64
19–64
19–64
19–64
52–68
19–59
19–64
19–64
30–60
45–69
19–64
19–64
18–60+
19–64
51–65
18–30
949
742
1171
1047
1032
964
830
778
883
963
947
851
872
899
Fig. 1 Mean (SD) calcium intake in mg/d and mean (SD) energy intake in kJ/d for males (M) and females (F) by country and region
(separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and Eastern Europe).
Dietary intake method: EFR 5estimated food record; 24hR 524 h recall; DH 5diet history; HFCS 5household food consumption
survey. NA 5not available. Plot shows mean intakes with 95% confidence intervals represented by horizontal bars: J, males; ’,
females; ——, Average Nutrient Requirement (800 mg/d for females and males)
Micronutrient intake/status in CEE 7
Public Health Nutrition
Dietary
intake
method
No. of
subjects;
sex
Age
range
(years)
Mean
(µg/d)
Energy
(kJ/d) SD
Sweden
(16)
500 M
500 F
232
215
73
65
9933
7841
Finland
(16)
730 M
846 F
270
226
120
88
9265
6804
2960
2028
Denmark
(16)
300 M
300 F
323
296 120
111
10 638
8232
2910
2209
Scotland
(16)
7925
Ireland
(16)
650 M
650 F
332
260
128
144
11 033
7623
3108
2007
Germany
(16)
5000 M
5000 F
321
277
202
124
11 041
8131
4112
2511
Spain
(16)
237
220
45
48
8925
7047
Portugal
(16)
1200 M
1200 F
302
304
130
144
9937
8731
2305
2108
Italy
(16)
700 M
700 F
315
283
91
100
10 336
8433
1906
1604
Serbia
(36)
1173 M
1227 F
293
228
148
116
11 415 (M&F)
Poland
(56)
4815 M
5044 F
322
321
118
124
9529
8727
2910
2608
Hungary
(69)
11 734
9227
Hungary
(68)
Estonia
(50)
126 M
190 F
213
171
121
99
9567
6888
4804
3217
Czech
Republic
(57)
3690 M
4223 F
294
303
115
135
8727
4867
3007
3007
Croatia
(52)
183 M
480 F
443
373
226
168
15 955
11 982
7534
5720
Sweden
Finland
Denmark
Scotland
Ireland
Germany
Spain
Portugal
Italy
Serbia
Poland
Hungary
Estonia
Czech
Croatia
100 200 300
Mean folate intake (µg/d)
400
Country SD
EFR
24hR
EFR 19–64
19–64
19–64
DH
EFR
FFQ 898 F
19–64
19–64
45–54 294 89
EFR
FFQ
2x24hR 750 M
750 F
19–64
19–64
19–59
HFCS
FFQ
FFQ
FFQ
24hR
24hR
3x24hR 352 F
473 M
18–30
51–65
55–65
18–59
18–60+
45–69
30–60
152
132
53
47
500
Fig. 2 Mean (SD) folate intake in mg/d and mean (SD) energy intake in kJ/d for males (M) and females (F) by country and region
(separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and Eastern Europe).
Dietary intake method: EFR 5estimated food record; 24hR 524 h recall; DH 5diet history; HFCS 5household food consumption
survey. NA 5not available. Plot shows mean intakes with 95% confidence intervals represented by horizontal bars: J, males; ’,
females; ——, Average Nutrient Requirement (200 mg/d for females and males)
Country
No. of
subjects;
sex
Age
range
(years)
Mean
(mg/d) SD
Energy
(kJ/d) SD
500 M
500 F
12
10
3
2
9933
7841
1100 M
1100 F
13
12
5
6
11142
730 M
846 F
14
10
6
3
9265 2960
3914
645
5000 M
5000 F
16
13
6
4
11 041
8131
4112
2511
954 M
800 F
15
11
4
3
NA
500 M
500 F
13
10
3
2
NA
750 M
750 F
13
11
2
2
8925
7047
1200 M
1200 F
17
15
5
4
9937
8731
2305
2108
700 M
700 F
15
14
4
19
10 336
8433
1906
1604
1173 M
1227 F
24
19
11
9
11 415 (M&F)
4815 M
5044 F
14
13
4
4
9529
8727
2910
2608
2606 M
1132 F
23
20
13
12
10 945
8202
4317
3494
1065 M
1235 F
19
13
10
7
10 848
7522
5023
3355
473 M
706 F
13
10
3
3
11 734
9227
900 M
1115 F
15
12
10
7
9567
6888
4804
3217
3690 M
4223 F
11
11
4
5
8727
4867
3007
3007
183 M
480 F
22
16
10
2
15 955
11 982
7534
5720
Sweden
Norway
Finland
Germany
France
Belgium
Spain
Portugal
Italy
Serbia
Poland
Lithuania
Latvia
Hungary
Estonia
Czech
Croatia
6 7 8 9 10 1 12131415
Mean Fe intake (mg/d)
16 17 18 19 20 21 22 23 24 25
Dietary
intake
method
EFR
FFQ
24hR
DH
EFR
24hR
2x24hR
FFQ
EFR
HFCS
FFQ
24hR
24hR
24hR
24hR
FFQ
Republic
FFQ
19–64
16–79
19–64
19–64
52–68
19–64
19–59
19–64
19–64
30–60
45–69
19–64
19–64
18–60+
19–64
51–65
18–30
1936
2028
6804
Fig. 3 Mean (SD) iron intake in mg/d and mean (SD ) energy intake in kJ/d for males (M) and females (F) by country and region
(separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and Eastern Europe).
Dietary intake method: EFR 5estimated food record; 24hR 524 h recall; DH 5diet history; HFCS 5household food consumption
survey. NA 5not available. Plot shows mean intakes with 95% confidence intervals represented by horizontal bars: J, males; ’,
females; ——, Average Nutrient Requirement (ANR; 7 mg/d for males); – – –, ANR (10 mg/d for females)
8 R Novakovic
´et al.
Public Health Nutrition
Country
Dietary
intake
method
No. of
subjects;
sex
Age range
(years)
Mean
(mg/d) SD SD
EFR 500 M
500 F
19–64 7
7
6
4
5
9933
7841
24hR 730 M
846 F
19–64
5
6
6
3
9265
6804
2960
2028
WFR 400 M
400 F
19–64
4
3
3
10 638
8232
2910
2209
EFR 700 M
700 F
19–64 5
4
4
4
11 033
7623
3108
2007
DH 5000 M
5000 F
19–64 7
4
4
2
11 041
8131
4112
2511
EFR 125 M
125 F
>64 5
4
2
2
8026
6921
2x24hR 750 M
750 F
19–59 5
4
1
1
8925
7047
FFQ 1200 M
1200 F
19–64 9
9
4
4
9937
8731
2305
2108
HFCS 1173 M
1227 F
30–60 6
5
4
4
11 415 (M&F)
24hR 3132 M
3529 F
20–74 6
3
9
4
17
8
10 386
7060
24hR 93 M
159 F
>65
2
2
2
10 432
8828
2205
1705
24hR 126 M
190 F
55–65
6
3
2
9567
6888
4804
3217
FFQ 183 M
480 F
18–30 9
7
5
4
15 955
11 982
7534
5720
Sweden
Finland
Denmark
Ireland
Germany
Austria
Spain
Portugal
Serbia
Poland
Hungary
Estonia
0.01.42.84
.25
.6
Mean vitamin B12 intake (µg/d)
7.08
.49
.811
.2
Croatia
Energy
(kJ/d)
50
50
52
Fig. 4 Mean (SD) vitamin B
12
intake in mg/d and mean (SD) energy intake in kJ/d for males (M) and females (F) by country and
region (separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and Eastern
Europe). Dietary intake method: EFR 5estimated food record; 24hR 524 h recall; WFR 5weighed food record; DH 5diet history;
HFCS 5household food consumption survey. NA 5not available. Plot shows mean intakes with 95 % confidence intervals
represented by horizontal bars: J, males; ’, females; ——, Average Nutrient Requirement (1.4 mg/d for females and males)
Country
Dietary
intake
method
No. of
subjects;
sex
Age
range
(years)
Mean
(mg/d) SD
Energy
(kJ/d) SD
EFR 500 M
500 F
19–64 79
98
102
90
45
50
9933
7841
24hR 730 M
846 F
19–64
118
88
82
9265
6804
2960
2028
WFR 400 M
400 F
19–64
107
56
61
10 638
8232
2910
2209
EFR 700 M
700 F
19–64 116
108
223
183
11 033
7623
3108
2007
DH 5000 M
5000 F
19–64 153
153
106
84
11 041
8131
4112
2511
EFR 954 M
1369 F
52–68 100
96
49
43
NA
2x24hR 750 M
750 F
19–59 830
778
200
170
8925
7047
FFQ 1200 M
1200 F
19–64 883
963
354
359
9937
8731
2305
2108
EFR 700 M
700 F
19–64 947
851
309
264
10 336
8433
1906
1604
FFQ 68 M
109 F
19–68 90
90
NA
HFCS 1173 M
1227 F
30–60 146
112
93
71
11 415 (M&F)
24hR 3132 M
3529 F
20–74 76
73
74
75
10 386
7060
24hR 2606 M
1132 F
19–64 128
121
108
112
10 945
8202
4317
3494
24hR 1065 M
1235 F
19–64 70
64
65
63
10 848
7522
5023
3355
24hR 93 M
159 F
>65 78
69
49
36
10 432
8828
2205
1705
24hR 900 M
1115 F
19–64 82
82
96
81
9567
6888
4804
3217
FFQ
Republic
3690 M
4223 F
51–65 160
229
135
242
8727
4867
3007
3007
FFQ 183 M
480 F
18–30 177
185
111
132
15 955
11 982
7534
5720
24h R 186 M
194 F
60–75 89
83
70
70
10 231
8127
4116
2608
Sweden
Finland
Denmark
Ireland
Germany
France
Spain
Portugal
Italy
Slovakia
Serbia
Poland
Lithuania
Latvia
Hungary
Estonia
Czech
Croatia
Bulgaria
40 60 80 100 120 140
Mean vitamin C intake (mg/d)
160 180 200 220 240
50
52
50
Fig. 5 Mean (SD) vitamin C intake in mg/d and mean (SD) energy intake in kJ/d for males (M) and females (F) by country and region
(separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and Eastern Europe).
Dietary intake method: EFR 5estimated food record; 24hR 524 h recall; WFR 5weighed food record; DH 5diet history;
HFCS 5household food consumption survey. NA 5not available. Plot shows mean intakes with 95 % confidence intervals
represented by horizontal bars: J, males; ’, females; ——, Average Nutrient Requirement (ANR; 60 mg/d for males); – – –,
ANR (50 mg/d for females)
Micronutrient intake/status in CEE 9
Western European countries (136 mg/d) and higher
than in Scandinavia and the Mediterranean (107 and
119 mg/d, respectively). The same held for CEE males: the
pooled estimate for CEE was 118 mg/d, for other regions
it ranged from 93 to 142 mg/d. Both genders in CEE
countries had mean intake above the ANR.
The pooled mean vitamin D intakes for females and
males of CEE countries were 3 and 4 mg/d, respectively
(Fig. 6). These values were comparable to those of the
other regions; pooled estimates for females and males
were 7?8mg/d in Scandinavia, 2?4mg/d in Western Europe
and 3?3mg/d in Mediterranean countries. The mean
intakes in CEE and in other regions were below the ANR
with exception of Norway.
Data for the other micronutrients (Cu, iodine, Se and Zn)
were limited and available for one or two CEE countries
and for some population groups only (see Table 2).
The mean Cu intake in CEE countries was comparable
to those in other European countries, 1?2–1?9mg/d
(16)
,
except for Serbia, which reported the highest intake. The
mean intakes were above the reference values set for Cu.
Iodine intake data were available only for Serbia, and
the mean intake was in the range of other regions
(108–253 mg/d for males; 101–194 mg/d for females)
(16)
being above the ANR. Se intake data for CEE adults were
available for Croatia, and the mean intake value was above
the range observed in the other regions (36–73 mg/d for
males; 31–55 mg/d for females)
(16)
. The mean intakes for
both genders were well above the ANR. Data on mean Zn
intake were available for three CEE countries, and the
values were similar to those for non-CEE countries
(7?8–13?6 mg/d for males; 7?8–10?3 mg/d for females)
(16)
;
the average intakes were considerably above the ANR.
Data on micronutrient intakes in CEE children were
available from Croatia, Hungary and Serbia. The mean
micronutrient intakes in these countries (Table 3) were
in range of intakes in children in other European coun-
tries
(16)
: Ca (600–1381 mg/d), Cu (0?8–1?9 mg/d), folate
(138–428 mg/d), iodine (94–209 mg/d), Fe (7?7–17?9mg/d),
Se (28–110 mg/d), vitamin C (78–197 mg/d), vitamin D
(1?2–4?8mg/d) and Zn (6?5–14?6mg/d), except for the
intake of vitamin B
12
in Hungary, which was lower in
comparison to other European regions (2?9–11?8mg/d). In
these three CEE countries, mean daily intakes below the
ANR were observed for Ca (except in boys in Serbia), folate,
vitamin D and for Se in Croatia.
Comparison of micronutrient status
For micronutrient status most CEE data were available for
iodine and Fe status in children. Figures 7 and 8 show the
median urinary iodine concentrations and the mean (SD)
Hb concentrations, respectively, for children in Europe.
The data on iodine and Fe status were retrieved mainly
from the WHO VMNIS database. Exceptions are the data
for The Republic of Srpska and Serbia. CEE countries had
lower median urinary iodine levels than other European
Public Health Nutrition
Country
Dietary
intake
method
No. of
subjects;
sex
Age
range
(years)
Mean
(µg/d) SD
Energy
(kJ/d) SD
Norway(16) FFQ 1100 M
1100 F
16–79 11
10
11
9
11 142
1936
3914
645
Finland(16) 24h 730 M
846 F
19–64 7
5
6
4
9265
6804
2960
2028
Denmark(16) WFR 400 M
400 F
19–64
3
3
2
10 638
8232
2910
2209
Ireland(16) EFR 700 M
700 F
19–64
4
4
4
4
3
9
11 033
7623
3108
2007
Germany(16) DH 5000 M
5000 F
19–64
2
4
1
11 041
8131
4112
2511
Austria(16) EFR 170 M >64 3 5NA
England(16) FFQ 898 F 45–54 4 2 7925 2205
Spain(16) 2x24hR 750 M
750 F
19–59 2
1
1
1
8925
7047
Portugal(16) FFQ 1200 M
1200 F
19–64 4
4
2
2
9937
8731
2305
2108
Italy(16) EFR 700 M
700 F
19–64 4
3
2
2
10 336
8433
1906
1604
Serbia(36) HFCS 1173 M
1227 F
30–60 5
5
3
3
11 415 (M&F)
Poland(75) 24hR 3132 M
3529 F
20–74 4
3
5
4
10 386
7060
Hungary(69) 24hR 473 M
706 F
18–60+ 2
2
1
1
11 734
9227
Estonia(50) 24hR 126 M
190 F
55–65 4
3
8
4
9567
6888
4804
3217
Norway
Finland
Denmark
Ireland
Germany
England
Austria
Spain
Portugal
Italy
Serbia
Poland
Hungary
Estonia
0.02
.55
.0
Mean vitamin D intake (µg/d)
7.510
.0 12.5
Fig. 6 Mean (SD) vitamin D intake in mg/d and mean (SD) energy intake in kJ/d for males (M) and females (F) by country and
region (separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central
and Eastern Europe). Dietary intake method: EFR 5estimated food record; 24hR 524 h recall; WFR, weighed food record;
DH 5diet history; HFCS 5household food consumption survey. NA 5not available. Plot shows mean intakes with 95 % confidence
intervals represented by horizontal bars: J, males; ’, females; ——, Average Nutrient Requirement (10 mg/d for females
and males)
10 R Novakovic
´et al.
regions: mild iodine deficiency (median urinary iodine
,100 mg/l) in CEE was found in children and adolescents
from Estonia, Hungary, Latvia and Lithuania, whereas
children in Albania suffered from moderate iodine defi-
ciency (median urinary iodine ,50 mg/l). Data from other
European countries showed an adequate iodine status
(median urinary level .100 mg/l) for all countries, except
for Italy and Belgium.
The mean Hb levels in CEE children and adolescents
were lower than in other European countries, for which
the data were scarce. Mean levels were in general above
the cut-off values; only infants in Lithuania were at risk of
Fe-deficiency anaemia (Hb ,110 g/l), whereas children in
Romania had borderline concentration.
CEEdataoniodineandFestatusinadults,andon
folate, vitamin B
12
and Zn status for all population groups,
were too limited to allow between-region comparisons. An
overview of the available status data for CEE populations is
presented in Table 4.
Median urinary iodine concentration in CEE adults
ranged from 51 to 158 mg/d, similar to those in other
European regions (source: WHO VMNIS database for
non-CEE countries; not included in the table). In CEE,
mild iodine deficiency (median urinary iodine ,100 mg/l)
was observed in Romanian females. In other regions,
both males and females from Italy, France and Germany
had mean urinary iodine levels below the cut-off.
Prevalence of iodine deficiency in Europe was recently
outlined by Zimmerman and Andersson
(35)
. For CEE
countries (data on school-aged children; if not avail-
able, pre-school children, adolescents or adults) iodine
deficiency was reported in Albania, Estonia, Hungary,
Latvia and Lithuania.
For Fe status, CEE data were available only for
Serbia
(36)
and for females from Macedonia
(12)
. Reported
mean Hb concentrations were in the same range as those
in other European countries included in the WHO global
database (e.g. Spain, France, Denmark and Finland) and
above the cut-off value of 120 or 130 g/l.
Overall, the results on Fe status (Hb levels above the
cut-offs) confirm the results on Fe intake for all countries
in the present study (except Hungary).
Data on folate status were available for adults in Croatia,
Czech Republic and Hungary. Mean serum folate levels in
CEE were comparable to those from other European
countries (range mean: 16 to 18 nmol/l)
(37–39)
,withthe
exception of Norwegian adults (7 nmol/l)
(40)
.Themean
serum folate levels in CEE populations and in other regions
were above the cut-off values for both genders, except
for Roma mothers in Czech Republic. The findings on folate
status are in accordance with observed results on folate
intake from the present study for all European regions
(except Hungary and Estonian females).
For vitamin B
12
status, only one study from CEE was
identified. In the Czech Republic reported mean levels
of serum vitamin B
12
were comparable to those in other
European countries, such as Norway
(40)
, and above the
reference value (150 pmol/l). These findings are con-
sistent with the vitamin B
12
intake results from the present
study (Fig. 4).
Data on Zn status were available for adults and
children in three CEE countries. CEE adults from Czech
Public Health Nutrition
Table 2 Mean energy and micronutrient intakes (copper, iodine, selenium and zinc) by Central and Eastern European country in males and
females
Nutrient/country Dietary intake method No. of subjects; sex Age range (years) Mean SD Energy (kJ/d) SD
Cu (mg/d)
Croatia
(52)
FFQ 183 M 18–30 2 1 15 955 7534
480 F 2 1 11 982 5720
Hungary
(69)
24hR 473 M 18–6011 1 11 734
706 F 1 0?5 9227
Poland
(75)
24hR 3132 M 20–74 1 0?5 10 386
3529 F 1 0?4 7060
Serbia
(36)
HFCS 1173 M 30–60 5 7 11 415 (M&F)
1227 F 4 5 11 415 (M&F)
Iodine (mg/d)
Serbia
(36)
HFCS 1173 M 30–60 184 139 11 415 (M&F)
1227 F 144 112 11 415 (M&F)
Se (mg/d)
Croatia
(52)
FFQ 183 M 18–30 215 106 15 955 7534
480 F 141 65 11 982 5720
Zn (mg/d)
Croatia
(52)
FFQ 183 M 18–30 18 9 15 955 7534
480 F 13 6 11 982 5720
Hungary
(69)
24hR 473 M 18–60110 3 11 734
706 F 8 2 9227
Serbia
(36)
HFCS 1173 M 30–60 15 9 11 415 (M&F)
1227 F 12 8 11 415 (M&F)
24hR, 24 h recall; HFCS, household food consumption survey.
Reference values: Average Nutrient Requirement (value from Nordic Nutrition Recommendations or US Institute of Medicine) for adults per d: Cu 0?7 mg;
iodine 100 mg; Se 30 mg for females, 35 mg for males; Zn 5 mg for females, 6 mg for males.
Micronutrient intake/status in CEE 11
Republic and Hungary had mean Zn status concentrations
(13–17 mmol/l) comparable to those in Western European
countries (range mean: 13–14 mmol/l)
(41–43)
and higher
than the reference value. Mean status levels for Polish and
Czech children were in the range from 12 to 15 mmol/l
(above the cut-offs), and similar to findings from other
European countries such as the UK (15 mmol/l)
(44)
.
Discussion
The present study reports the first comprehensive over-
view of CEE nutritional data using both open access
and grey literature sources with a twofold objective:
evaluation of intake and status for targeted micronutrients
in CEE in comparison to (i) those of other European
countries and (ii) the reference values.
From the limited data available, the results of this
review show no differences in micronutrient intake
and status in CEE populations in comparison to other
European regions except for intake of Ca in adults, and
iodine and Fe status in children (intake and status levels
lower in CEE than in non-CEE countries). Comparisons
with the intake/status reference values suggest highest
risk of inadequacy in intake of vitamin D in all age ranges,
and of Ca, folate and iodine in children.
We collated data using EURRECA’s best practice
guidance on dietary assessment methods and status
biomarkers
(30)
. In general, CEE studies on micronutrient
intake and status for all age ranges were scarce: even after
being less strict in inclusion criteria, only a few intake
studies could be added to the current comprehensive
overview. The largest knowledge gap regarding intake
refers to children; whereas data on status were scarce for
all population groups, with the exception of Fe and
iodine in children. The available studies on micronutrient
intake and status studies in CEE countries are diverse with
regard to design: they differ in dietary assessment, food
composition databases, sampling procedures and age
range, and this may confound regional and between-
country comparisons. Cooperation with the nutritional
network from CEE
(17)
resulted in obtaining nine studies
from grey literature. Even though this was not sufficient to
fill an evident knowledge gap in nutritional data from
CEE, it added to the existing open sources. However,
despite a paucity of data and the variations in meth-
odologies that can influence the true differences in
intake
(45)
, some regional variations were observed: it
seems that nutritional health in CEE in comparison to
other European countries is less favourable but only for
certain micronutrients.
Since CEE is less affluent compared with other
European regions, it would be interesting to examine
the variations in micronutrient intake and status within
CEE countries across different socio-economic layers.
That would indicate specific subgroups that are most at
Public Health Nutrition
Table 3 Energy and micronutrient intakes by Central and Eastern European country in boys and girls – means and SD, dietary intake method, age range and number of subjects (n)
Ca
(mg) SD
Cu
(mg) SD
Folate
(mg) SD
Iodine
(mg) SD
Fe
(mg) SD
Se
(mg) SD
Vitamin B
12
(mg) SD
Vitamin C
(mg) SD
Vitamin D
(mg) SD
Zn
(mg) SD
Energy
(kJ) SD
Croatia
(55)
, FFQ, 8–16
years
Boys and girls, n315 927 306 162 63 19 7 22 8 5 2 135 68 2 1 12 4 9017 2604
Hungary
(67)
, FFQ, 11–14
years
Boys, n124 798 288 1 0?3 151 58 11 3 3 2 99 79 2 1 9 2 10 453 1902
Girls, n111 696 238 1 0?3 140 65 10 3 2 1 94 70 2 1 7 2 9219 1503
Serbia
(36)
, HFCS, 10–15
years
Boys, n1225 1123 499 4 7 230 117 147 112 19 9 5 4 114 72 4 3 12 8 11 533
Girls, n1228 958 428 3 4 196 97 124 94 16 7 4 3 97 60 3 2 10 7 9769
HFCS, Household food consumption survey.
Reference values: Average Nutrient Requirement (value from US Institute of Medicine) for children per d: Ca 1100 mg; Cu 0?5 mg; folate 250 mg; iodine 73 mg; Fe 6 mg; Se 35 mg; vitamin B
12
1?5mg; vitamin C 39 mg;
vitamin D 10 mg; Zn 7 mg.
12 R Novakovic
´et al.
Public Health Nutrition
Poland
R. of Srpska_girls
Romania
Serbia
Slovakia
Slovenia
Greece
Italy
Spain
Austria
Belgium
Germany
Luxemburg
Netherlands
Switzerland
Sweden
Lithuania
Latvia
Hungary
Estonia
Croatia
Bulgaria
Bosnia
Albania
20 40 60 80 100 120
Median urinary iodine concentration (µg/l)
140 160 180 200 220 240
R. of Srpska_boys
Macedonia
Fig. 7 Median urinary iodine concentration in mg/l per d in children and adolescents by country and region (separated at — - —,
from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and Eastern Europe). ——, Optimal range for
median urinary iodine concentration (100–199 mg/l). Source of data: WHO Vitamin and Mineral Nutrition Information System,
except for studies from Republic of Srpska
(82)
and Serbia
(80)
Bulgaria
Croatia
Hungary_boys
Hungary_girls
Lithuania
Macedonia
Poland
Romania
Serbia_boys
Serbia_girls
Portugal
UK_boys
UK_girls
Iceland
Sweden_girls
100 105 110 115 120 125 130
Mean Hb concentration (g/l)
135 140 145 150 155 160
Fig. 8 Mean Hb concentrations (with 95 % confidence intervals represented by horizontal bars) in g/l per d in children and adolescents
by country and region (separated at — - —, from top to bottom, into Scandinavia, Western Europe, Mediterranean and Central and
Eastern Europe). Age range of the subjects: Bulgaria 2–4 years; Croatia 7–8 years; Hungary 15–19 years; Lithuania 0?5–2 years;
Macedonia 0?5–5 years; Poland 10–13 years; Romania 1 year; Serbia 15 years; Portugal 1 year; Iceland 1 year; UK 7–10 years;
Sweden 15–16 years. Hb concentration below which anaemia is present: - - -, 110 g/l (children aged 0?5–5 years); – – –, 115g/l
(children aged 5–11 years); ——, 120 g/l (children aged 12–14 years and females aged .15 year s); — - - —, 130 g/l (males aged
.15 years). Source of data: WHO Vitamin and Mineral Nutrition Information System, except for study from Serbia
(36)
Micronutrient intake/status in CEE 13
risk of poor nutritional health. For future research, we
recommend reviewing grey literature, and its accessibility
and reliability need further attention. However, to bring a
comprehensive conclusion on the nutritional situation in
CEE countries much work is required: for developing
tailored, sound, evidence-based nutritional policy, the
knowledge gaps and establishing nutritional surveys of
comparable quality, covering the diversity of population
groups, need to be addressed. The inclusion of CEE
countries in pan-European nutritional surveys is highly
essential to achieve this objective.
Acknowledgements
Sources of funding: The work reported herein has been
carried out within the EURRECA Network of Excellence
(http://www.eurreca.org), which is financially supported
by the Commission of the European Communities,
specific Research, Technology and Development (RTD)
Programme ‘Quality of Life and Management of Living
Resources’, within the Sixth Framework Programme,
project no. FP6 036196-2. This report does not necessarily
reflect the Commission’s views or its future policy in
this area. Conflict of interest: The authors declare that
they have no conflicts of interest. Authorship responsibi-
lities: R.N. and A.E.J.M.C. conceptualised the paper,
collected the data and drafted the manuscript. A.E.J.M.C.
supervised the overall work, assisted with analysis
and editing of the manuscript. G.E.B., B.R.-V., J.N.,
M. Golesorkhi, M.W.M., M.N. and Z.S. helped with data col-
lection, reviewing the literature and analysis. M. Gurinovic
´,
M. Glibetic
´, L.S.M., P.v.V., A.G. and L.C.P.G.M.d.G. were
involved in development of the study hypothesis, editing
the working versions of the manuscript and provided
advice regarding interpretation of the results. Acknowl-
edgements: The authors acknowledge the members of the
UNU/SCN Network for Capacity Development in Nutrition
in Central and Eastern Europe (http://www.agrowebcee.
net/ncdn) for the identification and translation of grey
literature. It gave added value to the review and enabled a
comprehensive overview of available data and implied to
knowledge gaps in CEE.
Public Health Nutrition
Table 4 Micronutrient status by Central and Eastern European country: folate, vitamin B
12
and zinc in adults and children, iodine and iron in
adults – medians or means and SD
Country No. of subjects; sex Age range (years)
Mean status marker level
(or median where indicated) SD
Serum folate (mean and SD/median; nmol/l)
Croatia
(53)
100 F 20–30 23 9
Czech Republic (lactation)
(58)
227 F 20–35 20 (median) Polish;
7 (median) Roma
Czech Republic
(61)
126 M 25–65 14 0?4
125 F 14 0?4
Czech Republic
(62)
250 M 18–65 14 (median)
261 F 18–64 14 (median)
Hungary
(71)
1173 M .18 20 9
1386 F 21 10
Urinary iodine (median; mg/l)
Poland
(78)
491 M .16 121
933 F 106
Romania
(WHO database)
1387 F 15–46 51
Czech Republic
(WHO database)
254 M&F 18–66 114
Bulgaria (pregnancy)
(51)
355 F 26 65 165
Czech Republic (pregnancy)
(59)
168 F 17–41 367
Serbia (pregnancy)
(80)
347 F 20–35 158
Hb (mean and SD; g/l)
Serbia
(36)
544 M 20–21 148 10
725 F 128 11
Macedonia
(WHO database)
1018 F 15–46 134 14
Serum vitamin B
12
(mean and SD/median; pmol/l)
Czech Republic
(61)
126 M 25–65 239 7
125 F 239 7
Czech Republic
(62)
250 M 18–65 278 (median)
261 F 278 (median)
Serum Zn (mean and SD;mmol/l)
Czech Republic
(63)
118 M 36–49 13 3
118 F 13 3
Hungary
(71)
1173 M .18 17 3
1386 F 17 3
Czech Republic
(63)
90 boys 10 15 3
194 girls 14 3
Poland
(79)
157 boys and girls 11 12 2
WHO database, WHO Vitamin and Mineral Nutrition Information System; M, males; F, females.
Proposed cut-off values
(20–27,30–33)
: serum folate 10 nmol/l for adults; urinary iodine 100 mg/l for adults, 150 mg/l for pregnant women; Hb 130 g/l for males,
120 g/l for females, 110 g/l for pregnant women; serum vitamin B
12
150 pmol/l for adults; serum Zn 10 mmol/l for children and females, 10?7mmol/l for males.
14 R Novakovic
´et al.
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