roczniki państwowego zakładu higieny - Wydawnictwa NIZP-PZH

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ISSN 0035-7715
ROCZNIKI
PAŃSTWOWEGO
ZAKŁADU HIGIENY
ANNALS
OF THE NATIONAL
INSTITUTE OF HYGIENE
Quarterly
2014
Volume 65
Number 2
EDITOR and PUBLISHER:
NATIONAL INSTITUTE OF PUBLIC HEALTH
– NATIONAL INSTITUTE OF HYGIENE
Warsaw, Poland
ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY
(ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE)
Published since 1950
Quarterly, 4 issues in 1 volume per year (No 1 - March, No 2 - June, No 3 - September, No 4 - December)
The journal is devoted to research studies on food and water safety, nutrition, environmental hygiene, toxicology
and risk assessment, public health and other related areas
Available at http://www.pzh.gov.pl/roczniki_pzh/
Edited and published by the National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
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Statistical Editor
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Subject Editors: Kazimierz Karłowski – food safety, Ewa Bulska – food and environmental analysis, Anna
Gronowska-Senger – nutrition, Barbara Gworek – environmental hygiene, Jan K. Ludwicki – toxicology and risk
assessment, Mirosław J. Wysocki – public health
INTERNATIONAL EDITORIAL BOARD
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Krzysztof Chomiczewski, Warsaw, Poland
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Małgorzata M. Dobrzyńska, Warsaw, Poland
Jerzy Falandysz, Gdansk, Poland
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Aleksander Giwercman, Malmö, Sweden
Muhammad Jamal Haider, Karachi, Pakistan
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Masahide Kawano, Ehime, Japan
Grażyna Kostka, Warsaw, Poland
Tao Li, Yunnan, China
Honggao Liu, Kunming, China
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Julia Melgar Riol, Lugo, Spain
Regina Olędzka, Warsaw, Poland
Krzysztof Pachocki, Warsaw, Poland
Andrea Raab, Aberdeen, Scotland, UK
Mark G. Robson, New Brunswick, NJ, USA
Martin Rose, York, UK
Kenneth S. Sajwan, Savannah, USA
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Marcello Spanò, Rome, Italy
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Bogumiła Urbanek-Karłowska, Warsaw, Poland
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Bogdan Wojtyniak, Warsaw, Poland
Jan Żmudzki, Puławy, Poland
Indexed/abstracted in: MEDLINE/Pubmed, Index Copernicus Int., EBSCO, Agro Base, Food Science and
Technology Abstracts, Global Health, NISC SA Databases, EMBASE/Excerpta Medica, Polish Medical Bibliography/
Central Medical Library, Polish Ministry of Science and Higher Education (MNiSW), Web of knowledge
Abstracts and full text are freely accessible on the journal’s website: http://www.pzh.gov.pl/roczniki_pzh/
The printed version of the journal is an original reference version.
Editorial office address:
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e-mail: roczniki.pzh@pzh.gov.pl
© Copyright by the National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
Edition: 515 copies
[ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE]
Volume 65
2014
Number 2
CONTENTS
REVIEW ARTICLES
Flavonoids – food sources and health benefits.
A. Kozłowska, D. Szostak-Węgierek .................................................................................................................................. 79
Diacetyl exposure as a pneumotoxic factor: a review.
B. Starek-Świechowicz, A. Starek ...................................................................................................................................... 87
ORIGINAL ARTICLES
Development and validation of a method for determination of selected polybrominated diphenyl ether congeners
in household dust.
W. Korcz, P. Struciński, K. Góralczyk, A. Hernik, M. Łyczewska, K. Czaja, M. Matuszak, M. Minorczyk,
J. K. Ludwicki ................................................................................................................................................................... 93
Variations of niacin content in saltwater fish and their relation with dietary RDA in Polish subjects grouped by age.
M. Majewski, A. Lebiedzińska ......................................................................................................................................... 101
Evaluating adult dietary intakes of nitrate and nitrite in Polish households during 2006-2012.
A. Anyżewska, A. Wawrzyniak ......................................................................................................................................... 107
School pupils and university students surveyed for drinking beverages containing caffeine.
M. Górnicka, J. Pierzynowska, E. Kaniewska, K. Kossakowska, A. Woźniak ................................................................ 113
The use of vitamin supplements among adults in Warsaw: is there any nutritional benefit?
A. Waśkiewicz, E. Sygnowska, G. Broda , Z. Chwojnowska ........................................................................................... 119
Energy and nutritional value of the meals in kindergartens in Niš (Serbia).
K. Lazarevic, D. Stojanovic, D. Bogdanović .................................................................................................................. 127
Comparing diabetic with non-diabetic overweight subjects through assessing dietary intakes and key parameters
of blood biochemistry and haematology.
K. Gajda, A. Sulich, J. Hamułka, A. Białkowska ............................................................................................................ 133
Nutritional values of diets consumed by women suffering unipolar depression.
E. Stefańska, A. Wendołowicz, U. Kowzan, B. Konarzewska, A. Szulc, L. Ostrowska .................................................... 139
Awareness of factors affecting osteoporosis obtained from a survey on retired Polish subjects.
N. Ciesielczuk, P. Glibowski, J. Szczepanik .................................................................................................................... 147
Responsiveness to the hospital patient needs in Poland.
L. Gromulska, P. Goryński, P. Supranowicz, M.J. Wysocki ............................................................................................ 155
Instruction for authors ................................................................................................................................................. 165
Abstracts and full texts: http:// www. pzh.gov.pl/roczniki_pzh/
About the guide
This provides comprehensive definitions and explanations to the terminologies used throughout toxicology, ecotoxicology, food safety, risk assessment, public health and other related disciplines.
Over 1700 words or phrases
explained
The definitions given are based on many
sources, however the main ones are from European Union legislation, OECD and FAO/
WHO documents together with official releases by the European Food Safety Authority
(EFSA). To ensure convenient use for readers,
the guide is divided into four parts as follows;
o terms in Polish, their definitions
and equivalent terms in English
o terms in English, their
equivalents and definitions in
Polish
o a list of Polish and English
abbreviations
o a list of the most important
references
About the authors
The authors are leading experts in Poland employed in the Department of Toxicology and Risk Assessment
at the National Institute of Public Health - National Institute of Hygiene in Warsaw. Their remit covers toxicology and risk assessment. They are also members of various working groups at the European Commission,
EFSA, OECD, Codex Alimentarius Commission of the FAO/WHO and the Risk Assessment team set up by
the Polish Chief Sanitary Inspector as well as other national and international bodies responsible for effecting
safety policy and strategy on chemicals, food, water and environmental threats to health.
How to place an order?
Please apply to:
Ms Diana Kowalczyk, Research Library
National Institute of Public Health - National Institute of Hygiene
24 Chocimska Street,00-791 Warsaw, Poland
Tel: +48 (22) 54 21 264, +48 (22) 54 21 262
e-mail: dkowalczyk@pzh.gov.pl
Price: 85 PLN
Rocz Panstw Zakl Hig 2014;65(2):79-85
FLAVONOIDS - FOOD SOURCES AND HEALTH BENEFITS
Aleksandra Kozłowska1, Dorota Szostak-Węgierek2*
1
Department of Preventive Medicine and Hygiene, Institute of Social Medicine, Medical University of Warsaw, Poland
2
Department of Human Nutrition, Faculty of Health Science, Medical University of Warsaw, Poland
ABSTRACT
Flavonoids are a group of bioactive compounds that are extensively found in foodstuffs of plant origin. Their regular consumption is associated with reduced risk of a number of chronic diseases, including cancer, cardiovascular disease (CVD)
and neurodegenerative disorders. Flavonoids are classified into subgroups based on their chemical structure: flavanones,
flavones, flavonols, flavan-3-ols, anthocyanins and isoflavones. Their actions at the molecular level include antioxidant
effects, as well the ability to modulate several key enzymatic pathways. The growing body of scientific evidence indicates
that flavonoids play a beneficial role in disease prevention, however further clinical and epidemiological trials are greatly
needed. Among dietary sources of flavonoids there are fruits, vegetables, nuts, seeds and spices. Consumption of these substances with diet appears to be safe. It seems that a diet rich in flavonoids is beneficial and its promotion is thus justifiable.
Key words: flavonoids, cancer, cardiovascular diseases, neurodegenerative disorders
STRESZCZENIE
Flawonoidy to grupa związków bioaktywnych występujących powszechnie w żywności pochodzenia roślinnego. Aktualne
dane literaturowe wskazują, że substancje te, spożywane wraz z dietą człowieka, wykazują działanie ochronne przed wieloma chorobami przewlekłymi, w tym przed niektórymi nowotworami oraz schorzeniami układu sercowo-naczyniowego,
a ponadto pozytywnie wpływają na układ nerwowy. W zależności od struktury chemicznej wyróżnia się takie podklasy
flawonoidów jak: flawony, flawanony, flawonole, flawanole, antocyjany i izoflawony. Przypuszcza się, że mechanizm
działania tych substancji opiera się na ich silnych właściwościach antyoksydacyjnych oraz innych mechanizmach, takich
jak zdolność do modulowania licznych szlaków enzymatycznych. W wielu badaniach wykazano ich korzystne działanie w
prewencji chorób przewlekłych. Jednakże poznanie dokładnego metabolizmu tych substancji wymaga prowadzenia dalszych
badań. Źródłami flawonoidów w diecie człowieka są warzywa, owoce, orzechy i nasiona, a także niektóre przyprawy. Spożywanie tych substancji wraz z dietą człowieka wydaje się być bezpieczne. Uzasadnionym zatem wydaje się promowanie
diety bogatej we flawonoidy.
Słowa kluczowe: flawonoidy, nowotwory, choroby sercowo-naczyniowe, choroby neurodegeneracyjne
INTRODUCTION
Flavonoids are a diverse group of plant metabolites
with over 10,000 compounds that have been identified
until now. However, only very few of them have been
investigated in detail [25]. They have several important
functions in plants, such as providing protection against
harmful UV radiation or plant pigmentation. In addition,
they have antioxidant, antiviral and antibacterial properties. They also regulate gene expression and modulate
enzymatic action [25]. All naturally occurring flavonoids possess three hydroxyl groups, two of which are on
the ring A at positions five and seven, and one is located
on the ring B, position three. Biochemical actions of
flavonoids depend on the presence and position of various substituent groups, that affect metabolism of each
compound. They can be found in free or bound forms:
aglycones or β-glycosides [17]. The flavonoid subclasses, based on types of chemical structure, include:
flavonols, flavones, flavanones, flavanols, anthocyanins
and isoflavones [17, 20]. Table 1 shows some common
examples according to this classification.
Antioxidant properties of foodstuffs depend not only
on polyphenol content, but also on their type. For instance, quercetin and catechin demonstrate the greatest
antioxidant properties in vitro [6, 11, 36]. However, their
*Corresponding author: Dorota Szostak-Węgierek, Zakład Żywienia Człowieka, Warszawski Uniwersytet Medyczny,
ul. Ciołka 27, 01-445 Warszawa, tel. +48 22 8360913,
e-mail: dorota.szostak-wegierek@wum.edu.pl
© Copyright 2013 by the National Institute of Public Health - National Institute of Hygiene
80
Nr 2
A. Kozłowska, D. Szostak-Węgierek
Table 1. Subclasses of flavonoids; authors’ selection based
on [17]
Subclass
Flavonols
Flavones
Flavanones
Flavanols,
Anthocyanins
Isoflavones
Examples of compounds
Quercetin, kaempferol, myricetin
Luteolin, apigenin, tangeretin
Naringenin, hesperetin
Catechin, epicatechin, epigallocatechin,
glausan-3-epicatechin, proanthocyanidins
Cyanidin, delphinidin, pelargonidin, malvidin
Genistein, daidzein
human metabolism is incompletely understood. Current
studies on biological effects of flavonoids focuse on
their absorption mechanisms, metabolism and bioavailability. Thus, in order to elucidate their physiological
role, molecular studies are required. The results would
enable to evaluate their effectiveness in the treatment
and prevention of certain diseases, together with eventual risks arising from their use [18, 33].
FLAVONOIDS CONSUMPTION AND
SAFETY
At present, consumption of dietary flavonoids is
regarded as safe. Nevertheless, it is worth noting that the
use of pharmaceutical products that contain high doses
of bioactive substances is increasing. Such supplements
provide an alternative source of flavonoids to those obtained from the diet. It is of concern that the toxicity of
concentrated sources of flavonoids is unknown, together
with their interactions with other dietary components or
taken medications [12]. Administration of large doses of
a single flavonoid may decrease bioavailability of trace
elements, vitamins or folic acid. Besides, it may exert
an adverse effect on the thyroid function [12]. There is
a special concern about possible side effects of taking
several flavonoid-containing products at the same time
as flavonoid-flavonoid interactions are little known so
far [12]. A consumer may be misled that flavonoids are
entirely safe because they are so-called ’natural’ products. Uncontrolled use of pharmaceutical preparations
containing flavonoids may come out disadvantageous
for health. Furthermore, the packaging labels for some
dietary supplements have scant information about safety, adverse reactions, interactions, contraindications,
and efficacy [7, 12].
It is clear that the molecular mechanisms of action
of flavonoids need to be thoroughly understood and
intensive research on this problem should be performed.
However, it should be emphasised that in the light of
recent findings the best and safest source of these substances is a properly balanced diet.
DIETARY CONSUMPTION AND SOURCES
OF FLAVONOIDS
It is estimated that inhabitants of the Western Europe
consume on average 100 – 1000 mg flavonoids/day/
person [17, 36]. This was confirmed by the European
Prospective Investigation into Cancer and Nutrition
(EPIC) study, which showed the median daily intake
of flavonoids in Greek and Spaniard subjects equal
to 93 mg (n ≥ 28,000) and 126.1 mg (n = 40,683) per
Table 2. Content of flavonoids, according to their sub-classes, in chosen foodstuffs (mg/100g foodstuff);
authors’ selection based on [2]
Flavanones
Artichokes
Grapefruit juice
Orange juice
Oranges
Limes
Lemons
Grapefruit
Dried oregano
12.51
18.98
18.99
42.57
46.40
49.81
54.50
412.13
Flavonols
Apples
Cooked brussel sprouts
Fresh figs
Dried & sweetened
cranberries
Buckwheat
Chicory
Morello cherries
American bilberries
Blackcurrants
Cooked asparagus
Fresh cranberries
Goji berries
Red onions
Flavones
Kohlrabi
1.3
Red grapes
1.3
Lemons
1.9
Chicory
2.85
Celeriac
3.90
Green pepper
4.71
Artichokes
9.69
Fresh parsley
216.15
Dried oregano
1046.46
Dried parsley
4523.25
Anthocyanins
Mean
Hazel nuts
3.40
5.24 Morello cherries
5.47 Pears
6.91 Black grapes
7.09
8.94
9.41
10.59
11.53
15.16
21.59
31.20
38.34
Red table wine
Pecan nuts
Strawberries
Red bilberries
Raspberries
Red cabbage
Red currants
Blackberries
American
bilberries
Black currants
Chickpeas
Bilberries
Rocket lettuce
Radish
Sorrel
Elderberry juice
concentrate
69.27
78.09
102.20
Dried parsley
331.24
Fresh capers
493.03
Flavanols
Cooked broad
5.96
beans
8.41 Blackberries
8.6 Cocoa, dry powder
9.17 Dark chocolate
11.05 Black tea, brewed
15.99 Green tea, brewed
Apple juice
Apricots
Peaches
Apples
Red table wine
Pecan nuts
108.16 Aronia
Elderberry juice
concentrate
6.71
7.45
12.18
21.63
23.18
25.02
27.76
40.15
40.63
63.50
75.02
90.64
141.03
154.77
262.49
285.21
349.79
411.4
20.63
42.5
52.73
108.60
115.57
116.15
Nr 2
Flavonoids – food sources and health benefits
person respectively [9, 39]. The Greek survey was
performed in 1992 – 1996 and thus the results may be
underestimated as the database concerning flavonoid
levels in foodstuffs was incomplete that time. On the
other hand, it is assumed that inhabitants of countries
in the Far East, such as Japan, because of high intake
of legumes, soy and tea, may consume up to 2 g of
flavonoids daily [36]. In contrast, the Polish National
Multi-centre Health Survey (WOBASZ) demonstrated
that the mean flavonoid intake in the Polish population
was 1 g/person/day [41].
Important dietary sources of flavonoids are vegetables, fruits, seeds, some cereals, together with wine,
tea and certain spices. Table 2 demonstrates flavonoid
content in chosen foodstuffs. It should be noted that
the presence of particular flavonoids in vegetables and
fruits depends on the crop variety, location and type of
cultivation, as well as the specific plant morphological
part [13]. Differences in flavonoid contents between
varieties of species are usually small, although in a
few cases very high amounts have been observed, e.g.
in certain berries and tea prepared from leaves of the
Quingmao tree [2].
EFFECTS OF FLAVONOIDS ON THE
CARDIOVASCULAR SYSTEM
The well recognised anti-oxidant properties of
flavonoids resulted in the interest about their potential
role in prevention of cardiovascular diseases [18]. For
example, a recent study clearly showed health benefits
of dietary flavonoids as there was a positive association
between their intake and reduction of the risk of cardiovascular death in adult Americans [22]. The study
demonstrated that both male and female subjects who
consume large amounts of flavonoids (the top quintile)
had the 18% lower mortality risk of cardiovascular diseases (CVD) compared to those whose intake was in
the lowest quintile. Another study [3] demonstrated that
high flavonoid consumption (flavones and flavanols)
protected against hypertension. Subjects whose intake of
these substances was in the top quintile, in comparison
with those of the lowest consumption, exhibited the
8% risk reduction of development of this condition [3].
Atherosclerosis is a multifactorial disease. High
blood concentration of oxidatively modified low density lipoproteins (ox-LDL) accelerates its development.
Other causative factors include blood vessel inflammation and disorders of coagulation [18, 31]. Because of
their antioxidant and chelating properties, flavonoids
inactivate reactive oxygen species (ROS) and this
way counteract plasma LDL oxidation and ameliorate
inflammation of the blood vessel endothelium. Furthermore, flavonoids decrease activity of xanthine oxidase,
81
NADPH oxidase, and lipoxygenase ie. the enzymes that
increase ROS production. Anti-arteriosclerotic action of
flavonoids is related also to the reduction of inflammation in the blood vessel wall through inhibition of the
influx of leucocytes. Flavonoids also decrease activity
of such enzymes as 15-lipoxygenase (15-LOX) and
cyclooxygenase (COX, particularly COX-2). These
enzymes participate in formation of, prostaglandins
and leukotrienes, substances that mediate inflammation, from arachidonic acid. Decline in their secretion
results in reduction of synthesis of prostaglandin PGE2,
leukotriene B4 and thromboxane A2, what in turn leads
to decrease in inflammation and platelet aggregation.
Inhibition of these enzymes results also in protection of
LDL against oxidation and regulates capillary pressure
back to normal [18].
Beyond of protection of blood vessels against ox-LDL, antiatheromatous action of flavonoids results also
from suppression of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA) activity. This enzyme
plays a key role in the synthesis of cholesterol in the
human body, and thereby influences its plasma levels.
Inhibition of its activity lowers intracellular cholesterol
concentrations and results in the following increase in
expression of LDL receptors. This in turn raises the
cellular lipoprotein uptake and removal of cholesterol
from the circulation. Hesperetin is a good example of a
flavonoid, found in lemons and oranges, which reduces
blood cholesterol level in the aforementioned way [18].
Furthermore, a randomised, double-blind study, that
included cell culture, demonstrated in subjects with
metabolic syndrome that oral administration of 500 mg
of hesperetin daily over 3 weeks stimulated endothelial
nitric oxide (NO) formation, what was probably related
to the decreased activity of proinflammatory cytokines.
This study showed that a three week hesperetin supplementation improves endothelial function, reduces
inflammation and beneficially affects lipid profile in
patients with metabolic syndrome [27].
It was shown that such flavonoids as rutin and its
derivatives, along with hesperetin, help seal and reinforce blood vessel walls [18, 23]. These substances,
similarly to vitamin C, enhance collagen synthesis and
thus make the connective tissue in blood vessels more
elastic. Rutin and its derivatives are used as a medication aimed at regulation of capillary permeability and
improvement of peripheral circulation [23]. Flavonoids,
such as quercetin or rutin, have anti-aggregating properties, and thereby reduce the risk of clot formation
near the damaged endothelium [18]. By interaction with
platelet integrins, these substances prevent platelets
from sticking. They also stimulate NO formation in the
vascular endothelium what facilitates vasodilation, and
thus plays a key role in regulation of blood pressure [18].
82
Obesity is an important and independent risk factor
for CVD and is strongly associated with dyslipidaemia,
insulin resistance and type 2 diabetes [29]. Research on
the effects of long-term flavonoid dietary supplementation in obese or normal body mass mice, in comparison
with diet without addition of these substances, showed
improved lipid profile, decreased insulin resistance and
reduced visceral adipose tissue mass. The non-obese
mice that consumed flavonoids demonstrated reduced
levels of atherogenic cholesterol fractions (non-HDL
cholesterol) [29]. These findings confirm the protective
effects of flavonoids on the cardiovascular system.
EFFECTS OF FLAVONOIDS ON THE
NERVOUS SYSTEM
Effectiveness of flavonoids in prevention of age-related neurodegenerative diseases has been much
investigated in the recent years. It concerns particularly
dementia, Parkinson’s and Alzheimer’s diseases. It seems that flavonoids can modulate neuronal function [21,
26, 34, 38]. Diets rich in these substances were shown
to beneficially affect maintenance of human cognitive
functions, probably through protection of neurons,
enhancement of their function and regeneration [38].
Reactive oxygen and nitrogen species are involved in
the development of many neurodegenerative diseases,
whilst dietary flavonoids have been shown to counteract
effectively oxidative neuronal damage.
It was demonstrated that use of the extract from
the gingobiloba plant, that is rich in flavonoids, may
beneficially influence treatment of the age-related
dementia and Alzheimer’s disease [1]. Tangeretin, a
flavonoid that belongs to the flavone subclass, found
mainly in citrus fruits, was shown to provide protection
in Parkinson’s disease. Animal models of this condition
is based on striatal damage by the neurotoxic substance
6-hydroxydopamine, what in turn leads to damage of the
nigrostriatal pathway that connects the substantia nigra
with the striatum. The latter is responsible, amongst
others, for planning of body movements. Damage of
this area underlies Parkinson’s disease. It was shown
that tangeretin given to mice passes the blood-brain
barrier (BBB) and protects the nigrostriatal pathway
against adverse effects of 6-hydroxydopamine [8].
The PAQUID study (Personnes Age’es QUID), published in 2007, convincingly demonstrated that dietary
flavonoids in the elderly support their cognitive functions
[16]. The 10 years long observation was performed in
1640 subjects aged above 65 years, free from dementia
at baseline. The data about flavonoid consumption were
obtained by means of a food frequency questionnaire
that listed foodstuffs containing these substances. At
each visit (four times) every subject underwent cogni-
Nr 2
tive tests including Mini-Mental State Examination,
Benton’s Visual Retention Test and the ‘Isaacs’ Set
Test. Participants whose flavonoid intake was in the
two highest quartiles (ie. above 13.6 mg/day) had better
cognitive function after 10 years than those who consumed less of these compounds. Moreover, subjects who
ingested the least amounts of flavonoids (below 10.38
mg/day), lost on average 2.1 points in the Mini-Mental
State Examination scale, while those with the highest
consumption (above 17.7 mg/day) lost only 1.2 points.
These findings demonstrated that regular consumption
of dietary flavonoids exerts beneficial effect on cognitive
function maintenance during aging [16].
The multitude of effects resulting from consuming flavonoids, both with foodstuffs and concentrated
sources, appears to be related to two parallel processes.
The first is regulation of the neuronal signal cascade
what results in the inhibition of cell apoptosis that is
caused by the action of neurotoxic substances. This
promotes neuronal survival and differentiation [34].
Secondly, flavonoids seem to exert beneficial effects on
the peripheral and central nervous systems by generation
of changes in the cerebral blood flow. This can induce
angiogenesis and growth of new nerve cells in the hippocampus. These processes are important for maintenance of neuronal and cognitive brain functions [34].
It seems that regular consumption of foods rich in
flavonoids reduces the risk of neurodegenerative diseases and counteracts or delays the onset of age-related
cognitive disorders. However, mechanisms of flavonoid
action are not entirely clear. The question then arises as
to when to use these substances to ensure their optimal
effectiveness and which of them produce the strongest
protection of the nervous system. Further studies on
this wide group of compounds are therefore necessary
to provide satisfactory answers to these questions.
ANTICANCER ACTION OF FLAVONOIDS
Chemoprevention is defined as the use of natural or
synthetic substances to inhibit or reverse carcinogenesis [24]. Much attention, in this respect, is focused on
flavonoids [4, 5, 10, 14, 19, 28, 35]. Epidemiological
and clinical studies suggest that these compounds can
prevent cancer through their interaction with various
genes and enzymes [4]. It seems that biologically active
substances found in foodstuffs may affect such stages of
carcinogenesis as initiation, promotion and progression
[24]. Many mechanisms of flavonoid action have been
discovered. In the initiation and promotion stages, they
include: inactivation of the carcinogen, inhibition of cell
proliferation, enhancement of DNA repair processes,
and reduction of oxidative stress. In the progression
phase flavonoids may induce apoptosis, inhibit angio-
Nr 2
83
genesis, exhibit antioxidant activity, and also cytotoxic
or cytostatic action against cancer cells [4, 19, 24, 40].
Prevention of metabolic activation of procarcinogens is related to flavonoid interaction with phase I
enzymes that are responsible for metabolism of various
endogenous or exogenous substrates. This results from
inhibition of the cytochrome P450 enzymes, such as
CYP1A1 and CYP1A2. Flavonoids thus protect against
cellular damage arising from the activation of carcinogenic factors. Another mechanism of their action is related
to reinforcement of mutagen detoxification through
induction of the phase II enzymes, such as glutathione
S-transferase (GST) and UDP-glucuronyl transferase
(UDP-GT), which detoxify and eliminate carcinogens
from the body [4, 15].
The anticancer effects of flavonoids can also be
explained by the cell cycle inhibition. There are two
classes of regulatory molecules responsible for cell
cycle progression: cyclins and cyclin-dependent kinases (CDKs), which are activated under the influence
of mitogenic signals within the cell. The uncontrolled
activation of CDKs plays a key role in the pathogenesis of cancer. Various types of cancer are linked to
excessive CDKs activity through gene mutation. For
this reason, much research is increasingly focused on
substances that can inhibit or modulate CDKs. These
actions may exhibited by such flavonoids as: genistein,
quercetin, daidzein, luteolin, kaempferol, apigenin, and
epigallocatechin.
Current evidence about the anticarcinogenic potential of flavonoids are however still equivocal. Some
studies, that were performed in animals or various cell
models, indicate that certain flavonoids may inhibit both
cancer initiation and progression [10, 30, 37]. However,
experiments on rats, conducted to determine the effect of
tangeretin and quercetin on the risk of cancer occurrence
arising from alphatoxin B1 induction (initiation and
promotion of hepatic cancer) showed that whereas tangeretin administrated during tumour initiation reduced
the number of precancerous lesions, quercetin did not
exhibit such effect [30]. Another study showed that the
development of lung cancer in mice exposed to tobacco
smoke was arrested by consumption of both black and
green teas. The results demonstrated that catechins contained in tea may protect against development of cancer
[37]. A further research that tested influence of selected
compounds on cultured human liver cells demonstrated
that luteolin and apigenin also provided effective protection against cancer development. These flavonoids
seem to inhibit CDKs. However, other studies indicate
that flavonoids have weaker actions in vivo compared
to that in vitro [11, 32]. An investigation on whether
quercetin prevents lung cancer in mice showed that this
substance, in spite of its strong biological activity, is
not absorbed by these animals efficiently enough. The
authors however suggest that further work should be
focused on making the absorption mechanism of this
substance more effective what would probably promote
the expected anticancer action [32].
The studies quoted above were performed in animals, and so the conclusions should be extrapolated to
humans with caution. Observational studies conducted
on various human populations are also equivocal [10,
14, 35]. The Iowa Women’s Health Study investigated
the effect of dietary flavonoid consumption on the incidence of cancer of the lung, colon, breast and pancreas
in 34,708 post-menopausal women who were observed
in 1986 – 2004. Their dietary habits were determined by
means of a food frequency questionnaire. Results showed that regular flavonoid consumption significantly
reduced the risk of the lung cancer, particularly in the
women who had stopped smoking. However, there was
no evident effect of flavonoid consumption on the risk
of other cancers [5]. Another study, performed in 34,408
women (aged above 45 years), demonstrated no significant link between intake of foods rich in flavonoids
and the risk of cancer [35]. Despite of these findings,
a meta-analysis of 12 studies showed a reduced risk of
breast cancer in women, especially postmenopausal,
who consumed large amounts of flavonoids, such as flavonols and flavones [14]. Further studies are therefore
required to assess the promising influence of flavonoids
on the human body.
SUMMARY
Flavonoids exhibit manifold effects in protection of
the human body. However, the underlying mechanisms
are still not fully understood. According to current
knowledge, a diet that includes flavonoid containing
products should be promoted. Among foods that provide large amounts of these substances there are: citrus
fruits, blueberries, blackberries, onions, peppers, a
variety of teas, and also oregano and parsley. However,
it should be emphesized that toxicity of flavonoids consumed in large doses remains unknown. For this reason,
use of their dietary supplements should be considered
with caution. The question arises as to when to use these
substances to enable their most effective action, and as
to which flavonoids are the most beneficial to human
health. It is presumed that flavonoids exert stronger
effects in vitro than in vivo, and thus it is important to
determine their mechanisms of action at the molecular
level. Further studies in this area are therefore greatly
needed.
Acknowledgement
This paper was financed by the Warsaw Medical University, Poland
84
Conflict of interest
The authors declare no conflict of interest.
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Received: 07.11.2013
Accepted: 12.03.2014
Mrs. President of the Polish
Society of Nutritional Sciences
Berlin, 20th February 2014
Dear Prof. Dr. hab. Anna Brzozowska:
It is my pleasure to inform you that the website of the next 12th Conference of the Federation of
European Nutrition Societies (FENS), which will be held in Berlin from the 20th to the 23rd October
2015 with the following title: “Nutrition and health throughout life-cycle – Nutritional sciences for
the benefit of European consumers“ is now open.
The website address is www.fensberlin2015.org.
Please also find attached the Conference announcement. We kindly request you to upload it on
the website of your society.
From now on, you will receive information via the newsletter the technical secretariat will be
sending.
Please help us spread the information and forward the newsletters to all partners and
professionals in your country.
Prof. Dr. Heiner Boeing (Chairman of the Organizing Committee) and Dr. Helmut Oberritter
(Secretary of the Organizing Committee), along with other members of the Organizing and
Scientific Committees, are preparing a scientific programme which will be of great interest from
both an educational and a participative level for all of us.
I would like to highlight that Berlin is one of the most attractive European cities with one of the
richest cultures. This perfect combination of science and culture will make the FENS conference a
memorable event.
I would like to thank you in advance for your support and cooperation and I look forward to
meeting you in Berlin to exchange ideas and knowledge on the wide field of Nutrition.
Yours sincerely,
Ascensión Marcos
President of FENS
DIACETYL EXPOSURE AS A PNEUMOTOXIC FACTOR: A REVIEW
Beata Starek-Świechowicz, Andrzej Starek*
Chair of Toxicology, Department of Biochemical Toxicology, Jagiellonian University, Medical College, Kraków, Poland
ABSTRACT
Diacetyl (2,3-butanedione) is a natural ingredient in foodstuffs which is not generally regarded health risk to consumers.
Nevertheless, when manufactured for use as a synthetic flavouring/additive in processed foods (e.g. microwave popcorn), it
poses a human health threat at the workplace. Its pneumotoxic action consists of inflammation, obstruction and restriction in
the distal respiratory tract. One of the factors causing bronchiolitis obliterans is also recognised to be diacetyl. The scientific
literature mostly describes human exposure to diacetyl in factory settings where functional disorders and structural changes
of the respiratory system have been recorded, particularly bronchiolitis obliterans. Moreover, differential diagnosis shows
pathological changes in the distal respiratory tract and in the pneumotoxic actions of diacetyl.
Key words: food flavourings, additives, diacetyl, bronchiolitis obliterans
STRESZCZENIE
Diacetyl (2,3-butandion) jako naturalny składnik żywności nie wydaje się stwarzać zagrożenia dla zdrowia konsumentów. Związek ten będąc syntetycznym dodatkiem do żywności przetworzonej jest czynnikiem szkodliwym dla zdrowia
pracowników zatrudnionych przy jego syntezie i stosowaniu w produkcji prażonej kukurydzy do mikrofalówek. Pneumotoksyczne działanie tego związku manifestuje się zmianami zapalnymi, obturacyjnymi i restrykcyjnymi, szczególnie
w dystalnych drogach oddechowych. Diacetyl uznano za czynnik etiologiczny zarostowego zapalenia oskrzelików. Na
podstawie piśmiennictwa przedstawiono narażenie na diacetyl w warunkach przemysłowych, zaburzenia czynnościowe
i zmiany strukturalne w układzie oddechowym u osób narażonych, ze szczególnym uwzględnieniem zarostowego zapalenia
oskrzelików. Ponadto zwrócono uwagę na diagnostykę różnicową zmian patologicznych w dystalnych drogach oddechowych
oraz na mechanizmy pneumotoksycznego działania diacetylu.
Słowa kluczowe: środki aromatyzujące do żywności, diacetyl, zarostowe zapalenie oskrzelików
INTRODUCTION
Diacetyl (2,3-butanedione; CAS: 431-03-8) is natural ingredient of butter, caramel, beer, coffee, cocoa,
honey, vegetable oil, whisky, brandy and some other
foodstuffs. It arises during primary milk maturation or
in the manufacture of butter or margarine [1, 6] and is
synthesised from methyl ethyl ketone and by special
fermentation of glucose via methylacetylcarbinol [26,
38]. Diacetyl imparts an aroma/flavour similar to other
diketones such as 2,3-pentanodione, 2,3-hexanodione
and 2,3-heptanodione used in liquid form, pastes or
powders to intensify such food flavour/aroma. It is a
foodstuff ingredient of butter flavourings [5]. Synthetic
diacetyl is used in the manufacture of popcorn, chips
(i.e. french fries), confectionery, dairy products that
include cheese, sour cream, mayonnaise, sauces, mari-
nades and other processed foods and beverages where it
imparts a buttery taste and aroma to foodstuffs [31, 37].
In order to fortify the natural odour of milk, the
final concentrations of diacetyl used are 1-3 mg/kg. In
microwave popcorn, levels of diacetyl used to range
1-25%, however this has now been decreased or indeed
replaced by other substances with similar properties.
Most confectionery flavouring contain 1% diacetyl [31].
In USA, France, Belgium, Norway and Sweden diacetyl
is permitted as an additive to foodstuffs and in the EU
it is manufactured on a large scale in Italy and the UK.
The physico-chemical properties of diacetyl are
given in Table 1.
Industrial scale of microwave popcorn production
is multi-stage. Sweet corn seed is stored in silos for a
maximum of 2 months followed by sieving, air purification and roasting. By automated means, the product
*Corresponding author: Andrzej Starek, Chair of Toxicology, Department of Biochemical Toxicology, Jagiellonian University,
Medical College, Poland, Medyczna Street 9, 30-688 Kraków,
phone +48 12 62 05 651, e-mail: mfstarek@cyf-kr.edu.pl
88
B. Starek-Świechowicz, A. Starek
Table 1. Physico-chemical properties of diacetyl [1, 31, 37]
Molecular formula
Structural formula
Appearance
Sensory qualities
Molecular mass
Melting point
Boiling point
Density
Vapour pressure
Saturated vapour
density
Concentration of
saturated steam
Ignition temperature
Auto-ignition
temperature
Limits of
flammability
Partition coefficient
(log Pow)
Solubility
C4H6O2
CH3-CO-CO-CH3
Yellowish green liquid
Buttery odour, similar to benzoquinone
or chlorine, odour threshold in water 4 x
10-3 mg/l, in air 0.323 mg/m3 x 10-3, taste
threshold: butter - 1 mg/kg, in milk – 1.4
x 10-2 – 2.9 10-2 mg/kg, in water - 5.4 x
10-3 mg/l
86.09
-1.2°C
88.0°C (1013 hPa)
1.1 (water = 1)
7.6 kPa (25°C)
3.0 (air = 1)
268,500 mg/m3
27.0°C (closed cup)
365.0°C
2.4-13.0% vol. (in air)
-1.34
Soluble in water at 200 g/l (15°C), and
in benzene, tetrachloromethane, acetone,
propylene glycol, glycerol and ethanol.
is then packed into polyethylene bags together with
flavourings that contain diacetyl; with all these processes taking place in premises where the flavourings are
also mixed. Flavourings consist of soya oil, salt, butter
flavourings and food colourings which are mixed together at 64 - 66°C. When ready, the liquid form mixture
is transferred into storage at temperatures >51°C [22].
Because of the relatively low boiling-point of diacetyl
(88°C) but its high vapour pressure (7.6 kPa at 25°C),
this compound very readily permeates the air atmosphere at the workplace.
Human exposure to diacetyl only ever becomes
toxic under industrial conditions. During its synthesis
however, which occurs at temperatures ~360°C under
enclosed conditions, there is no present of exposure;
this only happens when the reactor is opened. Within
the Dutch chemicals industry, operators where diacetyl
was manufactured were exposed to 1.8 – 351 mg/m3 or
3 – 396 mg/m3 in more specific tasks. In addition to
diacetyl, it was found that in such places the workplace
air also contained around 0.4 – 29 mg/m3 of acetaldehyde
[38]. It should note that emission of diacetyl from liquid
or paste forms is more intense than from powders. In the
USA microwave popcorn plants, exposure to diacetyl
was from below the limits of detection of the analytical
method (LOD) to 350.8 mg/m3. The mean arithmetic
concentrations ± standard deviation (M ± SD) was 29 ±
66.2 mg/m3 whilst those in the microwave mixing rooms
Nr 2
were 135.3 ± 98.8 mg/m3 [22]. In Poland, the average air
concentrations of diacetyl found at the manufacture of
confectionary were on average 51 mg/m3 [15]. However,
the maximum admissible concentration (MAC) value
for diacetyl has not yet been established. In the EU, an
occupational exposure limit (OEL) for this compound
is recommended at level of 0.352 mg/m3 [37], whereas
the ACGIH in USA proposes using threshold limit value
- time weighted average (TLV-TWA) and threshold limit
value - short-term exposure limit (TLV-STEL) values of
0.04 mg/m3 and 0.07 mg/m3, respectively [1].
It has been found that there are over 100 different
volatile organic compounds (VOCs) in the microwave
area where microwave popcorn is manufactured, and the
flavourings are in storage. These mostly included the ketons: diacetyl, butanone, 3-hydroxybutanone (acetoin),
2-nonanone and acetic acid. The average diacetyl concentration reached 125.5 (9.6 – 325.4) mg/m3. For machine operators this value was 5.6 (0.86 - 18.4) mg/m3
and for those packaging 6.8 (1.5-17.7) mg/m3; all other
places were below 2.0 mg/m3. In addition, aerosols of
salt and oil were found at mean concentrations of 0.13
± 0.11 mg/m3 [22]. For quality control purposes, the
opening of microwave popcorn bags released 780 µg
diacetyl/bag into the air as well as other VOCs [36].
Thus, the actual human exposure to flavouring ingredients is in general mixed. Tobacco smoke contains
300-430 µg diacetyl/cigarette [8].
Occupational exposure controls implemented in the
USA during 2000-3 led to decrease diacetyl levels at
the workplace air. When the flavourings are mixed, peak
diacetyl levels were reduced from 462 to 0.97 mg/m3
[34]. In turn, average concentrations of this compound at
the places where mixing occurs, machines are operated
and the popcorn product is packaged, have been reduced
from 205, 9.9 and 2.9 mg/m3 in 2000 to 10.3 mg/m3 or
below LOD in 2003, respectively [17].
ACUTE TOXIC EFFECTS
Repeated exposures to diacetyl at single instances or
at short intervals lead to pronounced irritation to the eyes,
respiratory tract and skin. Symptoms include persistent
cough, muco-purulent secretion from the respiratory
tract, wheezing, dyspnoea/breathlessness, fatigue, mild
fever, generalized body aches and skin rash. The substance can also cause central nervous system (CNS)
depression, sometimes leading to a loss of consciousness
[14, 37]. A case study on a 36 year old never-smoking
man with normal lung function and normal serum α-1
antitrypsin activity, but exposed to diacetyl for several
hours revealed sore and reddened his eyes, painful eyes
and eyelids, together with a sticky conjunctival secretion.
Spirometry was normal after 3 months of exposure, but
Nr 2
89
Diacetyl exposure as a pneumotoxic factor
when repeated 6 months later, showed decease the flow
rate of the midportion of the expiratory spirogram (the
FEF 25%–75%) attaining 30% of the predicted value, thus
indicating altered small-airway function [12].
CHRONIC TOXIC EFFECTS OBLITERATIVE BRONCHIOLITIS
Occupational exposure to diacetyl-containing food
flavourings has led to respiratory disease including obstruction of the small airways [3, 4, 16, 21-24] frequently
coupled with persistent dry cough and breathlessness after
exertion [25], together with spirometric changes [4, 16, 18,
22-24, 33, 38] (Table 2). Bronchiolitis obliteranswas found
in 5/184 persons exposed to diacetyl during its synthesis
or in microwave popcorn manufacture. This exposure
was however mixed because the air at the workplace also
contained acetoin, acetaldehyde and acetic acid [4, 38].
The incidence of bronchiolitis obliterans, often
named constructive bronchiolitis or obliterative bronchiolitis, is a rather rare but irreversible disease of the
lungs, where obstruction occurs in the distal air passages
[11, 40]. The bronchioles become inflamed, exhibit
submucosal fibrosis and fibrous tissue proliferation in
capillary adventitia and adjacent interalveolar septa [4].
Centrifugal scarring can lead to more frequent obstruction of the small-airways and then complete blockage.
These obstructions arise through excess fibroblast
proliferation and accumulation of collagen deposits. A
loss of lung tissue elasticity resulting from damage to
collagen and elastin fibres, as well as secondary atonia
of the lung parenchyma causes the peripheral bronchi
to collapse and increases air flow resistance in the bronchiole ends; which explains the symptoms of shortness
of breath upon exertion. Clinical symptoms are a dry
cough and dyspnoea, particularly during expiration that
can either appear progressively or suddenly.
Blocked airways prevent the rapid emptying of
the distal part of the respiratory tract during expiration
[11]. This leads to excessive lung aeration resulting
in ‘air-trapping’ pockets which become visible during
radiology [4, 38]. The next stage in the progression,
is an increase in total lung capacity (TLC) and other
the volumes of the lungs, termed hyperinflation. Such
changes are permanent and are not reversible by drugs
that dilate the bronchi [11]. Factors responsible for these
changes can be irritants like chlorine, sulphur dioxide,
phosgene or ammonia [20].
Bronchiolitis obliterans is diagnosed by histopathology of a lung biopsy [4]. Whenever respiratory
tract blockages are coupled with changes observed by
radiology, using high resolution computed tomography
(HRCT), then this condition is defined as bronchiolitis
obliterans syndrome – BOS [4, 9, 39]. If there are no
radiological changes observed then it is recommended
Table 2. Epidemiological findings for chronic effects of diacetyl on the respiratory system
3.
Subject numbers Diacetyl concentration
Study results
studied
(mg/m3)
Flavouring manufacture for foodstuffs
Cross-sectional
34
0.11 - 0.80 (PS)
Decreased FEV1 or TLV values, lung obstruction.
BO, decreased FEV1 or TVC values.
Longitudinal
175
3.04 - 404.5 (PS)
Increased neutrophils, chronic cough, bronchial
1.83 - 356.9 (AS)
asthma.
Microwave popcorn manufacturing
Case report series
3
Not available
Decreased FEV1 or TVC values.
4.
Cross-sectional
5.
Case report series
6.
No.
1.
2.
Study type
117
2.0 – 115.5 (PS)
9
6.8 - 115.6 (AS)
Cross-sectional
108
0.09 - 26.9 (AS)
7.
Cross-sectional
135
8.
Cross-sectional
9.
Cross-sectional
10. Longitudinal
References
[16]
[38]
[39]
[33]
Lung obstruction, dysopnoea , fatigue, skin
irritation.
BO, decreased FEV1 or TVC values.
[21]
[3]
0.09 - 26.9 (AS)
Lung obstruction, increased neutrophils-OR: 3.8
(1.3 – 11.5).
Increased muscle tone of Chest.
537
0.72 - 4.3 (AS)
0.07 - 3.6 (PS)
Decreased FEV1 or FVC values, dyspnoea, chronic
cough, wheezing.
[18]
3
< LOD
Decreased FEV1 or FVC values, lung obstruction.
[23]
725
1.25 - 3.08 (PS)
Decreased FEV1 or FVC values, lung obstruction.
[24]
AS – area sampling
PS – personal sampling
LOD – detection limit
BO – bronchiolitis obliterans confirmed by histology and radiology
FEV1 – the forced expiratory volume in 1 second
FVC – the forced vital capacity
[4]
[2]
90
that the concept of ‘fixed airways obstruction’ be used. A
non-invasive method of evaluation the levels of obstructive changes in the airways is spirometry. Here, a forced
expiratory volume in 1 second (FEV1) value below 60%
of the predicted value, as well as lowered forced vital
capacity (FVC) and the ratio of these measures (FEV1/
FVC) indicate fixed airflow obstruction of the distal
respiratory tract [9]. Because this condition is rare, there
is a potential for mis-diagnosing it as either bronchial
asthma, bronchitis, emphysema or pneumonia.
There are a number of differences between bronchiolitis obliteransand other more common obstructive
lung diseases such as asthma or chronic obstructive
pulmonary disease (COPD). For example, in asthma,
the degree of airway obstruction expressed by the FEV1/
FVC ratio is not long lasting and alters from day to
day. Furthermore, FEV1 values return to normal when
treating asthma with short-term bronchiole dilators.
Moreover, COPD nearly always results in decreased
diffusion capacity of the lungs for carbon dioxide
(CO2) together with excessive reactivity of respiratory
tract. These described symptoms are not characteristic
features of bronchiolitis obliterans. This condition can
be distinguished from fibrotic changes of the lung, such
as those in idiopathic pulmonary fibrosis or asbestosis
by means of impairment of air flow but not FVC value. Notwithstanding, during the early disease stage,
the TLC value is raised however, when fibrotic lung
changes occur, this indicator becomes lowered [11].
When screening for early signs of bronchiolitis
obliterans, the FEF 25-75% value is recommended coupled
with both the diffusing capacity of the lung for carbon
monoxide (DLCO) and lung volumes which are highly
regarded diagnostic features of this condition [4, 38].
When diagnosing airway inflammation, the bronchoalveolar lavage (BAL) is used. Amongst other things,
this procedure provides a profile of inflammatory cells
and interleukin concentrations of IL-6 and Il-8; these
being mediators of inflammation [11]. Salivary tests can
also yield relevant information, where workers exposed
to food flavourings show increased levels of neutrophils
(>1.63x105 ml-1) with odds ratio (OR) 3.8 (95% CI: 1.311.5) as well as increased IL-8 and eosinophil cationic
protein (ECP) concentrations [3].
Bronchiolitis obliterans can indeed lead to death or
qualify for a lung transplant. However milder symptoms
of obstructed or restricted airways are usually seen in
those persons exposed to diacetyl. Studies performed on
workers at an USA microwave popcorn factory showed
9/450 persons (aged 27 - 51 years) suffering from bronchiolitis obliterans, of whom only 2 were also confirmed
histologically. Five out of these nine workers were employed as mixers of flavourings. Most subjects had never
smoked cigarettes and the lengths of employment varied
between 1 – 17 years. Those who had worked from 5
Nr 2
months to 9 years experienced coughing, dyspnoea and
wheezing. TEV1 values were 14.0 – 66.8% of expected
whilst HRCT showed significant bronchial thickening.
Once the exposures had stopped then all persons recovered normal lung function within 2 years [4].
TOXICOKINETICS AND MECHANISMS
OF PNEUMOTOXIC ACTION
Diacetyl is a hydrophilic substance and is readily
absorbed by the upper respiratory tract; as observed in
rat studies [29]. The pharmacokinetics of diacetyl using
a physiologically-based pharmacokinetic (PBPK) modelling, indicates that inhaling diacetyl penetrates more
deeply in those persons breathing through their mouths
than in rats breathing through their noses. Uptake of this
substance by the upper respiratory mucosa was clearly
intensified by its metabolism.
Mucociliary clearance of diacetyl was dominated by
its biotransformation and slow reaction with arginine.
The absorption efficiency in rats was greater at lower
levels of exposure. At higher exposures, the enzymes
metabolizing diacetyl become saturated and hence levels of the parent compound are increased which pass
into the distal regions of the respiratory tract. It has
been calculated that when rats are exposed to 3.58 mg/
m3 diacetyl concentration, only 2% reach the bronchi;
for persons breathing through their noses this value is
8%. However in the latter case, when breathing via the
mouth then this amount becomes slightly increased.
During mild exercise and whilst breathing through
the mouth, 24% of the received diacetyl dose passes
into the bronchi. The calculated amount of diacetyl
present in the bronchial tissue of an exposed person, at
rest, breathing through their nose is 5 times higher than
in rats but 7 times higher when breathing through the
mouth, but in the latter becomes 20 – 40 times higher
during mild exercise [10, 29]. Concentration differences in the distribution of diacetyl within the respiratory
tract for humans and rodents provoke differences in
the localisation of any pathological changes. Whilst in
the former these occur mainly in the distal regions, in
rodents they affect the upper respiratory tract. Exposing
rats or mice to relatively high concentrations of diacetyl results in fibrinopurulent inflammation or necrotic
rhinitis of regions such as nose, larynx, trachea and
bronchus together with the loss of microvilli and cilia
of ciliated epithelium [13, 28].
Diacetyl, like acetoin and 2,3-butanediol is a metabolite of acetaldehyde. The former two are rapidly reduced
in mammalian tissues to 2,3-butanediol which undergoes
glucuronidation before being excreted. Acetoin is enzymatically formed through the pyruvate dehydrogenase
complex or by a non-enzymatic reaction between ace-
Nr 2
91
Diacetyl exposure as a pneumotoxic factor
taldehyde and pyruvate in the presence of thiamine. Within mammalian hepatic tissue or homogenates thereof,
acetoin and 2-3-butanediol are very slowly oxidized to
diacetyl and as a result they accumulate in other tissue
e.g. brain [32]. Diacetyl is therefore an endogenous
compound with a significant toxicological role. Its reduction is catalysed by nicotinamide nucleotide dependent
diacetyl reductase present in mammalian tissue [30, 32],
which is regarded as a detoxification mechanism. This
reduction is inhibited by butyric acid which is present in
foodstuffs as flavourings/additives. It has been demonstrated that the efficiency of absorbing diacetyl alone in
the isolated upper respiratory tract of the rat is 36% of
the received dose, but in the presence of butyric acid this
value then significantly (statistically) decreases to 31%.
Thus inhibiting diacetyl metabolism in the upper airways,
may increase its transport to the bronchioles, where its
toxicological effects are manifested [29].
The mechanism by which bronchiolitis obliterans
arises still remains unknown. It is suggested that diacetyl directly damages airway epithelia resulting from
an induced inflammatory process and by carbonyl and
oxidative stress caused by the generation of reactive dicarbonyl and reactive oxygen species [41]. The presence
of two adjacent carbonyl groups in the diacetyl’s carbon
chain enhances the reactivity of these groups with protein
amino groups. When such products are formed, this leads
to excessive cytokine production and chronic states of
inflammation. Another source of these products comes
from cross-linking with structural proteins like collagen
and laminin or they can be the result of sclerosis processes
in the lungs, blood vessels or other tissue [27]. Furthermore, this leads to, amongst other effects, inhibition of
muscle enolase [35] and pyruvate kinase in erythrocytes
[19], key enzymes of glycolysis. Diacetyl also modifies
arginine in the inner mitochondrial membrane, impairing
its permeability [7]. Such disruption leads to an energy
deficit and cell death.
It is postulated that the processes of repairing the
distal respiratory tract occur during the uncontrolled
phases of fibroblast and myoblast proliferation. This
then leads to an accumulation of fibroblasts and collagen deposition, as well as scarring that is responsible
for the partial or complete obstruction of bronchioles
[11]. However, during the formation and development
of bronchiolitis obliterans, symptoms of allergic pulmonary inflammation, asthma , diffuse interstitial fibrosis
and granuloma can be excluded [11].
CONCLUSIONS
1. Diacetyl, as an ingredient of foodstuff flavourings/
additives, is a pneumotoxic substance under specific
workplace conditions.
2. Chronic exposure to this substance, particularly during the manufacture of microwave popcorn, leads
to obstructive changes in the distal regions of the
respiratory tract.
3. Diacetyl is one of the factors responsible for causing
bronchiolitis obliterans.
4. Reducing the occupational exposure to diacetyl in
industry seems to be the best method for preventing
bronchiolitis obliterans.
5. The presence of diacetyl as a flavouring/additive
in foodstuffs does not appear to constitute a health
hazard to consumers.
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DEVELOPMENT AND VALIDATION OF A METHOD
FOR DETERMINATION OF SELECTED POLYBROMINATED DIPHENYL
ETHER CONGENERS IN HOUSEHOLD DUST
Wojciech Korcz*, Paweł Struciński, Katarzyna Góralczyk, Agnieszka Hernik, Monika Łyczewska,
Katarzyna Czaja, Małgorzata Matuszak, Maria Minorczyk, Jan K. Ludwicki
Department of Toxicology and Risk Assessment, National Institute of Public Health – National Institute of Hygiene,
Warsaw, Poland
ABSTRACT
Background. Polybrominated diphenyl ethers (PBDEs) belong to group of so-called persistent organic pollutants (POPs).
These compounds occur in nearly all elements of the environment, including household dust which constitutes one of a
major route for human exposure. Their main adverse effects on human health are associated mainly with endocrine disruption – they interfere with thyroid function exhibit anti-androgenic action.
Objectives. To develop and validate analytical method for determination of BDE-47, BDE-99, BDE-153, and BDE-209
congeners in household dust.
Material and methods. Household dust was sampled in residences from Warsaw and the surrounding areas. An automated
Soxhlet extraction of samples was then performed and PBDE congeners were subsequently measured in cleaned-up extracts
by GC-μECD. The identity of quantified compounds was confirmed by GC/MS.
Results. Household dust samples were fortified at levels of 2.88, and 28.8 ng g-1 for BDE-47, BDE-999, and BDE-153, and
for BDE-209 at levels of 101.2, and 540 ng g-1. Recoveries ranged between 72 – 106%. The relative standard deviations (RSD)
were less than 16% for all PBDE congeners analysed. The relative error determined on the basis of multiple analyses of certified reference material ranged from 1.07 – 20.41%. The method’s relative expanded uncertainty varied between 16 – 21%.
Conclusion. The presented method was successfully validated and can be used to measure concentrations of BDE-47,
BDE-99, BDE-153 and BDE-209 congeners in household dust.
Key words. PBDEs, dust, method validation, recovery
STRESZCZENIE
Wprowadzenie. Polibromowane difenyloetery (PBDE) zaliczane są do trwałych zanieczyszczeń organicznych. Wykrywane
są praktycznie we wszystkich elementach środowiska, także w kurzu. Kurz jest istotnym źródłem pobrania polibromowanych difenyloeterów przez człowieka. Szkodliwy wpływ PBDE na zdrowie człowieka wiązany jest głównie z zaburzaniem
równowagi układu hormonalnego – zaburzają one m.in. funkcjonowanie hormonów tarczycy oraz działają antyandrogennie.
Cel badań. Opracowanie i walidacja metody analitycznej umożliwiającej oznaczanie kongenerów BDE-47, BDE-99, BDE153 i BDE-209 w kurzu domowym.
Materiał i metody. Materiał do badań stanowiły próbki kurzu pochodzące z domów osób zamieszkałych w Warszawie
i okolicach. PBDE ekstrahowano z kurzu z wykorzystaniem aparatu do automatycznej ekstrakcji Soxhlet. Ekstrakt oczyszczano i poddawano analizie instrumentalnej. Oznaczenia zawartości analizowanych kongenerów PBDE prowadzono na
GC-μECD, a tożsamość potwierdzano na GC-MS.
Wyniki. Próbki kurzu były wzbogacane na poziomie 2,88 ng g-1 i 28,8 ng g-1 dla BDE-47, BDE-99, BDE-153 oraz 101,2
ng g-1 i 540 ng g-1 dla BDE-209. Odzysk mieścił się w zakresie 72 - 106%. Względne odchylenie standardowe (RSD) było
mniejsze niż 16% dla wszystkich analizowanych kongenerów PBDE. Błąd względny wyznaczony na podstawie wielokrotnej analizy certyfikowanego materiału referencyjnego wynosił od 1,07% do 20,41%. Względna niepewność rozszerzona
zawierała się w zakresie 16-21%.
Wniosek. Metoda została zwalidowana i może być wykorzystywana do oznaczania zawartości kongenerów BDE-47, BDE99, BDE-153 i BDE-209 w próbkach kurzu domowego.
Słowa kluczowe: PBDE, kurz, walidacja metody, odzysk
*Corresponding author: Wojciech Korcz, Department of Toxicology and Risk Assessment, National Institute of Public Health –
National Institute of Hygiene, Chocimska 24, 00-791 Warsaw, Poland,
phone: +48 22 5421421, fax: +48 22 8497441, e-mail: wkorcz@pzh.gov.pl
94
W. Korcz, P. Struciński, K. Góralczyk et al.
INTRODUCTION
One of the negative consequences of a modern lifestyle is the plethora of harmful chemical compounds
present in the environment. Those environmental contaminants that are of particular concern are ones with
long persistence, the ability to readily migrate and ones
which are lipophilic. such persistent organic pollutants
(POPs) include the aforementioned polybrominated
diphenyl ethers (PBDEs) which consist of 209 congeners that differ in the numbers and position of bromine
substitutions on the two aromatic rings of the diphenyl
ether moiety. All of these congeners have an octanol:
water partition coefficient (LogOW) greater than 5, thereby showing their high fat solubility [12, 14]. PBDEs
were first used in the 1960s of the previous century as
flame retardants. They are commercially available as
three mixture types known as penta-BDE, octa-BDE
and deca-BDE. The former mainly consists of BDE47, BDE-99 and BDE-100, whilst the middle type is
principally composed of BDE-183, BDE-190, BDE-197
and BDE-196, but the latter is practically only made
up of BDE-209 (making up 97% of the content) [31].
Since 15th August 2004 there has been a ban in
force throughout the EU on penta-BDE and octa-BDE.
Furthermore, from 2008 the European Union Court of
Justice extended this ban to include deca-BDE used in
electric and electronic goods. Some USA states, like
California in 2006, banned the use of penta-BDE and
octa-BDE products which thus abolished their manufacture from the USA. At the end of 2013 the manufacture
of deca-BDE also became banned [4, 9, 40]. Despite
this stepwise withdrawal of PBDE and its manufactured
flame retardant products, such products will be nevertheless still present on the market for a long time yet,
as well as in the immediate environment [32].
It is estimated that the PBDEs as flame retardant
component may constitute up to 30% of the plastic
casings of computers, televisions, fabrics (automobile
seats and air), together with flooring and polyurethane
foams (in household furniture, mattresses or car seats)
[29]. As non-permanently chemically bonded components of products, they can be readily released into the
environment during the operation of electrical devices
when heating is generated. A 5 °C rise in temperature
has been shown to increase the emission of PBDEs from
television casings to the environment from 40 to 70%
[37]. Another factor responsible for such PBDE release
is by UV irradiation [38].
PBDEs can in fact be found throughout the environment that includes plant and animal tissue [10, 16,
25], together with human specimens [15, 34]. Many
published studies demonstrate that a significant source
of human exposure to PBDEs are various foodstuffs and
Nr 2
dust [5, 18, 27], where those particularly vulnerable to
exposure are small children aged 6 months to two years
[19, 41]. It has been shown that these compounds are
human endocrine disruptors altering thyroid, pituitary
and hypothalamic function as well as having neurotoxic
effects, that lead to behavioural changes and thought
process disorders [3, 17, 20, 21, 28]. The non-respirable
fraction of inhaled dust is a heterogeneous mixture of
dander, skin, hair, food debris, sand, fragments of fibres
from carpets, clothes and cigarette ash etc. [41]. PBDEs
in dust are mainly determined by gas chromatographic
(GC) methods with various means of detection eg. GC/
MS (mass spectrometric) or GC-ECD (electron capture)
[23, 24].
The aim of the study was to develop a simple method for measuring PBDE congeners in dust, serving
as a basis to thereby determine human exposures
from this source. Through performing a literature
review, four congeners were chosen, namely: BDE47 (2,2’,4,4’- tetrabromodiphenyl ether), BDE-99
(2,2’,4,4’,5-pentabromodiphenyl ether, BDE-153
(2,2′,4,4′,5,5′-hexabromodiphenyl ether) and BDE-209,
(2,2’,3,3’,4,4’,5,5’,6,6’-decabromodiphenyl ether) [8,
13, 30, 33, 35, 39].
MATERIAL AND METHODS
Reagents and Standards
Certified standard solutions of PBDEs (ie. BDE-47,
BDE-99, BDE-153 and BDE-209) were commercially
obtained in 1.2 mL aliquots, each at 50 µg/mL concentrations (in nonane), from Cambridge Isotope Laboratories
(Andover, USA). Merck (Darmstadt, Germany) supplied
the following; n-hexane and acetone for GC/ECD and
GC/FID, dichloromethane (for analysing pesticide residues), n-dodecane (for synthesis), silica gel (60 extra
pure 70-230 mesh ASTM; for column chromatography),
activated aluminium oxide 90 neutral (also for column
chromatography) and florisil. Cellulose extraction thimbles (43 x 123 mm) were bought from Munktell (Bärestein, Germany) whilst certified reference material SRM
2585 (NIST-2585) was provided by the LGC Standards.
Test sample material
Dust samples obtained from households in Warsaw
and the surrounding areas constituted the test material on
which the method was developed and validated. These
were taken using a vacuum cleaner at each place of residence and, as quickly as possible, were gathered at the
laboratory so that a visual segregation of large object could
be done to eliminate any plastics, wood, metal or hair and
then sieved on 150 µm vibrational steel sieving (Retsch
AS 200 basic). Samples were then placed into closed aluminium vessels and stored at -20 °C ready for further use.
Nr 2
Determination of polybrominated diphenyl ethers in dust - method validation
This was necessary to prevent photolytic debromination of
any PBDE occurring in the dust samples [1, 2].
Extraction
Before use, Florisil was heated for 2 hours at 130 °C
and left in an exsiccator until cooled, followed by deactivation through adding 2% of distilled water. Next,
1 g dust samples were placed into cellulose extraction
thimbles to which 3 g of deactivated florisil were added.
Automated extraction was then performed in a Soxhlet
B-811 (Büchi) extractor by adding a 100 mL mixture
of n-hexane:acetone (3:1, v:v). The details of extraction
conditions are shown in Table 1. To each extract, 50 µL
of n-dodecane (keeper) was added, which due to its high
boiling point (200 °C) prevents any analytical losses in
later stages of evaporation and changing of solvent [9].
The extract was then evaporated to almost dryness and
the residue reconstituted in 2 mL n-hexane.
Table 1. Parameters for Soxhlet’s extraction method (Büchi
B-811 system)
Parameter
Soxhlet warm mode:
Lower heating level
Upper heating level
Number of cycles
Rinse:
Lower heating level
Time
setting
10
2
30
8
15 min
Column clean-up
Prior to use, the aluminium oxide and silica gel were
heated at 130 °C for 24 hours, after which each were
respectively deactivated by adding 6% and 4.5% water. Extracts were then purified on columns containing
10 g silica gel and 5 g aluminium oxide that had been
pre-conditioned with 50 mL n-hexane. Samples were
then eluted with 75 mL mixture of dichloromethane:n-hexane (1:9, v:v) and collected eluates were evaporated
to dryness followed by reconstitution in 1 mL n-hexane.
Using glass Pasteur pipettes, samples were transferred
into glass amber vials ready for instrumental analysis.
Chromatography
Concentrations of the chosen PBDEs in the dust
samples were measured using a GC with μECD (electron capture detection) instrument; Agilent Technologies
6890N with automated sample injection (Agilent 7863)
controlled by Agilent ChemStation. Chromatographic
run conditions were as follows; DB-5MS column (30
m x 0,32 mm i.d. and film thickness 0.25 µm. The GC
oven temperature ramp programme was 70 ºC (1.7 min)
– 30 ºC min-1 – 210 ºC (0 min) – 5 ºC min-1 – 300 ºC (28
min). The PTV injector temperature ramp programme
in ‘solvent vent’ mode was 40 ºC (0.2 min) – 700 ºC
min-1 – 220 ºC (1 min) – 700 ºC min-1 – 260 ºC (2 min).
Detector temperature was 330 °C, sample volume 1 µL
with helium as the carrier gas. Retention times of the
chosen PBDEs were; BDE-47 – 13.077 min, BDE-99
Sample weight
1 g dust
+3 g florisil (2 % water)
Extraction
acetone : n-hexane (1:3, v:v)
100 mL
+ 50 µL n-dodecane
Evaporation
+ 2 mL n-hexane
+ 50 mL n-hexane
(column conditioning)
95
Clean-up
column
5 g aluminium oxide (6% water), 10 g silica gel (4,5% water)
+75 mL mixture of dichloromethane : n-hexane (1:9, v:v)
Evaporation
+ 1 mL n-hexane
GC - µECD
Figure 1. Diagram of the analytical method for the determination of selected PBDE congeners in the dust samples
Figure 1. Diagram of the analytical method for the determination of selected PBDE congeners
in the dust samples.
96
– 15.942 min, BDE-153 – 19.034 min and BDE-209 –
46.026 min The detailed scheme is shown in Figure 1.
The identity of quantified PBDE congeners was
confirmed by means of gas chromatography coupled
with mass spectrometric detector with the exception of
BDE-209, because of its thermal instability. The detector
was an ion-trap Varian 4000 and run conditions of the
GC system, using the same column, were as follows; 70
ºC (1 min); 30 ºC min-1 – 170 ºC, 8 ºC min-1 – 300 ºC (15
min), with temperatures of the detector and injector at
200 °C and 250 °C, a sample volume of 2 µL with helium
again being the carrier gas. Characteristic ions of the
PBDE congeners were chosen: BDE-47 – 326 and 486
m/z, BDE-99 – 406 and 564 m/z and BDE-153 – 484 m/z.
RESULTS AND DISCUSSION
Validation of a given analytical method enables
the assessment of possibility of an accurate and precise measurement of analyte concentration to be made.
The present study was carried out in accordance with
the published recommendations [6, 7, 11, 22]. The
limits of quantification (LOQ) corresponding to the
lowest points on the calibration curve were 1 ng mL-1
for BDE-47, BDE-99 and BDE-153, and 20 ng mL-1
for BDE-209 (equal to 1 and 20 ng per gram of dust).
However due to the influence of co-extracting matrix
complex components, an approach applied by Król et
al. (2012) has been applied, and LOQs were finally
estimated at 2 ng g-1 for BDE-47, BDE-99, and 30 ng
g-1 for BDE-209. Parameters characterizing the method
are shown in Table 2.
Recoveries were determined at two PBDE levels as
follows; 2.88 ng g-1 and 28.8 ng g-1 for BDE-47, BDE99 and BDE-153 whilst at 101.2 ng g-1 and 540 ng g-1
for BDE-209. For this purpose, a test portion of the
dust inserted in the cellulose thimble was spiked with
known volume of standard solution containing mixture
Nr 2
of PBDEs and was followed by the adopted scheme. The
fortification levels were adopted through performing a
review of scientific papers describing levels of these
compounds in dust [8, 13, 30, 33, 35].
Recoveries for BDE-47, BDE-99 and BDE-153 ranged from 75% – 82%. The method’s relative expanded
uncertainty for both fortification levels was estimated
to vary between 16 – 21%. In the case of BDE-209,
similar recoveries were found at 73 and 72% respectively at levels of 101.2 ng g-1 and 540 ng g-1 with the
relative expanded uncertainty in both cases being 18%.
In estimating the method’s uncertainty, only the intra-laboratory analytical procedure was taken into account
that included the PBDE congeners recoveries. Precision
of the method was also estimated and expressed as the
repeatability limit (r) of measurement.
During the validation, each stage of the method
was checked to determine which contributed to the
greatest measurement uncertainty; this was found to be
the solvent evaporation. The n-dodecane, as a keeper,
was checked for its effects on PBDE recoveries during
evaporation in the following manner; two sets of five
test tubes containing 1 mL of mixture of standards in
n-hexane (BDE-47 – 50.6 ng mL-1, BDE-99 – 51.2 ng
mL-1, BDE-153 – 51.2 ng mL-1 and BDE-209 – 253 ng
mL-1), were prepared with 50 µL of n-dodecane being
added to only the first set. Both sets were then evaporated to dryness and then reconstituted with 1 mL n-hexane. As shown in Table 3, n-dodecane reduces recovery
losses in the lower-brominated PBDE congeners (e.g.
BDE-47) but reduces recoveries in decabromodiphenyl
ether. For BDE-47, BDE-99 and BDE-153 congeners
an intra-laboratory reproducibility was checked for dust
samples (n=6) spiked with 28.8 ng-1 of these compounds. Recoveries of the PBDEs varied from 78 – 95%,
with RSDs (relative standard deviation) ranging 11
– 15% that were lower than the 27% RSDR value (relative standard deviation of reproducibility) calculated
according to the Horwitz equation [26].
Table 2. Summary of validation parameters for the method
Parameters
Working range [ng g-1]
Fortification level [ng g-1]
Average recovery [%] (n=6)
SD [ng g-1]
RSD [%]
Repeatability limit (r)
Relative expanded uncertainty [%]
Fortification level [ng g-1]
Average recovery [%] (n=6)
SD [ng g-1]
RSD [%]
Repeatability limit (r)
Relative expanded uncertainty [%]
BDE-47
2- 506
106
0.49
15.98
1.36
16
82
3.65
15.38
10.23
20
PBDE congeners
BDE-99
BDE-153
2 - 512
2 - 512
2.88
104
95
0.29
0.38
9.93
13.74
0.82
1.05
15
21
28.8
76
74
3.23
2.72
14.8
12.77
9.04
7.60
16
19
BDE-209
30 - 759
101.2
73
8.81
11.97
24.66
18
540
72
35.26
9.10
98.74
18
Nr 2
97
Table 3. The role of keeper (n-dodecane) addition at the stage of solvent evaporation
PBDE congeners
Concentation
[ng mL-1]
BDE-47
BDE-99
BDE-153
BDE-209
50.60
51.20
51.20
253.00
Evaporation with keeper (n=5)
Measured concentration
SD
[ng mL-1]
[ng mL-1]
52.12
0.47
55.42
1.26
54.83
1.48
215.02
11.48
The certified reference material SRM 2585 (NIST)
was used also for validation which is the sieved dust
contained numerous contaminants, including analysed
PBDEs [31]. Results of analysis of 6 such reference
dust samples are shown in Table 4.
Table 4. Results of standard reference material NIST SRM
2585 analyses (n=6)
PBDE
congener
BDE-47
BDE-99
BDE-153
BDE-209
Certified
concentration
[ng g-1]
497
892
119
2510
Measured
concentration ± SD
[ng g-1]
491.66 ± 18.17
751,64 ±20.95
94.71 ± 13.46
2746.54 ± 160.63
Relative
error a
(%)
1.07
15.74
20.41
9.42
calculated as (|average measured concentration– certified concentration| ∕ certified concentration)*100
a
Evaporation without keeper (n=5)
Measured concentration
SD
[ng mL-1]
[ng mL-1]
25.83
6.65
46.07
3.39
54.47
1.96
251.34
22.70
The results demonstrate the adequacy of the developed method for measuring the defined analytes. It
should however be mentioned that PBDE levels in the
certified reference material were very high (especially
for BDE-99 and BDE-209) and therefore either dilutions
are required at the final stages to fall within the working
range of calibration curve or smaller samples of dust
need to be taken. Indeed the latter option was used, where only 100 mg amounts of dust were sampled with the
final result being accordingly adjusted as per 1 g dust.
Because PBDEs are vulnerable to debromination
by photolysis, it is important to limit their exposure
to UV light at each stage of the analytical procedure,
particularly those involving organic solvents where
this process occurs most readily [36, 38]. The speed of
photo-degradation also increases with the number of
Figure 2. GC- µECD chromatograms obtained from standard reference material NIST SRM 2585 sample (a) and household
dust sample (b).
98
Nr 2
Figure 3. GC-MS chromatogram of household dust sample obtained in SIS mode.
bromine substitutions on the PBDE moiety [1, 2]. By
using the ‘warm extraction’ mode with the automated
Soxhlet, it was possible to shorten the extraction time
by 3 hours as compared to the original procedure [8,
9, 28, 35].
Due to dust being an extremely heterogeneous
matrix, the chromatograms of successive samples may
differ in the numbers of peaks observed and their intensities. Figure 2 shows chromatograms of a reference
SRM 2585 material and a sample of household dust
obtained by GC-µECD.
Figure 3 demonstrates an example of a chromatogram obtained from a dust sample using GC/MS in the
SIS (selected ion storage) mode which increases the
sensitivity of detecting specifically chosen ions, and
thus enables full identification of test substances. In the
presented sample, the presence of BDE-47 and BDE-99
were confirmed, however BDE-153 was absent.
CONCLUSIONS
1. This developed and validated method can be used
for measuring the concentrations of the selected
polybrominated diphenyl ethers congeners: BDE-47,
BDE-99, BDE-153, and BDE-209 in dust samples,
thus enabling human exposure to these substances
to be assessed within household environments or
other similar confined spaces, such as those found
in automobiles.
2. Recoveries and relative standard deviations are
analytically appropriate as are the repeatability and
reproducibility within the working conditions used
in the study. The method is also robust to changes
in the laboratory environment.
Acknowledgements
The presented study was funded by the National Science
Centre, Poland (Grant No. N N404 0881140).
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VARIATIONS OF NIACIN CONTENT IN SALTWATER FISH
AND THEIR RELATION WITH DIETARY RDA
IN POLISH SUBJECTS GROUPED BY AGE
Michał Majewski1*, Anna Lebiedzińska2
Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Varmia and Masuria,
Olsztyn, Poland
2
Chair and Department of Bromatology, Medical University of Gdańsk, Gdańsk, Poland
1
ABSTRACT
Introduction. A rich and natural source of readily assimilated dietary protein together with invaluable vitamins and minerals
are fish, particularly the saltwater species. The quality of any given foodstuff is determined by its nutritional value, which
in turn depends on the food type and methods used for manufacture, processing and storage. Many fish products contain
fewer water soluble vitamins than the source foodstuff as a result of using various technologies during food processing, such
as smoking or deep freezing, where vitamins are often either degraded or leached out. In the case of niacin it is relatively
easy to make good such losses by eating niacin-rich foods or by taking dietary supplements e.g. the essential amino acid
L-tryptophan.
Objectives. To determine niacin content in sea fish that are commonly available on the Polish market and to assess whether
this dietary source is sufficient to satisfy the RDA requirements for various age groups of selected subjects living in Poland.
Material and methods. Niacin levels were measured firstly in 10 saltwater fish species together with butterfish and Norwegian salmon that formed a separate group. Altogether, 15 types of fish products were analysed in all. They consisted
of smoked fish: whitefish, butterfish, sprat, trout, herring (kippers) and mackerel, and frozen fish: butterfish, Norwegian
salmon, sole, grenadier and panga. Each product was measured as ten replicates, thus in total 150 analyses were performed.
A microbiologically-based method was used for the niacin determination, with enzyme hydrolysis by 40 mg papain and
diastase on a 2 g sample (according to the AOAC procedure) to release the free form from the bioavailable form that is
bound to NAD and NADP.
Results. The most plentiful sources of niacin were found in smoked fish with the highest amounts in butterfish, after warm
temperature smoking, and in mackerel; respectively 9.03 and 8.90 mg/100 g. Such 100 g portions of smoked fish are a
good dietary source of niacin, in that for men and women above 19 years of age, they constitute respectively 22% - 56%
and 25% - 64% of the RDA (Recommended Daily Allowance). The highest levels of niacin in frozen fish were found in
butterfish and Norwegian salmon; respectively 8.05 and 5.75 mg/100 g which in turn represent respectively 10% - 50% and
11% - 56% of the RDA in men and women aged above 19 years.
Conclusions. Niacin concentrations varied according to fish species. The richest dietary sources were smoked fish consisting of butterfish, after warm temperature smoking, and mackerel. In frozen fish, butterfish and Norwegian salmon had the
highest niacin amounts. A 100 g serving of such sea fish can, to quite a large extent, satisfy the adult RDA.
Key words: niacin, nicotinic acid, nicotinamide, fish
STRESZCZENIE
Wprowadzenie. Ryby zwłaszcza morskie stanowią naturalne źródło łatwo przyswajalnego białka oraz wielu cennych witamin i minerałów. Witamina B3 to grupa związków w skład których wchodzą kwas nikotynowy (niacyna) oraz amid kwasu
nikotynowego (nikotynamid). Stosunkowo łatwo uzupełniać niedobory niacyny spożywając regularnie produkty bogate
w tą witaminę, jak i białko lub szeroko dostępne na rynku suplementy diety.
Cel badań. Celem pracy było oznaczenie zawartości niacyny w łatwo dostępnych na rynku rybach morskich, a także ocena
analizowanych ryb jako potencjalnego dobrego źródła niacyny w diecie człowieka (RDA) w różnych grupach wiekowych.
Materiał i metody. Oznaczono zawartość niacyny w piętnastu rodzajach ryb słonowodnych. w rybach wędzonych (sieja,
ryba maślana, szprot, pstrąg, śledź oraz makrela) i mrożonych (ryba maślana, łosoś norweski, sola, grenadier, panga). Łącznie
przebadano 150 produktów rybnych. Niacynę oznaczono metodą mikrobiologiczną według AOAC stosując hydrolizę en*Corresponding author: Michał Majewski, Department of Pharmacology and Toxicology, Faculty of Medical Sciences,
University of Varmia and Masuria, Żołnierska Street 14 C, 10-561 Olsztyn, Poland,
phone: + 48 89 524 61 88, fax: (89) 524 61 88, e-mail: michal.majewski@uwm.edu.pl
102
M. Majewski, A. Lebiedzińska
Nr 2
zymatyczną za pomocą papainy i diastazy w celu wyodrębnienia witaminy z analizowanych próbek. Metoda enzymatyczna
pozwala na wyodrębnienie tylko biologicznie dostępnych form niacyny związanych w NAD i NADP.
Wyniki. Najlepszym źródłem niacyny były ryby wędzone, a najwięcej witaminy stwierdzono w wędzonych na ciepło rybie
maślanej (9,03 mg/100 g) i makreli (8,90 mg/100 g). Porcja ryby wędzonej (100 g) może być bardzo dobrym źródłem niacyny realizując normy dziennego zapotrzebowania dla kobiet i mężczyzn w wieku powyżej 19 lat, odpowiednio w zakresie
wartości od 24% do 64% i od 21% do 56%. W grupie badanych ryb mrożonych najwyższą zawartość niacyny zawierała
ryba maślana (7,89 mg/100 g) i łosoś norweski (5,75 mg/100 g). Porcja ryby mrożonej (100 g) pokrywała dzienne zapotrzebowanie na niacynę normy dla kobiet i mężczyzn w wieku powyżej 19 lat, odpowiednio w zakresach od 11% do 56%
i od 10% do 49%.
Wnioski. Przeprowadzone analizy zawartości niacyny wykazały zróżnicowanie pomiędzy poszczególnymi gatunkami ryb.
Wykazano, iż najlepszym źródłem niacyny są ryby wędzone, spośród których najwięcej analizowanej witaminy posiadają
ryba maślana wędzona na ciepło oraz makrela. W grupie ryb mrożonych najwyższą zawartość niacyny oznaczono w rybie
maślanej oraz w łososiu norweskim. Porcja ryby morskiej (100 g) może być bardzo dobrym źródłem niacyny.
Słowa kluczowe: niacyna, kwas nikotynowy, amid kwasu nikotynowego, ryby
INTRODUCTION
Sea food, especially that consisting of so called
‘dark meat’, provides an excellent source of dietary
niacin. Furthermore, the presence of tryptophan, which
lends the meat its dark colouration, is a precursor in the
biosynthesis of kynurenine, serotonin and NAD; being
the biologically active form of niacin (Figure 1). A 60
mg amount of tryptophan is sufficient for generating
L-Tryptophan
NH2
(TRP)
O
HO
N
H
O
L-Kynurenine
NH2
(KYN)
O
OH
NH2
NADPH, FAD, B , B
6
O
2
Quinolinic acid
(QUIN)
OH
O
N
1 mg niacin. This reaction pathway requires B group
vitamins as enzyme cofactors.
Reasons for any niacin deficiencies may be malnourishment, alcoholism, medicines used for treating
Parkinson’s Disease or hydrazine derivatives used in
treating tuberculosis and inflammation. A diet containing fish affords many nutritional advantages [5, 17]. It
should be stressed that fish protein has a high nutritional
value and fish also contain long chain polyunsaturated
fatty acids EPA (eicosapentaenoic acid) and DHA
(docosahexaenoic acid), microelements and vitamins
[12-14, 18, 19, 21, 22]. A 100 g portion of fish covers
half the daily requirement for tryptophan rich protein;
tryptophan being a niacin precursor. Some publications
suggest that there may be significant differences in vitamin and fat content between farmed fish with those
living free. This may also depend on the fish species,
age, the season when fished (captured) and the type and
availability of feed. Data on these topics are sparse. [16].
The study aims were to determine the niacin content
in various species of sea fish, that included those who
had been smoked (under warm or cold conditions) or
deep frozen in relation to the sources of the human dietary requirement for niacin; RDA [12-14]. The types of
fish chosen were ones that were fatty, saltwater species,
easily available on the market and frequently consumed
in Poland, as determined from previous dietary surveys.
OH
O
PRPP, Mg2+
OH
N
Niacin
(Na)
Nicotinic acid
mononucleotide
(NaMN)
NAD - active form of niacin
Figure 1. The niacin pathway of tryptophan metabolism
Fig. 1. The niacin pathway of tryptophan metabolism.
The study material were samples of fish products
that had been smoked (under either warm or cold conditions) or deep frozen; Table 2 and Table 3. The fish
samples consisted of fillets, flakes, cutlets and whole
carcasses. Ten fish species were analysed; whitefish,
butterfish, sprat, trout, herring, mackerel, Norwegian
salmon, sole, grenadier and panga that amounted to
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103
Niacin in saltwater fish
19 years by their concordance with amended reference
values of nutrition in Poland, supplied by the Polish
Institute of Food and Nutrition [8].
Table 1. Accuracy and precision of niacin determination
Niacin content in fish
(mg/100 g)
n
7.89 ±015
10
Spiked
Recovery
(mg/100 g)
(%)
3
6
97.87
103.04
SD
(%)
2.89
3.13
Relative
error
(%)
- 2.13
+3.04
RESULTS AND DISCUSSION
n - number of samples, SD- standard deviation
Niacin concentrations found in the tested fish samples are shown in Tables 2 and 3. In smoked fish, the
highest niacin concentrations were found in butterfish
(warm treatment) and mackerel at respectively 9.03
and 8.90 mg/100 g. The lowest levels in smoked fish
were recorded in whitefish and sprats (whole and flesh),
respectively 3.50 and 4.06 – 4.58 mg/100 g (Table 2).
In the deep frozen fish, the highest amounts measured
were in butterfish (respectively 8.05 and 7.11 mg/100
g in cutlets and fillets) and Norwegian salmon (5.05 8.85 mg/100 g), whereas the lowest levels were in sole,
grenadier and panga; respectively 1.96, 1.71 and 1.53
mg/100 g (Table3). The observed differences in niacin
concentrations between smoked and deep frozen fish
could be explained by water losses incurred in the latter
during thawing, as well as the type of treatment (warm
or cold) used in smoking. As aforementioned, the thawing loss was 6% due to the discarding of water. Results
were subjected to statistical analysis by ANOVA using
p ≤ 0.05 as showing significance. For butterfish, the
treatment differences between warm and cold smoking
was compared and found to be significantly different
at p = 0.001.
The niacin levels found in the 100 g fish portions
are shown in relation to RDA requirements; for smoked
fish (Table 2) and deep frozen fish (Table 3) - taking
into account the age, gender and physiological status of
the human population. Using the mean RDA values for
children, a 100 g portion of butterfish (warm smoked)
and smoked mackerel, fulfils their RDA by respectively
113 and 111% (Table 2). Niacin reference values for
boys are equivalent to those of adult men; the same
15 fish products in total. Each were analysed as 10
replicates. Three samples of fish flesh were obtained
after homogenising and mixing each fish product type.
Previously, the fish had been thawed at 4°C, after being
frozen for over 24 hours under laboratory conditions,
then the thawed water was discarded. This being similar
to how fish is prepared domestically in the kitchen and
on average the discarded water amounted to a 6% loss.
Niacin was isolated from the samples (2 g) after enzymatic hydrolysis using papain and diastase (40 mg) according to the AOAC method [1, 15]. A microbiological
method [1, 7] was then used to determine niacin using
the Lactobacillus plantarum ATCC No. 8014 strain.
Niacin is one of the most stable water soluble vitamins in solution and its biological activity is retained
following thermal, light, pH or oxidation treatment.
Both acid or enzymatic hydrolysis is thus possible for
releasing free niacin from its biologically bound form
where it can be liberated from coenzymes or through
matrix degradation. When performing mineral acid
hydrolysis, this process is however non-physiological
and may release nicotinic acid which is not normally
bio-available. Studies by Ndaw et al. [18] have demonstrated that by replacing acid hydrolysis by enzymes it
is possible to isolate niacin liberated from its NAD and
NADP bound forms.
The precision and accuracy of the method were
established, at highly acceptable levels, on samples
spiked with known amounts of niacin (Table 1). Results
were checked to see if levels were sufficient to satisfy
the RDA requirements for adult subjects aged above
Table 2. Niacin content in smoked fish according to the RDA for the Polish population
Fish type
Smoked butterfish
(warm)
Smoked mackerel
Smoked trout
Smoked butterfish
(cold)
Smoked herring
Smoked sprats -flesh
Smoked sprats -whole
Smoked whitefish
RDA requirement in 100 g of fish product (%)
Niacin content
(mg/100 g)
X± SD
Children
1-9 years
10
9.03± 0.05
10
10
n
Men
Women
10–18
years
≥ 19
years
10–18
years
≥ 19 years
pregnant
nursing
112.88
56.44
56.44
64.50
64.50
50.17
53.12
8.90 ± 0.09
5.65± 0.04
111.25
70.63
55.63
35.31
55.63
35.31
63.57
40.36
63.57
40.36
49.44
31.39
52.35
33.24
10
5.54± 0.13
69.25
34.63
34.63
39.57
39.57
30.78
32.59
10
10
10
10
4.99± 0.20
4.58± 0.28
4.06± 0.10
3.50± 0.21
62.38
57.25
50.75
43.75
31.19
28.63
25.38
21.88
31.19
28.63
25.38
21.88
35.64
32.71
29.00
25.00
35.64
32.71
29.00
25.00
27.72
25.44
22.56
19.44
29.35
26.94
23.88
20.59
n - number of samples; X- average; SD- standard deviation
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M. Majewski, A. Lebiedzińska
Table 3. Niacin content in frozen fish according to the RDA for the Polish population
Fish type
Butterfish (cutlet)
Butterfish (fillet)
Norwegian salmon steak, tail
Norwegian salmon cutlet
Sole, fillet
Grenadier, fillet
Panga, fillet
n*
10
10
10
10
10
10
10
Niacin content
(mg/100 g)
X± SD
8.05 ± 0.15
7.11 ± 0.15
5.85 ± 0.12
5.05 ± 0,15
1.96 ± 0.08
1.71 ± 0.11
1.53 ± 0.10
Children
1-9 years
100.63
88.88
73.13
63.13
24.50
21.38
19.13
RDA requirement in 100 g of fish product
(%)
Men
Women
10–18
10– 18
10–18
10–18
10–18
years
years
years
years
years
50.31
50.31
57.50
57.50
44.72
44.44
44.44
50.79
50.79
39.50
36.56
36.56
41.79
41.79
32.50
31.56
31.56
36.07
36.07
28.06
12.25
12.25
14.00
14.00
10.89
10.69
10.69
12.21
12.21
9.50
9.56
9.56
10.93
10.93
8.50
nursing
47.35
41.82
34.41
29.71
11.53
10.06
9.00
n– number of samples; X- average; SD- standard deviation
applying to girls and adult women. Here, it was found
that the RDA was satisfied by respectively 56% and 64%
in men and women for both warm treated smoked butterfish and smoked mackerel; these being at the highest
levels. Those fish showing the lowest RDA fulfilment
were whitefish at 44% RDA in children and 22% and
25% respectively for men and women (Table 3).
In the frozen fish, sole grenadier and panga least satisfied the RDA where respectively they supplied 24%,
21% and 19% in children. For men the corresponding
results were 12%, 11% and 10% whilst 14%, 12% and
11% for women. A butterfish portion (100 g cutlet) best
satisfied the RDA in children and in men and women;
respectively 50% and 57%. There were almost 1.6
and 1.3 fold higher niacin levels in butterfish smoked
respectively under warm and cold conditions compared
to deep frozen butterfish. It is suggested that this arose
from technological losses incurred during processing
and the water loss during thawing.
As a component of two vital coenzymes NAD+
and NADP+ in electron transport, niacin takes part in
oxidation/reduction reactions catalysed by dehydrogenases [22]. It is vital for normal nervous system
function where it protects against oxidative stress and
takes part in the syntheses of the sex hormones: cortisol,
thyroxin and insulin [6, 9]. Dietary niacin deficiency in
children leads to many functional disorders, leading to
the development of diet-related diseases, developmental
and mental dysfunction [7]. As a nicotinic acid, niacin
increases plasma HDL-cholesterol, whilst at the same
time decreases fatty acids that induce arteriosclerosis,
such as triglycerides, VLDL-cholesterol, LDL-cholesterol and Lipoprotein A [2]. Furthermore, a high dose
of niacin can reduce inflammation [8].
Current nutritional recommendations clearly indicate that fish should be eaten 2 – 3 times weekly
and that the dietary presence of ‘oily fish’ and certain
‘fruits of the sea’ is beneficial to the health of those
at risk of cardiovascular disease, in pregnant women
and the elderly [4, 7, 10, 11, 17, 20]. Due to their high
nutritional value, fish should be consumed much more
than is currently the case in Poland, where in fact fish
consumption is falling.
CONCLUSIONS
1. The study demonstrated wide variations of niacin
content for different fish species. The highest levels
were found in warm smoked butterfish or smoked
mackerel whilst those levels highest in frozen fish
were butterfish and Norwegian salmon.
2. A 100 g portion of smoked fish can be an important
dietary source of niacin, satisfying the RDA by 22
- 56% in men and 25 - 64% in women.
3. In frozen fish, a 100 g portion satisfies the niacin
RDA by 10 - 50% in men and 11 – 57% in women.
Conflict of interests
REFERENCES
1. AOAC. Niacin and Niacinamide (Nicotinic Acid and
Nicotinamide) in Vitamin Preparations. 2003 Maryland.
http://www.eoma.aoac.org/methods/info.asp?ID=14717.
2. Backes J.M., Padley R.J., Moriarty P.M.: Important
considerations for treatment with dietary supplement
versus prescription niacin products. Postgrad Med
2011;123(2):70-83.
3. Balasubramanyam A., Coraza I., Smith E.O., Scott L.W.,
Patel P. et al: Combination of niacin and fenofibrate with
lifestyle changes improves dyslipidemia and hypoadiponectinemia in HIV patients on antiretroviral therapy:
results of “heart positive,” a randomized, controlled trial.
J Clin Endocrinol Metab 2011;96(7):2236-2247.
4. Bassan M.: A case for immediate-release niacin. Heart
Lung 2012;41(1):95-98.
5. Goede J., Verschuren W.M., Boer J.M., Kromhout D.,
Geleijnse J.M.: Gender-specific associations of marine
n-3 fatty acids and fish consumption with 10-year incidence of stroke. PLoS One 2012;7(4):1-14.
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6. Hamoud S., Kaplan M., Meilin E., Hassan A., Torgovicky
R. et al: Niacin administration significantly reduces oxidative stress in patients with hypercholesterolemia and
low levels of high-density lipoprotein cholesterol. Am J
Med Sci 2013;345(3):195-199.
7. Jarosz M.: Nutrition standards for the Polish population
– revision. Warsaw, IŻŻ, 2012 (in Polish).
8. Kapoor A., Thiemermann C.: Niacin as a novel therapy
for septic shock? Crit Care Med 2011;39(2):410-411.
9. Kirkland J.B.: Niacin requirements for genomic stability.
Mutat Res 2012;733(1–2):14–20.
10. Kołodziejczyk M.: Consumption of fish and fishery products in Poland – analysis of benefits and risks. Rocz
Panstw Zakl Hig 2007;58(1): 287-293.
11. Lavigne P., Karas R.: The Current State of Niacin in
Cardiovascular Disease Prevention. J Am Coll Cardiol
2013;61(4):440-446.
12. Lebiedzinska A.: Fish and shellfish as a source of vitamins B – own results in a view of literature data. Polish
J Environ Stud 2006;15(2):1322-1327.
13. Lebiedzińska A., Majewski M., Szefer P.: Butterfish as a
source of niacin. Rocz Panstw Zak. Hig 2008;59(2):197201 (in Polish).
14. Lebiedzińska A., Majewski M., Szefer P.: Niacin content
in canned tuna fish. Bromat Chem Toksykol 2008;1:2933 (in Polish).
15. Ndaw S., Bergaentzle M., Hasselmann C.: Enzymatic
extraction procedure for liquid chromatographic determi-
105
nation of niacin in foodstuffs. Food Chem 2002;78:129–
134.
16. Nettleton J.A., Exler J.: Nutrition in wild and farmed fish
and shellfish. J Food Sci 1992;57(2):257-260.
17. Oudin A., Wennberg M.: Fish consumption and ischemic
stroke in southern Sweden. Nutr J 2011;10:109.
18. Polak-Juszczak L.: Mineral elements content in smoked
fish. Rocz Panstw Zakl Hig 2008;59(2):187-196.
19. Regulska-Ilow B., Ilow R., Konikowska K., Kawicka A.,
Różańska D., Bochińska A.: Fatty acid profile of the fat
in selected smoked marine fish. Rocz Panstw Zakl Hig
2013;64(4):299-307.
20. Robinson J.G.: What is the role of advanced lipoprotein analysis in practice? J Am Coll Cardiol
2012;60(25):2607-2615.
21.WHO. Global strategy on diet, physical activity and
health. Fifty-seven world health assembly, Agenda item.
6.12.2004.
http://www.who.int/dietphysicalactivity/strategy/
eb11344/strategy_english_web.pdf
22. Zając M.: Vitamins and microelements. Poznan, Kontekst, 2000 (in Polish).
EVALUATING ADULT DIETARY INTAKES OF NITRATE AND NITRITE
IN POLISH HOUSEHOLDS DURING 2006-2012
Anna Anyżewska*, Agata Wawrzyniak
Chair of Nutritional Assessment, Department of Human Nutrition, Faculty of Human Nutrition and Consumer Sciences,
Warsaw University of Life Sciences, Warsaw, Poland
ABSTRACT
Introduction. Nitrates and nitrites commonly occur throughout nature as well as in foodstuffs. Their excess consumption
can however pose health risks, for example, arising from methaemoglobinaemia or from the formation of N-nitrosamines.
Objectives. To determine whether the levels of domestic nitrate and nitrite consumption are safe in Polish households during 2006-2012.
Material and methods. Appropriate consumption data was obtained from the Central Statistical Office in Poland (GUS),
whilst nitrate and nitrite intakes were estimated from nationally available data on foodstuff content taken from the literature.
Results. Mean nitrate and nitrite intakes were respectively 147 mg NaNO3 and 3.26 mg NaNO2 /per person/day, corresponding
to 41% and 45% of the ADI (acceptable daily intake). Statistically significant differences in intakes were observed between
types of households, with the highest seen in those of retired subjects; however the ADIs were not exceeded.
Conclusions. Domestic intakes of nitrates and nitrites were found to be at safe levels; nevertheless control over their intake
should be maintained because of potentially adverse health threats.
Key words: nitrates, nitrites, intake, households
STRESZCZENIE
Wprowadzenie. Azotany(V) i (III) występują zarówno w przyrodzie jak i w żywności. Nadmierne ich spożycie może powodować zagrożenie zdrowia, np. methemoglobinemię lub może przyczynić się do powstawania N-nitrozoamin.
Cel badań. Celem badań było oszacowanie pobrania azotanów(V) i azotanów(III) z żywością w gospodarstwach domowych
w Polsce w latach 2006-2012.
Materiał i metody. Oszacowanie pobrania azotanów(V) i azotanów(III) w gospodarstwach domowych wykonano na
podstawie danych o spożyciu żywności Głównego Urzędu Statystycznego (GUS) oraz zebranych krajowych danych z piśmiennictwa dotyczących zawartości tych związków w produktach spożywczych.
Wyniki. Średnie pobranie azotanów(V) i azotanów(III) w latach 2006-2012 wynosiło 147 mg NaNO3/os/dobę (41% ADI)
i 3,26 mg NaNO2/os/dobę (45% ADI). Pobranie azotanów(V) i azotanów(III) różniło się istotnie statystycznie w badanych
typach gospodarstw domowych. Największe średnie pobranie zarówno azotanów(V) jak i azotanów(III) zaobserwowano
w gospodarstwach emerytów, jednak wartości ADI nie zostały przekroczone.
Wnioski. Średnie pobranie azotanów(V) i azotanów(III) w gospodarstwach domowych w latach 2006-2012 kształtowało
się na bezpiecznym poziomie, niemniej jednak należy kontrolować pobranie tych związków z dietą ze względu na ryzyko
możliwych negatywnych skutków zdrowotnych.
Słowa kluczowe: azotany (V), azotany (III), pobranie, gospodarstwa domowe
INTRODUCTION
Both nitrates and nitrites are widespread and naturally occurring ions, mainly arising from organic
decomposition of nitrogenous substances. They are
found also in mineral salts as well as water. In the latter,
their presence is due to the run-off from industry or
agriculturally used fertilisers and constitutes the main
environmental source [10]. Nitrates can also be present
in foodstuffs, depending on the product type, resulting
from the technological method of manufacture; for e.g.
in the making of cured meats or from using fertiliser for
*Corresponding author: Anna Anyżewska, Chair of Nutritional Assessment, Department of Human Nutrition, Faculty of Human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (SGGW), Nowoursynowska Street 159c, 02-776 Warsaw, Poland,
phone +48 22 59 37 122, fax +48 22 59 37 129, e-mail-anna_anyzewska@sggw.pl
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A. Anyżewska, A. Wawrzyniak
plant cultivation. Nitrates have been shown to be decidedly less toxic than nitrites, where the latter arises from
nitrate reduction and may cause methaemoglobinaemia
[14]. In addition, nitrites can enzymatically react with
primary (I), secondary (II) and tertiary (III) amines (via
nitro-reductase), together with amino acids, amides,
indoles and phenylamines forming N-nitrosoamine
products that are well recognised to be carcinogens [9].
The study aims were to estimate nitrate and nitrite
intakes from foodstuffs in adults living in defined household groups throughout Poland during 2006-2012.
These were then related to ADI values.
The study was conducted using foodstuff consumption data from 2006-2012, within Polish household
budgets, as made available by the Central Statistical
Office in Poland. The following household group
categories were selected; manual and non-manual
workers, farmers/farm labourers, those self-employed,
retired persons and pensioners. Using national data,
mainly from the last seven years, the average nitrate
and nitrite contents in foodstuffs was obtained from
which consumption and intakes were calculated for
each of the defined groups. Technological food losses
and meal leftovers were not taken into account. In order
to relate the findings to ADI for each household type,
the following nitrate/nitrite values established by the
Joint FAO/WHO Expert Committee on Food Additives
(JECFA) were used; respectively 5.0 mg NaNO3 and 0.1
mg NaNO2 /kg body mass /24 hours [5], adopting the
average persons adult body mass in Poland [11]. The
structure of nitrate and nitrite intakes could be presented
as well as their sources the total intakes were taken as
being 100%.
Statistical analyses was performed by the ‘Statistica
10’ computer programme using ANOVA, taking P<0.05
as the critical value for significance.
RESULTS
The mean nitrate intake during 2006-2012 was 147
mg NaNO3/person/24hours, which decreased by 8%
throughout this time (Table 1). Statistically significant
differences between household groups were noted
(p<0.05), with pensioners having the highest nitrate
intakes (198 mg NaNO3/person/24hours). Lower values
(by respectively 7% and 9%) were observed for farmers/
farm labourers and retired persons. All other groups
Table 1. Dietary nitrate intakes in households during 2006-2012
Type of household
Non-manual
Self-employed
Years
Total
Manual workers
Farmers
workers
workers
mg NaNO3/per person/day
2006
154
132
131
195
134
2007
151
130
131
186
131
2008
149
131
130
187
130
2009
149
130
128
189
130
2010
144
127
124
182
124
2011
142
124
124
172
119
2012
141
125
121
175
121
x
147
128a
127a
184b
127a
±SD
5
3
4
8
5
* mean± standard deviation; results flagged with identical letters did not differ significantly
Retired persons
Pensioners
206
203
198
198
194
193
191
198c
5
185
185
181
180
175
180
170
179b
5
Table 2. Dietary nitrate intakes in households during 2006-2012 compared with ADI values in adults
Type of household
Years
Total
Manual workers
Non-manual
workers
2006
2007
2008
2009
2010
2011
2012
x
±SD
43
42
41
41
40
39
39
41
1
36
36
36
36
35
34
34
35a
1
36
36
36
35
34
34
33
35a
1
Farmers
% of adult ADI
54
51
52
52
50
48
48
51b
2
Self-employed
workers
Retired persons
Pensioners
37
36
36
36
34
33
34
35a
1
57
56
55
55
54
53
53
55c
1
51
51
50
50
48
50
47
49b
1
Nr 2
had substantially lower intakes by 35-36%. None of the
household groups exceeded the nitrate ADI, which on
average were found to be 41% of this value (Table 2).
The highest of the ADI (55%) was in the retired persons
group, whilst the lowest (35% ADI) was seen for both
the manual and non-manual workers group and those
self employed; differences being significant.
It was found that vegetables and their processed
products were the main foodstuff sources for nitrate
(88%); Figure 1.
kohlrabi, courgettes, peas, sweet corn as well as root and
tuber vegetables. Potatoes constituted 1/4th of the nitrate
source and beetroots and cabbage were 15% (Figure 2).
Fig. 2.
Fig. 1.
109
Nitrates and nitrites intake in Polish households in 2006-2012
Foodstuff sources of dietary nitrates and nitrites in
households (%)
It was also found, that out of the vegetables listed
above, 1/3 of the nitrate source came from the ‘other
vegetables’ category that included lettuce, leafy and
stem vegetables, cauliflower types, pumpkins, peppers,
Selected vegetables sources of dietary nitrates in
households (%)
Nitrite intakes were significantly different between
the selected household groups (p<0.05); Table 3. Likewise as for nitrates, intakes of nitrites were highest in the
retired persons group at 3.92 mg NaNO2/person/24hours, whilst the lowest were in the pensioners and farmers
group (by 4% and 5% respectively and differences being statistically significant). In all the other household
Table 3. Dietary nitrite intakes in households during 2006-2012
Years
Total
Manual wokers
2006
2007
2008
2009
2010
2011
2012
x
±SD
3.23
3.20
3.18
3.36
3.31
3.31
3.21
3.26
0.07
3.02
3.04
3.02
3.20
3.17
3.17
3.08
3.10a
0.08
Type of household
Non-manual
Self-employed
Farmers
Retired persons
workers
workers
mg NaNO2/per person/day
2.87
3.77
2.88
3.82
2.86
3.74
2.81
3.79
2.85
3.72
2.80
3.80
2.97
3.82
2.93
4.07
2.92
3.76
2.86
4.03
2.92
3.76
2.86
4.03
2.85
3.45
2.82
3.89
2.89b
3.72c
2.85b
3.92d
0.04
0.12
0.05
0.12
Pensioners
3.59
3,61
3.70
3.89
3.87
3.87
3.84
3.77c
0.13
Table 4. Dietary nitrite intakes in households during 2006-12 compared with ADI values in adults
Type of household
Years
Total
Manual
workers
2006
2007
2008
2009
2010
2011
2012
x
±SD
45
44
44
46
46
46
44
45
1
42
42
42
44
44
44
42
43a
1
Non-manual
workers
40
39
39
41
40
40
39
40b
1
Farmers
% of adult ADI
52
52
51
53
52
52
48
51c
2
Self-employed
Retired persons
workers
40
39
39
40
39
39
39
39b
1
53
52
52
56
56
56
54
54d
2
Pensioners
50
50
51
54
53
53
53
52c
2
110
groups (i.e. manual, non-manual workers and the self
employed) nitrite intakes were respectively 21%, 26%
and 27% lower than those for retired persons.
The intake of nitrites in all groups did not exceed the
ADI and varied between 39% of this value for the self
employed to 54% in pensioners; average 45% (Table 4).
Over three quarters of the nitrite foodstuff source
was meat and its processed products (Figure 1), including cold meats and other processed meat products (cold
poultry meat, offal, tinned meat, delicatessen products
and other culinary specialities, e.g. meat in aspic); Figure 3. High quality cold meats and sausages made up
1/5th of the nitrite intake source.
Fig. 3.
Nr 2
A. Anyżewska, A. Wawrzyniak
Meat and meat product sources of dietary nitrites
in households (%)
DISCUSSION
The amount of nitrate and nitrite intakes depends
not only on the original content in foodstuffs, but also
by the method of cooking used and the proportion of
source foods consumed within a given diet [7]. Other
studies have shown very wide variations in nitrate intakes, as for instance between New Zealand and Japan;
72 vs 1545 mg NaNO3/person/24hours, respectively
representing 20% and 500% of the ADI. For nitrite intakes this correspondingly ranged from 0.84 mg NaNO2/
person/24hours in New Zealand to 1.6 mg in Korea;
respectively 14 and 38% of the ADI ) [2, 12, 13].
In Europe, the ranges for nitrate intakes were between 215 and 626 mg NaNO3/person/24hours (respectively
71 and 205% of the ADI), whilst for nitrites from 0.29
to 1.14 mg NaNO2/person/24hours; respectively 5 and
20% of the ADI [4]. Analogous results from Poland,
during 2006-12, were 132 to 190 mg NaNO3/person/24hours and 3.0 to 3.5 mg NaNO2/person/24hours
[15]. The average nitrate intakes within these years were
6% less compared to previous studies, whereas those for
nitrites were 3% higher. Moreover, the current study has
demonstrated twice higher nitrate and nitrite foodstuff
intakes in households compared to those observed in
students aged 21 – 24 years [16].
Within Polish households, the nitrate and nitrite
intakes have not changed over the years and are maintained at safe levels of around half the ADI. It should
however be stressed that certain population groups,
especially children and the elderly, are more vulnerable
to the effects of nitrates/nitrites and their reactant products. In this respect vegetarians are also a susceptible
group, as their main dietary foodstuffs are by definition
vegetables, which constitute a rich source of these nitrates/nitrites, compared to those adopting traditional
diets. It is thereby estimated that nitrate intakes are three
times higher in vegetarians [3, 9, 14].
Excessive nitrite intakes may adversely impact
health such as in causing methaemoglobinaemia. Nevertheless, both they and their products also produce
beneficial effects on the human body such as on the
cardiovascular system, lowering blood pressure and
decreasing erythrocyte adhesion and aggregation [4,
12, 17]. Eating vegetables rich in nitrite also decreases
the oxygen demand during sub-maximal work whilst
consuming leafy vegetables lowers the risk of diabetes
in women [1, 6].
CONCLUSIONS
1. Nitrate and nitrite intakes, during 2006-2012, for
adults living in various types of households were
at appropriate levels of 127 – 198 mg NaNO3 and
2.85 – 3.92 mg NaNO2 /person/24 hours.
2. ADI values for both nitrates and nitrites were not
exceeded in any of the studied types households; the
mean observed intakes were 41 – 45% of the ADI
values.
3. The main dietary source of nitrates was vegetables
and their products (88%), whilst for nitrites these
consisted of cold and processed meats; both at 77%.
4. Observed nitrate and nitrite intakes were at levels
safe for health however their dietary intakes should
nevertheless be monitored because of the adverse
health effects arising when such levels are exceeded.
Acknowledgement
This study was financed by the Department of Human
Nutrition, Faculty of Human Nutrition and Consumer
Sciences, Warsaw University of Life Sciences (SGGW),
Poland
Nr 2
Nitrates and nitrites intake in Polish households in 2006-2012
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14. Traczyk I.: Nitrates and nitrites – occurrence and impact
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to nitrite. Hypertension 2008; 51(3):784-790.
Received:14.10.2013
Accepted:19.02.2014
SCHOOL PUPILS AND UNIVERSITY STUDENTS SURVEYED FOR
DRINKING BEVERAGES CONTAINING CAFFEINE
Magdalena Górnicka*, Jolanta Pierzynowska, Ewelina Kaniewska, Katarzyna Kossakowska,
Agnieszka Woźniak
University of Life Sciences, Warsaw, Poland
ABSTRACT
Background. Caffeine is a commonly found ingredient in many beverages. Its main dietary source is coffee, cola drinks
and in recent years, energy drinks.
Objectives. To compare the consumption of drinks containing caffeine (coffee, colas and energy drinks) and the reasons
and circumstances under which they were drunk by middle school (junior high school) pupils and university students.
Material and methods. Surveyed subjects were 90 middle school pupils from Warsaw and Kutno together with 100 students
attending the Warsaw University of Life Sciences (SGGW). A questionnaire, designed by the authors, was used to determine
the amounts, frequency and the reasons or circumstances in which coffee, colas and energy drinks were consumed. Statistics
used, consisted of the Mann-Whitney U and Chi-square (χ2) tests, with significance taken as α ≤ 0.05.
Results. Cola drinks were found to be the most popularly consumed beverages containing caffeine; 97% pupils and 93%
students. Coffee was however drunk twice less by pupils compared to students, whilst similar amounts of energy drinks
were consumed by both groups; respectively 48% and 53%. Gender differences were observed for the energy drinks with
young men drinking the most. Coffee and energy drink consumption also rose with age by respectively 39% and 57%. The
mean caffeine intake in pupils and students were respectively estimated to be 141 and 163 mg/day(d). The reasons why
these beverages were drunk varied, from drinking coffee to keeping awake and drinking cola because of its good taste.
Pupils also drank energy drinks due to its taste but students because of improved mental performance and in staying awake.
Conclusions. Drinking caffeine containing drinks by adolescents can be very variable and comes from many different
sources. Thus, its intakes may be very high and so require monitoring, particularly for the youngest. Further observational
studies are needed to assess the consumption of energy drinks in relation to physical activity.
Key words: caffeine, intake, school pupils/children, students
STRESZCZENIE
Wprowadzenie. Kofeina jest składnikiem wielu spożywanych napojów. Jej głównym źródłem w diecie jest kawa, napoje
typu cola, a w ostatnich latach dodatkowo napoje energetyzujące.
Cel badań. Celem badania było porównanie ilości i uwarunkowań spożywania napojów zawierających kofeinę (kawy,
napojów typu cola i napojów energetyzujących) przez młodzież gimnazjalną i akademicką.
Materiał i metody. Badaniami objęto 90 uczniów gimnazjum (Warszawa i Kutno) i 100 studentów ze Szkoły Głównej
Gospodarstwa Wiejskiego w Warszawie. Badania zostały przeprowadzone na podstawie autorskiego kwestionariusza, zawierającego pytania dotyczące ilości, częstotliwości i uwarunkowań spożywania kawy, napojów energetyzujących i typu
cola. Uzyskane dane poddano analizie statystycznej za pomocą testu U Manna-Whiteney’a oraz testu Chi2, przyjmując
poziom istotności α ≤ 0,05.
Wyniki. Powszechnie spożywanym napojem zawierającym kofeinę wśród badanej grupy były napoje typu cola, które
spożywało 97% gimnazjalistów i 93% studentów. Spożywanie kawy deklarowało prawie dwukrotnie mniej gimnazjalistów
w porównaniu ze studentami, natomiast napoje energetyzujące spożywał podobny odsetek badanych w obydwu grupach
(48% gimnazjalistów i 53% studentów). Spożywanie napojów energetyzujących zależało od płci, młodzież męska deklarowała częstsze ich spożywanie. Z wiekiem wzrastało spożycie kawy (o 39%) i napojów energetyzujących (o 57%). Średnie
spożycie kofeiny oszacowano w grupie gimnazjalnej na poziomie 141 mg/d, a w grupie studentów na poziomie 163 mg/d.
Uwarunkowania spożywania napojów zawierających kofeinę różniły się dla poszczególnych ich rodzajów: kawę spożywano
*Corresponding author: Magdalena Górnicka, Chair of Nutritional Assessment, Department of Human Nutrition,
Faculty of Human Nutrition and Consumer Sciences, University of Life Sciences, Nowoursynowska 159c, 02-776 Warsaw,
phone +48 22 5937122, e-mail: magdalena_gornicka@sggw.pl
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M. Górnicka, J. Pierzynowska, E. Kaniewska et al.
Nr 2
głównie dla zwalczenia senności, napoje typu cola ze względu na smak. Gimnazjaliści spożywali napoje energetyzujące ze
względu na smak, a studenci celem poprawy sprawności umysłowej i zwalczenia senności.
Wnioski. Spożywanie napojów zawierających kofeinę wśród młodzieży, z uwagi na fakt, iż zawartość w nich kofeiny
może być znacznie zróżnicowana, a łączne dostarczanie jej z różnymi produktami, może powodować znacznie wyższe jej
pobranie, wymaga monitorowania, zwłaszcza w młodszych grupach wiekowych. Dalszych badań wymaga zaobserwowana
zależność spożywania napojów energetyzujących w związku z wysiłkiem fizycznym.
Słowa kluczowe: kofeina, spożycie, gimnazjaliści, studenci
INTRODUCTION
blood glucose through stimulating adrenal hormones
that may lead to type II diabetes [5]. Sweetened fizzy
Caffeine is an alkaloid, naturally occurring in coffee drinks, such as colas or energy drinks, contribute tobeans, tea leaves, cola nuts, Yerba-mate leaves, cocoa wards the development of overweight and obesity due
beans and guarana seeds. Its main source of intake is to their high sugars’ content [2].
A study by Temple [18] has stressed that caffeine,
through drinking infusions of coffee, tea or cocoa. An
like
sugar, may activate the dopaminergic-reward
extract from cola nuts is used in the many cola drinks,
however synthetic caffeine is added to energy drinks system and thence lead to addiction. Their joint con[19]. Caffeine is also added to some foodstuffs and me- sumption in foodstuffs and beverages synergistically
dicines. Modest intakes of caffeine (i.e. 200 – 300 mg) increases dopamine release and as a result their effects
are beneficial to health through being a stimulant of the become potentiated, which, in the long term, during
central nervous system (CNS), muscle activity, heart and a critical stages of individual’s development are not
kidneys. It also increases mental processes/performance clearly understood. During childhood and adolescence,
and decreases fatigue and tension in smooth muscles the brain undergoes intensive development, especially
of the vasculature [4]. A safe level of daily caffeine those centres responsible for performance, planning and
intake is regarded as one not exceeding 400 mg [23]. emotional control, where frequent caffeine consumption
Excessive daily intakes above 400 mg may however by these groups may have adverse health impacts.
Additionally, energy drinks can contain ingredients
cause agitation, sleep disturbances, anxiety, irritability,
such
as guarana, taurine, inositol, group B vitamins,
nervousness [8, 21], as well as insulin resistance [6]. A
glucuronolactone
and others which enhance the action
regular, long-term and excessive caffeine intake may
lead to an addiction and adverse health consequences of caffeine [5]. Because of their composition, energy
[10]. A toxic dose of caffeine is difficult to precisely drinks should not be given to children nor adolescents
define as the literature reports wide variation between below 16 years, however in many countries, including
Poland, they are readily available [5, 8]. Nevertheless,
0.5 to 1.5 g for a healthy individual [23].
Children and adolescents widely consume many drinks are generally popular in these age groups. In
caffeine containing foodstuff products. Because the the USA it is estimated that children aged 2 – 5 years
effects of caffeine on their development and health consume 16 mg/d caffeine, those aged 6 – 11 years 26
are relatively unknown, surveillance of caffeine intake mg/d and 59 – 80 mg/d for ages above 11 years. As
levels becomes necessary. Due to the child’s nervous pointed out by Wierzejska [23], these surveys were
system being in growth and developmental stages, it is undertaken in the 1990s of the previous century, based
supposed that the effects of caffeine are different when on food interviews, when foodstuff products had much
compared to adults. In addition, as children are buil- less caffeine. For Polish children, there is a dearth of
ding up their bone mass, drinking caffeine containing data on this topic. For this reason, the presented study
beverages when coupled to any calcium deficiencies is therefore focused on comparing the amounts and
reasons/circumstances for consuming drinks containing
will decrease bone mass density [19, 23].
Only in Canada, have maximum daily intakes of caffeine (coffee, colas and energy drinks) in middle
caffeine been established for children aged below 12 school pupils and university students.
years at < 2.5 mg/kg body mass/d [23]. Other recommendations for children aged 4 – 12 years state safe
doses of 45 – 85 mg/d [20] and for adolescents up to 18
years at < 100 mg/d [16]. Children and adolescents most
The study was conducted on 90 pupils attending
often consume caffeine with sugar as from colas and
middle school at Warsaw and Kutno and 100 students
energy drinks. This is detrimental as it very likely leads
of the Warsaw University of Life Sciences in 2011-12,
to having a predilection for sweet tasting foodstuffs.
which had been preceded by a pilot study. A proprietary
Furthermore, another effect of caffeine is to increase
Nr 2
questionnaire was used to assess the consumption of
coffee, colas and energy drinks together with questions
on age, gender, height, body mass and the amounts,
circumstances/reasons why these drinks had been consumed – Table 3. The relevant features of the subject
groups are shown in Table 1.
The mean intakes of caffeine for both groups were
estimated from taking the average contents of caffeine
in coffee, colas and sweet drinks as respectively being;
60 mg/100 ml, 11 mg/100 ml and 32 mg/100 ml. To determine what effect age and gender has, the quantitative
data were analysed by the Mann-Whitney U-test whilst
the χ2 test was used to analyse the qualitative data using
the SPSS statistical software package. Significance was
taken as α=0.05.
RESULTS
Both groups had similar gender proportions. The
mean ages of middle school pupils was 15 years and 23
years for university students. The BMI was at normal
levels in both groups and did not differ significantly
(Table 1).
Table 1. Characteristics of the study groups
Group
pupils
n=90
students
n=100
115
Consumption of beverages containing caffeine by school pupils and students
Gender
F M
Age
(years )
Body
mass (kg)
Height
(cm)
BMI
(kg/m2)
46 44
15 ± 1
62 ± 9
173 ± 15
21 ± 3
50 50
23 ± 2
68 ± 11
173 ± 13
23 ± 2
F – females, M – males
The consumption of cola was found to be particularly popular in pupils and students, however drinking
coffee was significantly (p=0.02) more popular with
students than pupils (88% vs 51%). There were no
age differences in consuming colas and energy drinks.
Differences between genders were observed, in that
males more frequently (p=0.01) drank energy drinks
than females; this being true in both groups (respectively p=0.03 and p=0.001). Females from middle school
however, drank more coffee (p=0.02); Table 2.
The highest numbers of drinks consumed containing
caffeine were colas (average of 3 litres per week), where
pupils drank 33% more than students; Table 3. The older
student subjects significantly drank more energy drinks
than pupils (by 57%; p=0.04). Female students drank
more colas compared to males (p=0.01), whilst male
pupils drank more energy drinks than females (p=0.02).
The mean caffeine intakes were 141 mg/person/d
(pupils) and 163 mg/person/d (students). Significantly
higher mean caffeine intakes were observed in males;
p=0.04, Table 3. The main source of caffeine were coffee and colas, however energy drinks only contributed
10 – 20% of the caffeine consumption. The reasons for
consuming caffeine containing beverages varied according to category; Table 4. Coffee was mostly drunk to
prevent sleepiness and in students to improve mental
alertness (92%) and well-being (83%). Meantime, colas were drank because they tasted good and quenched
thirst. Pupils drank energy drinks mainly due to them
being tasty (65%) and 51% did so to increase physical
efficiency. Students however drank energy drinks to
improve their mental process function ie. performance
(68%) and for keeping awake (65%); Table 4. Most sub-
Table 2. Consumption of caffeine-containing beverages (%) in studied groups
Beverages
Coffee
Colas
Energy drinks
1
Subjects
pupils
n=90
51
97
48
students
n=100
88
93
53
p1
0.02
NS
NS
F
n = 96
74
94
34
M
p1
n= 94
67
NS
96
NS
67
0.01
F
n=46
63
98
36
Pupils
M
n=44
38
96
59
p1
0,02
NS
0.03
F
n=50
84
90
32
Students
M
p1
n=50
92
NS
95
NS
74
0.001
Chi2 test results, F– females, M – males, NS – statistically insignificant differences
Table 3. Average intake of caffeine-containing beverages (ml/week) and estimated average caffeine intake (mg/d) in groups
Subjects
Beverage
Pupils
Students
p1
Pupils
F
M
p1
F
M
Students
p1
F
M
p1
N = 46
N = 88
N= 74
N= 63
N=29
N=17
N=42
N=46
752±323 1044±415 NS 912±405 884±336 NS 844±350
660±399 NS 980±360 1108±470 NS
N = 87
N = 93
N=90
N=90
N=45
N=42
N=45
N=48
Colas
3666±1184 2750±1024 NS 2494±990 3922±1108 NS 3394±1074 3938±1054 NS 1594±894 3906±1157 0.01
Energy
N = 43
N = 53
N=33
N=63
N=17
N=26
N=16
N=37
419±192
656±103
0.04
384±202
692±252
NS
255±199
584±171
0,02
512±125
800±158
NS
drinks
Caffeine
141±57
163±61 NS 134±48
170±59 0.04 137±58
146±62
NS 132±49
193±67 0.03
Coffee
1
Mann-Whitney U test results, F – Females, M – Males, NS – Statistically insignificant differences
116
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M. Górnicka, J. Pierzynowska, E. Kaniewska et al.
Table 4. Determinants of caffeine-containing drinks intake (% responses) for middle school pupils and university student
subjects
Reasons and circumstances for
drinks’ intake*
Reasons
Keeping awake
Taste
Thirst quenching
Improved mood
Improved mental alertness
Increased physical efficiency
Circumstances
During studying
On social occasions
During/after physical exertion
Coffee
Colas
Energy drinks
Pupils
Students
n=43
n=53
Pupils
n=46
Students
n=88
Pupils
n=87
Students
n=93
74
60
11
28
5
5
85
78
2
82
92
15
7
85
53
39
10
4
2
90
65
20
20
20
10
65
23
33
33
51
65
24
19
26
68
25
55
40
11
89
75
7
31
65
14
30
78
59
23
30
60
50
18
17
*Several replies could be given (values do not add up to 100)
jects also declared that the circumstances for drinking
coffee (i.e. caffeine containing beverage) was during
studying and social occasions (58%). Colas were drank
most often socially but in students also after physical
exertion (59%). Pupils drank energy drinks mostly to
do with physical exercise (60%), whilst 50% students
did so during study.
DISCUSSION
Caffeine containing products are consumed at all
ages, resulting from their availability, popularity and
stimulating effect, and are widely enjoyed even by
younger population groups. Children and adolescents
are however most vulnerable to the adverse effects of
caffeine because of their still developing metabolism
and nervous system [19]. The risk of untoward effects
on a developing individual increases when coupled to
raised caffeine intakes from various sources [18, 20, 23].
The current study demonstrates that drinking caffeine containing beverages is widespread irrespective
of age and does not differ between the two age groups
studied. Studies by Wierzbicka et al. [22] on women,
Bartosiuk et al. [3] on female students and Semeniuk
[17] on students indicated that energy drinks are becoming increasingly popular. According to Kopacz et al.
[12], over half of the student subjects consumed energy
drinks, with consumption significantly rising during
examination periods. The presented study however
showed that cola was the most popular.
Significant gender differences were observed in
especially energy drink consumption. These findings
agree with studies by Attele and Cakir [1] and Wanat
and Woźniak-Holecka [19] which reported that males
drank more energy drinks than females. Caffeine intakes rose with age, particularly from coffee and energy
drinks, consistent with the aforementioned Wanat and
Woźniak-Holecka [19] study on high school pupils and
university students that found that the latter drank more
coffee than the former.
In children and adolescents, caffeine intake should
not exceed 100 mg/d [16], but in the middle school pupils this value was 141 mg which did not differ with the
students (i.e. adults). These estimations were somewhat
lower than results reported by Wanat and Woźniak-Holecka [19] or Wierzbicka et al. [22]; at respectively
196 – 241 mg/d and 251 mg/d, but the caffeine sources
were not accounted for. Furthermore, these estimations
were given as mean caffeine intakes, where the ranges
may have shown wide variations. The amount of caffeine in coffee depend on the coffee type and method
of preparing the drink. For energy drinks there are no
legal regulations and established limits, which results
in wildly fluctuating caffeine levels in many varieties of
products where added caffeine is ever increasing [23].
The main grounds for consuming caffeine in drinks
was to improve well-being so that sleepiness could be
prevented and that intellectual or physical performance
be enhanced. These were likewise found in other studies
[1, 11, 14, 17]. Energy drinks were drunk more due to
physical exercise in pupils which concurs with studies
by Łagowska et al. [13] and Malinauskas et al. [14],
which showed that they are mostly drunk for increasing
physical and mental efficiency. Similarly, Bajerska et
al. [2] found that adolescents engaged in sport are twice
more likely to drink energy drinks compared to their
peers undertaking lower levels of physical activity.
This requires further studies. Energy drinks can cause
much harm and even lead to caffeine poisoning. They
are perceived by young consumers as being drinks that
have a cool image and intensive advertising campaigns
are launched to popularise these products as increasing
physical-mental endurance and efficiency without having any ill effects on health [5]. The problem is that
there are no restrictions on the sale of these products to
Nr 2
Consumption of beverages containing caffeine by school pupils and students
children and adolescents who have lower tolerances to
caffeine [15]. An 2013 EFSA (European Food Standards
Agency), report indicated that 68% teenagers (aged 10
– 18 years) consume energy drinks, of whom 12% do
so at rates of 7 litres per month.
In conclusion, the study has demonstrated that the
popular consumption of such beverages may lead to an
excess caffeine intake in middle school pupils which
does not differ from their older student counterparts
i.e. in effect adults.
CONCLUSIONS
1. For adolescents, the consumption of beverages
containing caffeine may lead to excessive intakes
because of the wide variations in product content.
This requires monitoring, particularly for the more
vulnerable, younger age groups.
2. Further studies are needed to assess the observed
relation between energy drinks and undertaken
physical activity.
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studentek Uniwersytetu Medycznego w Białymstoku.
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w wybranych napojach kawowych w proszku. Bromat
Chem Toksykol 2009;3:426-430.
5. Cichocki M.: Napoje energetyzujące – współczesne
zagrożenia zdrowotne dzieci i młodzieży. Przeg Lek
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6. Dworzański W., Opielak G., Burdan F.: Niepożądane
działania kofeiny. Pol Merk Lek 2009;161:357-361.
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press/news/130306.htm (10.09.2013)
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9. Gunja N., Brown J.: Energy drinks: health risks and
toxicity. Med J Aust 2012;196:46-51.
10. Jarosz M., Wierzejska R., Mojska H., Świderska K., Siuba M.: Zawartość kofeiny w produktach spożywczych.
Bromat Chem Toksykol 2009;3:776-781.
11. Kopacz A., Wawrzyniak A., Hamułka J., Górnicka M.:
Studies on the determinants of energy in drinks intake
by students. Rocz Panstw Zakl Hig 2012;63(4):491-497
(in Polish).
12. Kopacz A., Wawrzyniak A., Hamułka J., Górnicka M.:
Evaluation of energy drink intake in selected student
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Polish).
13. Łagowska K., Woźniewicz M., Jeszka J., Posłuszny M.:
Ocena częstotliwości spożycia produktów, potraw i
napojów o wysokiej wartości energetycznej przez młodzież szkolną o różnym poziomie aktywności fizycznej.
Zeszyty Nauk Wielkopol Wyż Szk Turyst Zarządz w
Poznaniu 2011;6:91-99.
14. Malinauskas B.M., Aeby V.G., Overton R.F., CarpenterAeby T., Barber- Heidal K.: A survey of energy drink
consumption patterns among college students. Nutrition
J 2007;6:35-38.
15. Reissig C. J., Strain E. C., Griffiths R. R.: Caffeinated
energy drinks – a growing problem. Drug Alcohol Depend 2009;99:1-10.
16. Seifert S.M., Schaechter J.L., Hershorin E.R., Lipshultz
S.E.: Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011;127:511-528.
17. Semeniuk W.: Spożywanie napojów energetyzujących
wśród studentów Uniwersytetu Przyrodniczego w Lublinie. Probl Hig Epidemiol 2011;92:936-939.
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Neurosci Behav Rev 2009;33:793-806.
19. Wanat G., Woźniak-Holecka J.: Ocena konsumpcji
produktów zawierających kofeinę wśród młodzieży akademickiej i licealnej. Probl Hig Epidemiol 2011;92:695699.
20. Warzak W.J., Evans S., Floress M.T., Gross A.C., Stoolman S.: Caffeine consumption in young children. J
Pediatr 2011;158:508-509.
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N.D., Axelson D.A., Birmaher B., Dahl R.E.: Caffeine
consumption, sleep and affects in the natural environments of depressed youth and healthy control. J Pediat
Psychol 2008;33:358-367.
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spożycia kofeiny z całodzienną racją pokarmową w
wybranej grupie dorosłych kobiet. Probl Hig Epidemiol
2010;91:564-571.
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and its influence on human health. Rocz Panstw Zakl
Hig 2012;63(2):141-147 (in Polish).
THE USE OF VITAMIN SUPPLEMENTS AMONG ADULTS IN WARSAW:
IS THERE ANY NUTRITIONAL BENEFIT?
Anna Waśkiewicz 1*, Elżbieta Sygnowska 1, Grażyna Broda 1 , Zofia Chwojnowska 2
Department of CVD Epidemiology, Prevention and Health Promotion, Institute of Cardiology, Warsaw, Poland
Independent Unit of Nutritional Epidemiology and Dietary Recommended Intakes, National Food and Nutrition
Institute, Warsaw, Poland
1
2
ABSTRACT
Background. The use of dietary supplements is widespread and can contribute substantially to total nutrient intake. However,
it also generates some potential risks in the case of unreasonable and excessive use of such products.
Objective. To estimate the prevalence of supplementation and the vitamin supplement contribution to total intake among
Warsaw population aged 20-74 years.
Material and methods. Nutrient intake and supplement use were studied in a representative sample of Warsaw population
in years 2011/12 (486 men and 421 women) and in 2001 (658 and 671 respectively). The vitamin levels were analyzed in
reference to the Recommended Dietary Allowance (RDA) and the tolerable upper intake level (UL).
Results. In the years 2011/12 the use of dietary supplements (vitamins and minerals) was reported by 31% men and 40%
women. Vitamin intake from food showed the deficiency of vitamins D, B1 and folates and adequate intake of vitamins A,
C, E, B2, B6, B12. Supplementing with vitamins D and B1 as well as folic acid contributed to better RDA fulfillment. Supplementing with vitamins A, C, E, B2, B6 and B12 was not justified because these vitamins were taken in sufficient amounts
with food. In 1.3%-14.9% supplement users, the total intake of vitamins A, C, E and B6 exceeded the UL. The prevalence
of supplementation of vitamins A, C and E did not change between 2001 and 2011/12, but the total intake of vitamin A in
both sexes and vitamins C, E in women was significantly higher in 2001.
Conclusions. The use of dietary supplements in Warsaw population was widespread and in case of some vitamins- unreasonable.
Key words: vitamin supplements, vitamin intake, adult population, recommended dietary allowances, tolerable upper
intake level
STRESZCZENIE
Wprowadzenie. Przyjmowanie suplementów diety jest popularne i może stanowić istotne źródło witamin i składników
mineralnych. Jednocześnie niekontrolowane ich pobranie może stwarzać niebezpieczeństwo nadmiernego spożycia.
Cel badań. Ustalenie rozpowszechnienia i zasadności stosowania suplementacji wśród mieszkańców Warszawy w wieku
20-74 lat.
Materiał i metody. Sposób żywienia oraz przyjmowanie suplementów oceniono w reprezentatywnej próbie populacji Warszawy w roku 2011/12 (u 486 mężczyzn i 421 kobiet) oraz w roku 2001 (u odpowiednio 658 i 671 osób). Pobranie witamin
analizowano w odniesieniu do zalecanego dziennego spożycia (RDA) oraz górnych bezpiecznych poziomów spożycia (UL).
Wyniki. W latach 2011/2012 suplementy witaminowo-mineralne przyjmowało 31% mężczyzn i 40% kobiet. Spożycie
witamin z żywnością było niedoborowe w przypadku witamin D, B1 i folianów oraz zgodne z zaleceniami dla witamin
A, C, E, B2, B6, B12. Suplementacja witaminami D i B1 oraz kwasem foliowym przyczyniła się do lepszej realizacji RDA.
Natomiast uzupełnianie diety witaminami A, C, E, B2, B6 oraz B12 nie miało uzasadnienia, ze względu na wystarczające ich
spożycie z żywnością. W przypadku 1,3%-14,9% osób stosujących suplementy witamin A, C, E, i B6 notowano przekroczenie poziomów UL. Częstość przyjmowania suplementów witamin A, C i E była podobna w latach 2001 i 2011/12, ale
sumaryczne pobranie witaminy A u obu płci oraz C, E u kobiet było istotnie wyższe w roku 2001.
Wnioski. Wzbogacanie diety suplementami przez mieszkańców Warszawy było szeroko rozpowszechnione, a w przypadku
niektórych witamin nieuzasadnione.
Słowa kluczowe: suplementy witamin, spożycie witamin, dorosła populacja, zalecane spożycie, górny bezpieczny poziom
spożycia
*Corresponding author: Anna Waśkiewicz, Department of CVD Epidemiology, Prevention and Health Promotion,
Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland, Alpejska 42 04-628 Warsaw,
Tel.: 48 22 8156556; Fax: 48 22 8125586, e-mail: awaskiewicz@ikard.pl
120
A.Waśkiewicz, E. Sygnowska, G. Broda et al.
INTRODUCTION
If a human organism is to function correctly, it also
needs vitamins, most of which it cannot synthesize on
its own. Some of them, particularly antioxidants, i.e.
vitamins A, C, E and B group (including folates), play
an important role in the prevention of chronic diseases,
including cardiovascular diseases [10, 13, 14].
It must be stressed that vitamin intake should be
supplied by a healthy diet, not by using supplements.
Yet it turns out insufficient in numerous situations, such
as using low energy diets or such stimulants as tobacco
or alcohol, as well as in women in childbearing age. On
the one hand, dietary supplements can play a significant
role in lowering the risk of the vitamin deficiency; on
the other hand, their uncontrolled consumption may
result in crossing the thresholds of the tolerable upper
intake level [6]. Since the dietary supplements have
become popular, they should be considered as a source
of vitamins and dietary minerals while evaluating the
dietary patterns [22, 23].
It should be emphasised that no current studies
regarding the supplementation that would include a
representative group of all adult individuals in central
Poland have been conducted recently. The results of
our project based on standardised methods allowed the
evaluation of the discussed issues in the population of
Warsaw.
The aim of the study was to estimate the patterns of
supplementation and to evaluate the vitamin supplement
contribution to the total intake among Warsaw adult
population.
Subjects and study design
The material for the analysis comprised the data
from the European Health Examination Survey–Joint
Action (Polish part) - EHES-JA and from the Warsaw
Health Survey – WAW-KARD, which was a continuation of the EHES project [7, 16]. The objective of
both projects, performed in 2011/12, was to assess
the health condition of Warsaw’s inhabitants in terms
of risks leading to the development of cardiovascular
and some other chronic diseases. The study included a
representative randomized sample of the whole of Warsaw’s population aged 20 years and above – there were
1081 people examined. The operator of randomization
was the PESEL system (PESEL – Universal Electronic
System for Registration of the Population). The sample randomization scheme was a one-step scheme – a
simple sample stratified in terms of sex and place of
residence (department of Warsaw). In accordance with
Nr 2
the international recommendations on epidemiological
studies, a profile of classic risk factors for developing
chronic diseases was assessed in all subjects, based on
questionnaire, laboratory, anthropometric, blood pressure measurement findings and on subjects’ dietary habits.
Dietary patterns and supplement intake were assessed using the 24-hour recall method, in which respondent provides all the products, food and beverages
consumed within 24-h before recall. Due to its advantages (low costs, possibility to standardize, a short time
of interviewing and no impact on dietary habits) 24-h
recall method is commonly used in epidemiological
studies. Portion sizes of food consumed was determined
based on the album with photographs of more than 200
foodstuffs prepared specifically for this type of research
by the National Food and Nutrition Institute (NFNI)
(Instytut Żywności i Żywienia). Subjects were asked if
they had taken any form of dietary supplement on the
recall day and the supplement type, name brand, and
dose were recorded. The vitamin intake in the diet was
calculated based on the amount of food consumed, with
the use of “Polish Food Composition Tables”, including
vitamin losses arising during the technological processes of food preparation [15]. The amount of vitamin
derived from supplementation was estimated using the
NFNI 4D Diet (IŻŻ Dieta 4D) software, that includes a
database nutrient pharmaceutical formulations in 1231
supplements, available on the Polish market.
The 2001-year data were obtained from the Pol-MONICA bis study, which covered a representative
sample of the right-bank Warsaw’s population aged
20-74 years – 679 men and 691 women. Details regarding study were published previously [28]. Their
dietary patterns and supplement intake (only vitamins
A, C and E, calcium and magnesium) were assessed in
the same way as it was done in the EHES and WAW-KARD projects.
The analyses included the data on 486 men and 421
women from the EHES and WAW-KARD studies, and
658 men and 671 women from the Pol-MONICA study;
who were aged 20-74 years, and whose dietary data were
reliable.The vitamin levels were analyzed in reference
to the Recommended Dietary Allowance (RDA) [13]
and the tolerable upper intake level (UL) [6].
Statistical methods
The statistical analyses were performed with the
Statistical Analysis System (SAS) 9.2 program using
an analysis of covariance (GLM-procedure) and chi2
test (FREQ-procedure) to compare mean values or
prevalence of the analyzed factors. The methods of
descriptive statistics were employed, the percentage
of subjects taking supplements and the mean vitamin
intake from food and from supplements were calculated.
Nr 2
121
Vitamin supplements use among adults in Warsaw
RESULTS
Table 1. Prevalence of vitamin/minerals supplementation use
in adult Warsaw population in years 2011/12 (%)
Dietary supplementation prevalence
Adult Warsaw’s inhabitants supplemented their
diets with vitamins and minerals quite prevalently. It
was more popular among women (40%) than among
men (31%). The decision to take such supplementation
was most popular among single. The supplementation
prevalence was influenced by the subjects’ educational
and income status – those with higher education supplemented their diet more often than those with primary
education (1.6 times men and around 4.8 times women).
The highest supplementation intake was noted among
people of the highest income (Table 1).
Doses of supplemental vitamins (among supplement
users of a selected nutrients)
In supplement users, the mean vitamin intake only
from this source (excluding food) exceeded the RDA
(except for folates). Depending on the vitamin, the
actual intake ranged from 130% to 440% of the RDA.
Using vitamin doses higher than UL was reported by
1.3%-4,5% of respondents in the case of vitamins A, E
and B6 (Table 2).
Men
31.3
Women
40.0
31.1
28.5 (ns)*
31.9
40.0
37.4 (ns)*
48.2
21.6
27.2
35.5
9.9
30.3
47.7
29.3
34.3
34.2
45.9
19.5
18.8
35.1
38.2
23.6
33.6
41.1
45.1
Supplement users
Age
20-40 years
40-60 years
60-74 years
Education **
primary
secondary
university
Marital status **
married
single
Net income per capita in the
family/month**
<1000 PLN
1001-2000 PLN
2001-3000 PLN
>3000 PLN
* - comparison of prevalence of supplementation use between age
groups (test chi2)
**- value standardized for age structure in Warsaw population for
30 June 2011
Vitamin intake in daily food ration
The analysis of the vitamin intake from food, both
in the group of supplement users and that of nonusers,
showed the deficiency of vitamins D, B1 and folates. The
Table 2. Vitamin intake from supplements (among supplement users of a selected nutrient) in relation to Recommended
Dietary Allowance (RDA) and the tolerable upper intake level (UL) in Warsaw population in years 2011/12
Vitamins
Suplement users
number (percentage)
Vitamin A (μg)
Vitamin C (mg)
Vitamin E (mg)
54 (12.4%)
73 (16.9%)
65 (15.6%)
Vitamin D (μg)
37 (9.0%)
Vitamin B1 (mg)
Vitamin B2 (mg)
50 (12.4%)
50 (12.4%)
Vitamin B6 (mg)
80 (18.0%)
Vitamin B12 (μg)
Folate (μg)
30 (7.2%)
31 (7.9%)
Vitamin A (μg)
Vitamin C (mg)
Vitamin E (mg)
67 (16.0%)
83 (19.4%)
70 (15.8%)
Vitamin D (μg)
58 (12.7%)
Vitamin B1 (mg)
Vitamin B2 (mg)
50 (12.2%)
52 (12.6%)
Vitamin B6 (mg)
88 (20.5%)
RDA
Men
900
90
10
5-15
(5)1
1.3
1.3
1.3-1.7
(1.5)1
2.4
400
Women
700
75
8
5-15
(5)1
1.1
1.1
1.3-1.5
(1.4)1
2.4
400
Mean intake
% RDA
UL
Subjects with intakes
exceeding UL (%)
130
133
236
3000
1000
300
3.7
0
1.5
197
50
0
265
217
-
-
281
25
1.3
330
74
10002
0
137
166
348
3000
1000
300
4.5
0
2.9
151
50
0
137
153
-
-
440
25
3.4
10002
0
Vitamin B12 (μg)
24 (5.8%)
193
Folate (μg)
28 (8.0%)
73
1
- values in brackets assumed as RDA
2
- UL for folic acid ref. only to folic acid supplements (without folate in food)
122
Nr 2
Table 3. Vitamin intake from food and from supplements in daily diets among supplement nonusers and users in Warsaw
population in years 2011/12
Supplement nonusers
Average intake
% RDA
from food
Vitamins
Vitamin A (μg)
Vitamin C (mg)
Vitamin E (mg)
Vitamin D (μg)
Vitamin B1 (mg)
Vitamin B2 (mg)
Vitamin B6 (mg)
Vitamin B12 (μg)
Folate (μg)
1063±1784
86.4±78.5
11.2±6.6
4.1±5.4
1.27±0.62
1.54±0.76
1.79±0.78
4.08±6.17
252±126
118
96
112
82
98
118
119
170
63
Vitamin A (μg)
Vitamin C (mg)
Vitamin E (mg)
Vitamin D (μg)
Vitamin B1 (mg)
Vitamin B2 (mg)
Vitamin B6 (mg)
Vitamin B12 (μg)
Folate (μg)
1013±1634
90.2±92.1
8.4±5.3
3.0±4.3
0.88±0.41
1.30±0.62
1.42±0.63
3.56±6.31
225±124
144
150
105
60
80
118
101
148
56
from food
Men
1335±1573
105.1±98.6
12.8±6.3
4.0±5.8
1.29±0.62
1.70±0.80
2.02±0.91
4.81±9.34
328±213
Women
1224±1918
73.0±55.8
8.5±4.9
2.0±1.6
0.80±0.31
1.29±0.75
1.36±0.47
3.87±2.68
197±64
intake of other vitamins was within the RDA (except
for vitamin C in a group of men who did not use supplementation) (Table 3).
Supplementation effectiveness
Supplementing the diet with vitamins D, B1 and folic
acid was justifiable because it eliminated the deficiency
of these nutrients in the diet.
In the case of other vitamins, i.e. A, C, E, B2, B6, B12,
their supplementation was not necessary because their
Supplement users
Average intake
from supplements
total
% RDA
>UL
1170±1788
119.8±98.6
23.5±53.6
9.8±6.8
3.44±4.25
2.82±4.20
4.21±3.81
7.92±17.9
297±233
2505±2263
224.9±151.6
36.3±54.1
13.8±8.2
4.73±4.22
4.52±4.15
6.23±3.74
12.73±19.9
625±311
278
250
363
276
363
348
415
530
156
8.3
0
1.5
0
1.3
0
1234±2259
124.5±166.0
34.7±89.1
7.6±6.9
1.78±1.25
1.99±1.62
6.60±12.86
4.64±5.38
293±172
2458±3114
197.5±174.0
43.2±90.0
9.6±7.4
2.58±1.26
3.28±1.63
7.96±12.88
8.51±6.42
490±189
351
263
540
192
235
300
569
354
122
14.9
2.4
2.9
0
3.4
0
mean intake with food was sufficient to meet the RDA.
The total intake (from food and from supplements) of
vitamins mentioned above exceeded RDA within 250%570%. With vitamins A, E, B6 in both sexes and vitamin
C in women, UL levels were exceeded (Table 3).
Supplementation in 2011/12 in comparison to that in 2001
The prevalence of supplementation with vitamins
A, C and E did not change between 2001 and 2011/12.
(Figure 1). However, in the years 2011/12 the realization
%
25
men
women
19,4
20
16,1
17,1
16,9
16,0 16,0
15,6
15,4
15,8
15
10,9
12,6
12,4
10
5
0
vitamin A
vitamin C
vitamin E
vitamin A
2001
vitamin C
2011/12
Figure 1. Prevalence of selected vitamin supplements used in 2001 and 2011/12
Figure 1. Prevalence of selected vitamin supplements used in 2001 and 2011/12
vitamin E
nonparametric test Wilcoxon
Nr 2
123
% RDA
1100
men
1000
women
**
997
**
900
844
800
700
600
500
400
300
540
418
**
405
363
277
351
297
340
**
263
250
200
100
0
vitamin A
vitamin C
vitamin E
vitamin A
2001
2011/12
vitamin C
vitamin E
nonparametric test Wilcoxon
** p < 0.001
Figure
2. Total vitamin
in relation to
among
supplement
users of a selected
2001 and 2011/12
Figure 2. Total
vitamin
intakeintake
in relation
toRDAs
RDAs
among
supplement
usersnutrient
of a inselected
nutrient in 2001 and 2011/12
of RDA for vitamin A in both sexes and vitamins C, E
in women was significantly lower than in 2001 (Figure
2). In 2001, the rate of adherence to recommendation for
vitamins A and E in women was very high, and reached
844% and 997%, respectively.
DISCUSSION
The results of the present study show that enriching
a nutritional ration with dietary supplements was more
popular among the inhabitants of Warsaw (31% - men
and 40% - women) than in the population of the whole
of Poland. The findings of the study performed by NFNI
in Polish households showed that supplementation was
used by 20% of all people [25]; in the WOBASZ study,
which included a representative randomized sample
of the Polish population, dietary supplements were
consumed by 4.6% of men and 11.3% of women [24].
Among the elderly Warsaw dwellers with cardiovascular diseases, vitamin and mineral supplementation was
declared by 66.3% [26]. In other countries the frequency
of supplementation was very varied, e.g. in the US representative group of adults it was 54% [2] and in the
group of German women – 40%, men – 33% [21]. The
studies carried out by Flynn et al [8] on minerals and
vitamins taken with food and supplements by adults in
selected European countries showed that the percentage
of people taking supplementation was as follows: Finland 32% men and 58% women, Germany respectively
38% and 48%; Ireland 16%, 31%; the Netherlands 21%,
33%; Spain 8%, 10%; UK 29% and 40%.
The frequency of supplementation is dependent on
many factors, including socioeconomic ones. Both in
our study and in other projects, supplementing the diet
was more prevalent among women, elderly, single and
those of higher socioeconomic status [2]. Of note is the
fact that the discrepancy of methods applied to evaluate
the supplementation, especially the period covered by
the study, creates serious difficulties for making direct
comparisons. Our study included only the people who
took supplements during the day preceding the test;
in other studies the questions about supplementation
referred to the period ranging from one day to one year.
Additionally, some studies qualified only vitamins and
minerals as supplements, others also included herbal
supplements.
The precondition of effective supplementation is
taking such amounts of particular vitamins from pharmaceuticals that their deficiency is leveled, preferably
to the values recommended for daily intake in the diet.
The safe zone for nutrients intake lies between the recommended value and the tolerable upper intake level
(UL). The threat arises when the total vitamin intake,
both from food and supplements, exceeds UL.
In Warsaw’s population, the amount of vitamins
from supplementation (except for folic acid) covered
over 100% (130% – 440% range) of their daily recommendation; in the case of vitamins A, E and B6, UL was
exceeded (in 1.3% - 4.5% of respondents). An analysis
of dietary supplements examined by the Polish National
Food and Nutrition Institute showed that the daily vitamin doses in particular preparations (except for niacin)
did not exceed UL [22]. It means that at least part of
124
Warsaw’s inhabitants took a few preparations at a time
or more than one daily dose.
If only the vitamins taken with food were included
in the analysis, Warsaw’s inhabitants, both those taking
supplementation and those who did not, suffered from
significant deficiency of vitamin D, folates and, to a
lesser extent, vitamin B1. Many authors point out the
fact of universally present subclinical vitamin D deficiency both in Poland and in other countries [8, 17, 18].
The groups particularly prone to insufficient vitamin D
intake are vegans and people who eliminate any dairy
from their diet, postmenopausal women, in whom low
estrogen concentration is associated with bone mass
loss, and also elderly people [13].
A similar problem was observed with folates, which
are taken in insufficient amounts both in Poland [12, 27]
and in other European countries [5, 8]. Mandatory folic
acid fortification can be effective as shown by examples
from the US [1] and Northern Ireland [11].
Especially women in childbearing age should have
their diet supplemented with appropriate amounts of
folic acid in order to diminish the likelihood of neural
tube developmental defects and other neurological
malformations in the child. Unfortunately, most recent
studies have confirmed low intake of this nutrient even
in this age group and by pregnant women [4, 9]. Among
Warsaw’s inhabitants, the supplementation with the
vitamins mentioned was effective because it prevents
their deficiency.
In the case of other vitamins analyzed, i.e. A, E, B2,
B6, B12 and C, in women regardless of supplementing,
their mean intake with food was sufficient to meet the
RDA. Supplementing the diet with these vitamins was
not justified. There are reports that excessive vitamin
taking is not beneficial, and UL is not a recommended
level which should be reached when nutrition is correct.
In Warsaw’s adult population, UL was exceeded mainly
in the case of vitamin A (in 8.3% of men and 14.9%
of women taking vitamin A supplementation) and to
a smaller extent vitamins E and B6 in both sexes and
vitamin C in women. High doses of fat-soluble vitamins
are particularly worrying – they tend to cumulate in
tissue. Vitamin A and β-carotene are mentioned in the
EU as those whose excessive intake is risky and which
tend to exceed UL [6]. Also in the US, the percentage
of people who exceed UL for vitamin A is estimated at
10% – 15% [19]. There are reports in literature warning
against excessive vitamin E intake as it is associated
with the risk for peroxidative process stimulation [20].
Furthermore, there is no unequivocal scientific evidence
that dietary supplementation is justified in cardiovascular prevention, except possibly fish oil and niacin [10,
14]. A meta-analysis of 68 randomized studies did not
show any beneficial effect of supplements containing
antioxidants (A, E, C, β-carotene and selenium) on
Nr 2
mortality rates; in the case of β-carotene and vitamins
A and E, the effect may be quite opposite [3].
Although there are no established UL values for
vitamins B1, B2 and B12, their intake in the Warsaw population using supplementation was high (235% – 530%
of RDA). Yet according to the latest knowledge based
on data on the consumption in the EU countries, the
risk resulting from the excessive intake of the group B
vitamins mentioned above is believed to be nonexistent
[6]. It must be also added that the methodology applied
in this study did not allow us to differentiate whether excessive intake of some vitamins by Warsaw’s inhabitants
was short- or long-term, which might prove significant
in assessing how much their health was affected.
In summary, it seems that the analysis of benefits
and risks arising from the use of dietary supplements by
the inhabitants of Warsaw is an important issue. On the
one hand, as in the case of vitamins D, B1 and folates, it
can contribute to lowering the risk of the deficiency of
these nutrients in the diet. On the other, as in the case
of vitamins A, C, E, B2 and B12, their sufficient intake
with food along with high doses from supplements may
not be beneficial for the consumers’ health.
Referring to the range of dietary supplementation
by Warsaw’s inhabitants in the years 2011/12 vs 2001, it
should be noted that the share of people taking vitamins
A, C and E was similar even though range of dietary
supplements in Poland greatly expanded (in 2003 there
were available 557 of them, in 2004 – 1187, and in 2005
as many as 1285) [23]. A positive phenomenon was a
significant, over two-fold, drop in the intake of vitamins
A and E in the group of women who used supplementation of these vitamins. In the case of vitamin A, the
realization of RDA dropped from 844% to 351%; with
vitamin E from 997% to 540%. Such a high intake of
these vitamins in 2001 might have resulted from their
aggressive advertising pointing to their role both in the
prevention of chronic diseases and beneficial function
in dermatology and cosmetology.
CONCLUSIONS
1. Dietary supplementation with vitamins and minerals is very prevalent among Warsaw’s inhabitants,
more so among women, unmarried, and of higher
socioeconomic status.
2. Supplementing the diet with vitamins D and B1 as
well as folic acid contributed to better fulfilling
nutritional targets. Supplementing with vitamins A,
C, E, B2, B6 and B12 was not justified because these
vitamins were taken in sufficient amounts with food.
3. The prevalence of supplementation of vitamins A,
C and E did not change between 2001 and 2011/12,
but the total intake of vitamin A in both sexes and
Nr 2
vitamins C, E in women was significantly higher in
2001.
Acknowledgements
This study was supported by the Institute of Cardiology
grant 2.11/I/13.
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ENERGY AND NUTRITIONAL VALUE OF THE MEALS
IN KINDERGARTENS IN NIŠ (SERBIA)
Konstansa Lazarevic 1,2*, Dusica Stojanovic 2,3, Dragan Bogdanović 1,2
State University of Novi Pazar, Serbia
2
Public Health Institute, Niš, Serbia
3
School of Medicine, University of Niš, Serbia
1
ABSTRACT
Background. It is well known that high-energy diet, rich in fat and carbohydrates, increases the risk of obesity. Preschool
age is an important period to acquire the eating habits continued later in adulthood. Therefore, evaluation of child nutrition
in kindergartens is especially important in the prevention of future obesity.
Objectives. To determine the energy value and energy density of meals consumed by children in kindergartens in Niš (Serbia), including the different types of food, in respect to a probable risk of obesity.
Material and methods. The study had been conducted in the years 1998-2012. Three-hundred samples of the meals were
gathered and analysed, and the amount of selected food groups used to prepare the meals in kindergartens was calculated
(weight, protein, fat and carbohydrate content) in the accredited laboratory of the Public Health Institute in Niš according
to the ISO 17025 recommendation.
Results. The mean energy value of meals was 978.9 kcal (range: 810 – 1144 kcal). The energy density was low (mean:
1.02 kcal/g, range: 0.92 – 1.42 kcal/g) and decreased over the years, what would imply a reduction in the risk of obesity.
The intake of same high-energy food products, such as fats and oils as well as sweets (13,9% and 7,3%, respectively) was
higher compared to low-energy foods (fruits – 5.2% and vegetables – 10.8%).
Conclusions. The results of our study indicate that children in kindergarten in Niš, in general, were properly nourished in
total energy content. The energy value and energy density of the meals consumed did not pose a risk of developing obesity. However, the distribution of food groups differentiated by the energy density level was unfavourable; the deficit of
low-energy foods was observed. Planning the child nutrition in kindergartens, with laboratory control of meals, may be an
effective strategy in adequate energy intake and prevention of obesity. Providing the higher amount of low-energy foods
(fruits and vegetables) in meals in kindergartens is recommended.
Key words: energy intake, diet, children, kindergarten, Serbia
STRESZCZENIE
Wprowadzenie. Wiadomo, że wysokoenergetyczna dieta, bogata w tłuszcz i węglowodany, zwiększa ryzyko otyłości. Wiek
przedszkolny jest ważnym okresem nabywania nawyków odżywiania się kontynuowanych później w wieku dorosłym.
Dlatego też ocena żywienia dzieci w przedszkolu jest szczególnie ważna w zapobieganiu przyszłej otyłości.
Cel badań. Określenie wartości energetycznej i gęstości energii posiłków spożywanych przez dzieci w przedszkolach w Niš
(Serbia), z uwzględnieniem różnych typów żywności, w odniesieniu do potencjalnego ryzyka otyłości.
Materiał i metody. Badania prowadzono w latach 1998-2012. Zgromadzono i przeanalizowano 300 próbek posiłków. Obliczono
ilość wybranych grup żywności użytej do przygotowania posiłków w przedszkolach (zawartość białka, tłuszczu i węglowodanów). Analizę wykonano w laboratorium Instytutu Zdrowia Publicznego w Niš, akredytowanym zgodnie z normą ISO 17025.
Wyniki. Średnia wartość posiłków wynosiła 978,9 kcal (zakres: 810 – 1144 kcal). Gęstość energii była niska (średnia: 1.02
kcal/g, zakres: 0.92 – 1.42 kcal/g) i obniżała się w miarę upływu lat, co mogłoby pociągać za sobą zmniejszenie ryzyka
otyłości. Spożycie niektórych produktów żywności takich, jak tłuszcze i oleje, jak również słodycze (odpowiednio: 13,9%
i 7,3%) było wyższe w porównaniu z żywnością niskoenergetyczną (owoce – 5,2% i warzywa – 10,8%).
Wnioski. Wyniki naszych badań wskazują, że dzieci w przedszkolach w Niš, ogólnie rzecz biorąc, żywione były prawidłowo
w zakresie całkowitej zawartości energii. Wartość energetyczna i gęstość energii spożywanych posiłków nie stwarzała ryzyka rozwinięcia się otyłości, Jednakże, rozkład grup żywności różniących się poziomem gęstości energii był niekorzystny;
zaobserwowano niedobór żywności niskoenergetycznej. Planowanie żywienia dzieci, z laboratoryjną kontrolą posiłków,
może być efektywną strategią odpowiedniego spożycia energii i zapobiegania otyłości. Zalecono dostarczanie większej
ilości żywności niskoenergetycznej (owoce i warzywa).
Słowa kluczowe: spożycie energii, odżywianie się, dzieci, przedszkole, Serbia
*Corresponding author: Konstansa Lazarevic, Public Health Institute, Dr Zorana Djindjica 50, 18-000 Niš, Serbia,
phone: +38 1182333587, fax: +38118225974, e-mail: koni33@hotmail.com or higijena@izjz-nis.org.rs
128
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K. Lazarevic, D. Stojanovic, D. Bogdanović
INTRODUCTION
The up to date results of a number of the studies
indicate that the prevalence of obesity in preschoolers
is the high [8, 17], but little attention is paid to the role
of diet in obesity prevention in preschool children [18].
Larson’s at al review of 42 international studies on state
nutritional policy in childhood suggested that promoting
healthy eating as well as physical activity in child care
settings are considered to less extent [19]. Therefore,
the kindergarten intervention studies are needed to help
in prevention of obesity in preschool children [16, 24,
25], The evidences were provided that a reduction in
the meal energy density significantly decreases the
energy intake in preschool children [3, 20-22], however, it should be remembered that children choose the
energy-dense foods that were able to give them pleasant
feelings of fullness [15]. Duffey and Papkin reported
that probably reason for increasing the energy intake
are: energy density of meals, portion size and number of
eating/drinking occasions [10]. All these components of
the diet may be successfully controlled in kindergartens.
The aim of the study was to examine the value of
kindergartens meals, measured by energy value, energy
density, and distribution of low- and high-energy food
groups, whether they may affect the development of
obesity in children.
The study had been conducted in the years 19982012 in kindergartens in Niš, Serbia. The nutrition of
children, who reside in kindergartens, is planned by a
nutritionist, physician and nurse, and consists of three
meals: breakfast, lunch and snack. Accordingly to the
Serbian Book of Regulations (SBR), the kindergarten
meals must provided at least 90% (1600 kcal) of the
daily energy requirements of children, if they spend
12 hours in kindergarten [5]. The macronutrient contents in the energy intake should have the following
distribution: protein 10-15%, carbohydrates 50-60%
and fats 25-30%.
The material for analysis was collected as follows:
four time per year during five random days the one
sample of each meal ingredients was collected from
serving on the dinning room table in front of a child, and
300 samples (20 annually) of kindergarten meals were
gathered. The collected samples of meals in duplicate
were transported to the accredited laboratory of the
Institute of Public Health in Niš. The ingredients (i.e.
milk, tea, bread, cooked food, salads, fruits, justice,
etc.) were weighed separately and the level of moisture,
protein, carbohydrates, fat and ash was determined [1].
The analyses were done in accordance to the ISO 17025
recommendations.
Descriptive statistics (mean, standard deviation),
linear trends of energy density (defined as energy value
in kilocalories (kcal) divided by weight in grams (g), and
percentage distribution of food groups was calculated
using the Microsoft Excel software.
RESULTS
Mean energy value (kcal), weight (g) and energy
density (g) are shown in Table 1. The mean content of
energy was 978.9 kcal (range: 810 – 1144 kcal), mean
weigh of meals – 991.5 g (range: 823 – 1153.4 g), and
energy density – 1.02 kcal/g (range: 0.92 – 1.42 kcal/g).
Table 1. Mean energy intake, weight of food intake and
energy density of kindergarten meals in Niš in the
1998-2012 period
Recommended
values
Meal energy (kcal) 978.9± 121.8 810-1144
1600
Meal weight (g)
991.5± 95.3 823-1153.4
Energy density
1.02± 0.13 0.92 – 1.42
(kcal/g)
Variable
Mean ± SD
Min-max
Table 2 shows the macronutrient contents (protein,
fat and carbohydrates) in the analysed meals. The share
of macronutrients, protein (14.7%), fat (30.6%) and
carbohydrates (54.7%), in the total energy intake were
in accordance with the national recommendations.
Table 2. Macronutrients (protein, fats and carbohydrate)
contents of kindergarten meals in Niš in the 19982012 period
Macronutrients
Mean
± SD
(g)
Energy
from
macronutrients
(kcal)
Protein
Fats
Carbohydrates
35.0 ± 4.8
32.2± 6.3
130.6± 14.3
143.5
299.5
535.5
% of
total
energy
intake
(kcal)
14.7
30.6
54.7
Recommended
% of total
energy
intake
(kcal)
10-15
25-30
55-60
Figure 1 shows that the linear trends of the mean
energy density of the meals in kindergartens decreased
significantly in the 1998-2012 period. It would imply a
reduction in obesity in childhood due to improper diet.
Nevertheless, the greater contribution in energy density
of child meals, unfortunately, was noted for the high-energy foods, such as fats, oil and sweets, compared to
those of low-energy, i.e. fruits and vegetables (Figure 2).
Nr 2
1,5
y = -0,013x + 27,124
R2 = 0,2023
1,4
energy density (cal/g)
129
Energy density of meals in kindergartens in NIS, Serbia
1,3
1,2
1,1
1
0,9
1995
2000
2005
2010
2015
year
Fig. 1.
Trends of mean energy density of kindergarten
meals (kcal/g) in Niš in the 1998-2012 period
DISSCUSSION
Many countries have regulations concerning the
recommended level of energy intake in child nutrition,
but the agreement between the energy value of child
nourishment in kindergartens and the national and world
recommendations has rarely been the object of research. Our study confirmed that feeding of kindergarten
children in Niš, in general, was proper in total energy
content. The energy value of meals did not exceed the
level recommended by SBR, and energy density was
low and decreased over the years. The maximum energy
values presented in the table 1 were lower than the recommended values and were adequate to the time spent
by children in the kindergartens, usually shorter than 12
hours. Compared to our results, the Brazilian children
in day-care centers consumed meals of lower energy
value than required [14]. The children meals had the
energy value higher than required due to fat and protein
in Poland [13], and higher due to fat in kindergartens
of six cities in China [28]. In the 1998 – 1993 period,
in 10 out of 24 kindergartens in Zagreb (Croatia), at
least one of the analysed parameters of meals (energy
value, protein, fat, carbohydrate content) did not meet
the national recommendations [6].
Regarding the macronutrients in the child nutrition,
the Dietary Reference Intake (DRI) recommends the diet
of children aged over 4 years covering: protein 5-20%,
carbohydrates 45-65% and fat 30-40% [12]. It should be
noted that the SBR recommendations propose a much
lower percentage of fat (25 – 30%), and this regulation,
established 20 years ago, needs to be changed [5]. The
results of our study showed that proportion of selected
macronutrients (protein, fat, carbohydrates) in meals of
children in kindergarten in Niš met the criteria for both
DRI and SBR recommendations.
The proper selection of children diet with taking into
account the calorie contents of different food products
is the subject of a numerous studies. Our investigations
found the unfavourable structure of food products
differentiated by the level of the energy density in the
meals consumed by the kindergarten children in Niš,
inconsistent with the Food Guide Pyramid, were fruit
and vegetables present the important part of children
diet [29]. The distribution of high- and low-energy
foods in nutrition of preschool children in care centers
varied from country to country, and even between the
regions in the same country. The results of the study of
40 child-care centers in New York City indicated that it
is necessary to improve the dietary intake of vegetables
and foods rich in vitamin E, which was not provided to
children in sufficient quantity by preparing meals [11].
In contrast, the children from 20 child-care centers in
North Carolina consumed the recommended amount of
low-energy foods (whole grains, fruits and vegetables),
but also excessive amount of saturated fat and added
sugar [2]. Compared with other regions of the world, the
Scandinavian children attending daycare centers seem
to have the most balanced diet in terms of high- and
low-energy foods [23].
0,2%
Other
13,6%
Fats and oils
7,3%
Sweets
15%
Milk and products
5,2%
Fruit
10,8%
Vegetables
13,9%
Meats and products
34%
Cereals and products
0
5
10
15
20
25
30
35
Fig. 2. Distribution (%) of food groups in kindergarten meals in Niš in the 1998-2012 period.
130
Nr 2
K. Lazarevic, D. Stojanovic, D. Bogdanović
Children in kindergartens formed dietary behaviours
developing the preference for certain types of food. The
result of the study conducted in Mexico among children
aged 3-4 years reported that, in general, children preferred high-energy foods, but those of public daycares
were more likely to prefer healthy food of low-energy
[7]. Preventing the unhealthy eating habits in preschool
children is very important, because a minimum of 400
g fruits and vegetables per day is recommended for
protection against the chronic diseases, such as cardiovascular diseases, cancer, diabetes and obesity [29, 30].
The American Dietetic Association obligated the staff
of child care settings to promote healthy eating habits
in children [26].
The present study has same limitations. The research
focused on the children’s diet only in kindergartens. However, it is necessary to know the influence of children’s
diet at home in terms of energy and macronutrient intake
on their future habits. The children in Brazil received
proportionally more energy, proteins and lipids in their
meals at home than in the kindergarten [4]. The study
conducted in Texas found that the child nourishing at
home did not compensate the energy intake due to a
low amount of grain and vegetable consuming in the
care centers [27]. The role of parents in forming in their
children the habits of proper nutrition is essential, but
the healthy diet of preschoolers in kindergarten is also
important.
CONCLUSIONS
The findings of our long-term investigations allow
us to recognise the trends and current state of nutrition
quality of children in kindergartens in Niš with regards
to the adequacy of energy intake. In particular, the study
showed that:
1. Children in kindergartens were properly nourished
in the total energy intake. The mean energy value
of meals did not exceed the level statutory recommended. The energy density of meals was low and
decreased over the years, what would imply a reduction of the risk of obesity.
2. The distribution of food groups differentiated by the
energy density level was unfavourable. The deficit of
low-energy foods was observed. Planning the child
nutrition in kindergartens, with laboratory control
of meals, may be an effective strategy in adequate
energy intake. Providing the higher amount of low-energy foods (fruits and vegetables) in kindergarten
meals is recommended.
The authors declare no conflict of interest
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COMPARING DIABETIC WITH NON-DIABETIC OVERWEIGHT
SUBJECTS THROUGH ASSESSING DIETARY INTAKES AND KEY
PARAMETERS OF BLOOD BIOCHEMISTRY AND HAEMATOLOGY
Karolina Gajda*, Agnieszka Sulich, Jadwiga Hamułka, Agnieszka Białkowska
Warsaw University of Life Sciences (SGGW), Warsaw, Poland
ABSTRACT
Introduction. An important way of preventing type 2diabetes is by adopting a proper diet by which means appropriate
control over blood glycaemia and lipids can be achieved.
Objectives. To assess selected biochemical and haematological markers in overweight subjects or those suffering from type
2 diabetes in relation to their estimated dietary intake.
Material and methods. The study was conducted in 2012 on n=86 overweight or obese subjects living in Warsaw or its
environs, of whom n=43 had type 2 diabetes. Dietary intakes were compared between non-diabetics (control group) and
diabetics (test group) by 3 day records, whilst the relevant blood biochemistry and haematology results were obtained from
medical records; with patient consent.
Results. Diabetic subjects had significantly higher serum glucose and CRP levels than controls, respectively; 190 vs 98 mg/
dl and 1.4 vs 1.1 mg/dl. Lipid profiles were however more significantly abnormal in controls, compared to diabetics with
respectively; total cholesterol 220 vs 194 mg/dl, LDL-cholesterol 131 vs 107 mg/dl and triglycerides 206 vs 157 mg/dl.
There were no significant differences in HDL-cholesterol; respectively 55 vs 51 mg/dl. In the diabetics, calorific intakes
from carbohydrates, especially sugars, were significantly lower than controls i.e. 9% vs 13%. The proportional share of
calories derived from dietary fats did not differ between groups, nevertheless a positive correlation was observed between
dietary fat content with blood cholesterol concentrations in diabetics.
Conclusions. Disorders of carbohydrate metabolism were confirmed in both overweight and diabetic (type 2) subjects. In
addition, both groups demonstrated untoward lipid profiles that correlated with their improper nutrition.
Key words: overweight, obesity, type 2 diabetes, nutrition, lipid profile, C-reactive protein (CRP), adults
STRESZCZENIE
Wprowadzenie. Prawidłowe żywienie, którego celem jest wyrównanie glikemii oraz profilu lipidowego odgrywa zasadniczą
rolę w profilaktyce cukrzycy typu 2.
Cel pracy. Ocena wybranych wskaźników biochemicznych krwi (glukoza, lipidogram, białko CRP) u osób z nadmierną
masą ciała oraz cukrzycą typu 2 w aspekcie ich sposobu żywienia.
Materiał i metody. Badanie przeprowadzono w 2012 roku, wśród 86 mieszkańców Warszawy i okolic, z nadwaga i otyłością, w tym u 43 osób z cukrzycą. Do oceny sposobu żywienia wykorzystano metodę trzydniowego bieżącego notowania.
Dane dotyczące wskaźników biochemicznych krwi, za zgodą badanych uzyskano z ich kart zdrowia.
Wyniki. U pacjentów z cukrzycą odnotowano istotnie wyższe średnie stężenie glukozy w surowicy krwi (190 vs. 98 mg/dl), jak
również wyższe stężenie białka CRP (1,4 vs. 1,1 mg/dl). Biorąc pod uwagę wskaźniki gospodarki lipidowej stwierdzono większe
nieprawidłowości w grupie kontrolnej (cholesterol ogółem 220 vs. 194 mg/dl; cholesterol LDL 131 vs. 107 mg/dl; triacyloglicerole
206 vs. 157 mg/dl). Stężenie cholesterolu frakcji HDL nie różniło się istotnie w obydwu grupach (55 vs. 51 mg/dl). Spożycie
energii z węglowodanów, zwłaszcza prostych u chorych na cukrzycę było istotnie statystycznie niższe niż w grupie kontrolnej
(9 vs. 13%). Procentowy udział tłuszczu w dostarczeniu energii nie różnił się znacząco pomiędzy grupami, przy czym w grupie
z cukrzycą odnotowano dodatnią korelację pomiędzy ilością tłuszczu w diecie, a stężeniem cholesterolu we krwi.
Wnioski. Uzyskane wyniki potwierdzają występowanie zaburzeń gospodarki węglowodanowej u pacjentów z nadmierną
masą ciała oraz cukrzycą typu 2. Ponadto w badanych grupach zaobserwowano niekorzystny profil lipidowy korelujący
z ich nieprawidłowym sposobem żywienia.
Słowa kluczowe: nadwaga, otyłość, cukrzyca typu 2, sposób żywienia, lipidogram, białko C-reaktywne (CRP), osoby dorosłe
* Corresponding author: Karolina Gajda, Chair of Nutritional Assessment, Department of Human Nutrition,
Faculty of Human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (SGGW),
Nowoursynowska Street 159c, 02-776 Warsaw, Poland, tel. +48 22 59 37 122, e-mail: karolina_gajda@sggw.pl
134
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K. Gajda, A. Sulich, J. Hamułka et al.
INTRODUCTION
Having an excess body mass (overweight) and type
2 diabetes constitutes a serious health problem in both
Poland and worldwide. According to a World Health
Organisation (WHO) report, 1 billion people are now
overweight (BMI 25-29.9 kg/m2) and 300 million are
obese (BMI>30 kg/m2). It was also predicted that in
2015 such levels will rise to 1.5 billion overweight
and 700 million obese [27]. The WOBASZ studies
conducted in Poland during 2003-5, on subjects aged
20-74 years, demonstrated that respectively 40.4%
and 27.9% of men and women were overweight and
20.6% and 20.2% were obese [2]. In somewhat likewise
fashion, for type 2 diabetes, there were 285 million
people, aged 20-79 years, with this disease worldwide
in 2012, whereas in 2030, this figure is expected to rise
to 439 million [19].
Studies have demonstrated a close relationship
between excess body mass (by the amount of adipose
tissue) with a significantly higher risk of suffering from
type 2 diabetes [5, 17, 29]. The WHO recognises that
obesity, particularly the abdominal variety, accounts
for around 80% of type 2 diabetes incidence, with such
cases ever increasing [28]. Obese females and males
have respectively, an almost 30 and 40 fold risk of
developing type 2 diabetes when compared to persons
with a normal body mass [5]. An excess of adipose tissue in the body is responsible for a series of metabolic
disorders (both endocrinological and immunological)
that give rise to type 2 diabetes, hypertension and hyperlipidaemia and in turn lead to accelerated development
of arteriosclerosis and increased risk of cardiovascular
disease [17]. In recent years, the involvement inflammatory factors has been stressed in the pathogenesis
and development of many disease complications that
include diabetes [6]. Adopting a proper diet plays a key
role in the prevention and treatment of these diseases,
especially in the choices made in consuming certain
nutrients [8, 14, 22, 26]. The study aim was to assess the
significance of selected biochemical markers (ie. lucose,
lipid profiles, CRP and haematological parameters) in
overweight subjects and those with type 2 diabetes in
relation to their diets.
The study was conducted in 2012 on 86 adults
with excessive body weight (mean age 51 ±14 years)
of whom 43 had type 2 diabetes and which constituted
the separate test group. Subjects came from Warsaw
and the surrounding areas. Dietary intake was assessed by a three day dietary record which covered two
working days and one that was work-free. Most of the
consumed sizes of foodstuff dishes and meal portions
were defined from a photographic album [23] especially designed for such purposes. The daily calorific
value of the dietary intake, together with consumption
of protein, total carbohydrates (including sugars) and
total fat (fatty acids and cholesterol) was estimated by
the ‘Diet 5’ computer programme based on ‘Foodstuff
composition and nutritional value tables’ [11]. The obtained data were adjusted for nutritional losses incurred
during food processing and then compared to reference
standards and recommendations [10]. In order to assess
the dietary composition of basic components, their proportional (%) share of supplied calories were calculated.
For protein and total carbohydrate, this respectively
amounted to 10-15% and 50-70% (with sugars being
not greater than 10%). The amount of dietary calories
obtained from total fat was taken as the reference value
of 20-35%, whilst the intakes of saturated fatty acids
were assumed to be as low as possible, given that a diet
is nutritionally adequate. An acceptable dietary intake
value for cholesterol was taken as not being higher than
300 mg/day, whereas for dietary fibre this was taken as
being above 25 g/day [10].
Subjects were surveyed by questionnaire to obtain
both socio-demographic data (i.e. gender, age, place of
residence, self-assessment of health) and anthropometric parameters (height, body mass); the latter two being
additionally confirmed during control visits. Blood
analysis data were, with subjects’ consent, recorded
from their medical records. These consisted of measured
concentrations of biochemical markers (glucose, total
cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides and CRP) and haematological parameters haemoglobin-HGB, hematocrit-HTC, erythrocytes-RBC
and leukocytes-WBC). The biochemistry analyses were
performed at the Warsaw ALAB medical laboratories.
The lipid results were compared to those recommended
by the Polish Diabetes Association; PDA [20], whereas
the others were assessed according to reference values
used at the aforementioned ALAB laboratories. Statistical analyses were performed using the ‘Statistica
ver. 10 software’. Data normality was evaluated by the
Shapiro-Wilk test, whereas the Mann-Whitney U test
determined the significance of differences between
study groups for each studied parameter. The strength
of any associations were calculated by the Spearman
rank correlation coefficient. Significance levels were
taken as a p≤0.05 throughout.
RESULTS
All subjects were overweight, with a high Body
Mass Index (BMI) ranging 25-45 kg/m2 (mean 31 ± 6
kg/m2) of whom 50% had type 2 diabetes. Both groups
Table 1. Energy values and nutrient composition for the
daily diets of studied subjects
Overweight subjects
Diabetics
Non-diabetics
p3
n=43
n=43
Energy
(kcal)
1947 ± 2761
969 – 25752
2222 ± 387
1376 –2898
0.003
Total protein
(g)
84.8 ± 11.2
56.5 – 107.0
84.9 ± 12.6
56.4 – 115.0
NS
Total carbohydrate
(g)
294 ± 48
133 – 407
333 ± 64
188 – 460
0.0001
Sugars
(g)
43.2 ± 12.6
6.5 – 80.3
70.6 ± 24.6
6.6 – 119.4
<0.0001
Dietary fibre
(g)
35.0 ± 7.0
19.0 – 48.0
25.0 ± 5.0
12.6 – 33.8
<0.0001
Total fats
(g)
62.6 ± 9.2
31.7 – 79.8
70.5 ± 18.5
32.2 – 120.0
0.06
SFA
(g)
28.6 ± 5.8
8.6 – 37.0
30.9 ± 7.9
11.3 – 44.6
0.03
MUFA
(g)
22.1 ± 4.3
13.8 – 34.3
26.6 ± 9.0
9.3 – 54.5
0.004
PUFA
(g)
7.1 ± 2.4
5.0 – 16.4
8.2 ± 3.3
4.1 – 21.7
0.02
283.5 ± 63.0
168.4 – 491.5
297.7 ± 100.0
135.0 – 590.0
NS
Cholesterol
(mg)
1
Mean±SD; 2min - max; Mann-Whitney-U test results; significant
statistically significant differences, p≤ 0.05; NS –not significant
differences, p > 0.05; SFA – saturated fatty acids; MUFA monounsaturated fatty acids; PUFA - polyunsaturated fatty acids.
Targeted measurement of blood glucose is the
most important means used for determining diabetes
and evidence of glycaemic control. The diabetic group
showed a twice higher fasting glucose compared to
controls; 190 vs 98 mg/dl (Table 2). This high glucose
concentration was positively and significantly correlated with LDL-cholesterol (r=0.34, p≤0.05), whilst the
other lipid markers showed just a positive correlation
60
diabetics
*
non-diabetics
50
40
%
30
*
20
*
10
A
PU
F
UF
A
M
SF
A
Fa
ts
s
Su
ga
r
bo
hy
dr
at
e
te
in
s
0
Ca
r
(ie. non-diabetics and diabetics) had similar BMIs.
Those in the diabetic group were aged higher than
controls; (56 ± 14 vs. 46 ± 13 years), however other
socio-demographic features were much the same. In
terms of dietary calorific value and nutritional content,
there were more irregularities observed for the controls
than in diabetics (Table 1, Figure 1). The latter group
showed a significantly lower dietary intakes of calories
(by 12%), total carbohydrates (by 12%) and total fats
(by 11%); (p≤0.05). Cholesterol intakes varied widely
from 135-590 mg/day, but with no significant differences between the groups. Mean dietary protein intakes
were also similar in both groups at 85 ± 12 g/day. The
diabetics, however, on average consumed significantly
more dietary fibre (by 40%) than controls.
Consumption
135
Nutrition and biochemical parameters in people with excess body weight and type 2 diabetes
Pr
o
Nr 2
*Mann-Whitney-U test results; statistically significant differences,
p ≤ 0.05; SFA – saturated fatty acids; MUFA – monounsaturated
fatty acids; PUFA – polyunsaturated fatty acids
Figure 1.Proportions of calories derived from selected nutrients in the daily diets of studied subjects
alone. Both groups had higher than reference values
for CRP; this being a marker of inflammation (acute
phase response). Mean CRP levels in diabetics were
27% higher than controls and positively correlated
with glucose concentration (r=0.29, p≤0.05), leukocyte
count (r=0.32, p≤0.05) and the proportional daily share
of dietary saturated fatty acids (r=0.23, p≤0.05). Compared to PDA reference values, all subjects demonstrated
somewhat high total cholesterol, LDL-cholesterol and
triglycerides; respectively 207 mg/dl, 119 mg/dl and 181
mg/dl. Significantly higher levels of these lipids were
observed in those non-diabetics with the higher BMIs.
HDL-cholesterol concentrations were however
similar in both groups and lay within the reference
value range. There was much individual variation seen
in the lipid parameters irrespective of diabetic status;
the greatest being for triglycerides (41-702 mg/dl) and
LDL-cholesterol (46-236 mg/dl). Those with diabetes
showed respectively a 35%, 44% and 56% agreement
with PDA reference levels for total cholesterol, LDL-cholesterol and triglycerides as well as respectively
72% and 50% for men and women in the case of HDL-cholesterol. More normal lipid profiles were seen
in both the overweight and diabetic group for those
subjects eating healthier diets, particularly in terms of
calories, intakes of total fats, fatty acids and fibre compared to the overweight, non-diabetic subjects.
Blood morphology results conformed to reference
values, however in diabetic women, the erythrocyte
count, haemoglobin concentrations and haematocrit
were significantly higher than in control women. All
other haematological parameters were similar.
There was a positive relationship between glucose
concentration with intakes of dietary macro-components
and cholesterol but a negative association with fibre;
but were not statistically significant. Furthermore, in
all subjects, positive correlations were found between
dietary characteristics, ie. intakes of carbohydrates,
136
Nr 2
Table 2. Results of selected biochemical parameters in blood for studied subjects
Analyte
Glucose
(mg/dl)
CRP
(mg/dl)
Total cholesterol
(mg/dl)
LDL-Cholesterol
(mg/dl)
HDL-Cholesterol
(mg/dl)
Triglycerides
(mg/dl)
Leukocytes
(10³/μl)
Erythrocytes
(10³/μl)
Haemoglobin
(g/dl)
Hematocrit
(%)
Platelets
(10³/μl)
Reference value
<110.0
<0.5
<175.0
< 100.0
W* > 50.0
M* > 40.0
< 150.0
4.0-10.0
W* 3.7-5.1
M* 4.1-6.2
W* 12.0-16.0
M* 14.0-18.0
W* 37.0-47.0
M* 40.0-54.0
150.0-450.0
Overweight subjects
Diabetics
Non-diabetics
n=43
n=43
189.7 ± 112.81
98.0 ± 13.1
87.0 – 519.02
51.0 – 129.0
1.4 ± 3.5
1.1 ± 3.3
0.0 – 21.4
0.0 – 21.4
194.2 ± 44.9
219.6 ± 46.6
83.0 – 324.0
91.0 – 333.0
107.0 ± 36.1
130.8 ± 36.5
46.0 – 236.0
58.0 – 236.0
54.9 ± 18.7
50.8 ± 13.1
23.0 – 88.0
33.0 – 85.0
55.5 ± 17.0
50.85 ± 16.9
29.0 – 90.0
29.0 – 99.0
156.8 ± 109.6
205.8 ± 107.1
41.0 – 702.0
55.0 – 702.0
8.3 ± 2.9
8.1 ± 2.4
2.2 – 15.6
4.2 – 13.7
4.0 ± 0.6
4.6 ± 0.4
2.2 – 5.0
3.9 – 5.1
4.3 ± 0.7
5.1 ± 2.2
2.4 – 5.3
3.4 – 15.5
12.1 ± 2.2
13.6 ± 1.5
6.9 – 15.9
9.1 – 15.2
13.3 ± 2.2
13.8 ± 1.8
7.8 – 16.9
10.7 – 17.5
35.7 ± 5.9
40.1 ± 3.5
20.2 – 45.0
29.5 – 43.
38.9 ± 6.1
40.4 ± 5.1
23.7 – 49.9
31.1 – 51.8
280.7 ± 88.6
278.3 ± 79.5
103.0 – 474.0
126.0 – 480.0
p3
<0.001
NS
0.01
<0.001
NS
NS
<0.001
NS
0.001
NS
0.02
NS
0.002
NS
NS
Mean ±SD; 2min-max, W* - Women, M* - Men; 3 Mann-Whitney-U test results, statistically significant differences, p ≤ 0.05; NS –
statistically not significant differences, p > 0.05
1
sugars, saturated fatty acids and LDL-cholesterol together with the effect of sugar intake on the increase in
cholesterol. Such results indicate a relationship between
the prevalent dietary habits and in achieving normal
levels of lipids during treatment.
DISCUSSION
As defined by the American Diabetes Association
[1], diabetes is a metabolic disease of varied aetiology,
demonstrating hyperglycaemia resulting from disorders of insulin secretion or its action or a combination
of both. The literature shows that this condition is
chronic and is caused by disorders of carbohydrate
metabolism, where eating an improper diet leads to
glycaemic abnormalities and a disruption of the blood
lipid profile [22]. Type 2 diabetes risk factors include
genetic disorders and environmental factors, where
in the latter, an improper diet, high dietary intakes of
calories, saturated fat and cholesterol are important as
well as the link to overweight and obesity [14, 21, 25].
In addition, the pathogenesis of type 2 diabetes also
includes the role of adiponectin proteins (secreted by
white adipose tissue) which improves glucose tolerance.
Serum adiponectin levels depend on the BMI and also
whether type 2 diabetes is present, where in such cases
its levels are lower [15].
Subjects all had excess body mass, which was likewise observed in a study by Włodarek and Głąbska
[26], who showed that diabetics above the age of 40
years have, in 87% cases, excess body mass. Studies by
Pisarczyk-Wiza et al. [17] and Zielke and Reguła [29]
demonstrated that obesity is an important risk factor for
acquiring type 2 diabetes, whose effect becomes more
pronounced with increasing age.
A key factor in the pathogenesis of this condition is
insulin resistance that depends on dietary habits which,
if improper, leads to an abnormal lipid metabolism.
In accordance with PDA guidelines [20], a given diet
should not deviate from basic dietary recommendations
for healthy people. Nelson et al. [13] found that the
majority of diabetics, especially those overweight and
obese, do not adopt healthy/appropriate diets. Studies
Nr 2
Nutrition and biochemical parameters in people with excess body weight and type 2 diabetes
by Mędrela-Kuder [12] on type 2 diabetics have shown
that the commonest failings in diets are a lack of eating
regular meals, snacking between meals, eating sweets
and using inappropriate cooking methods.
The presented study found structural shortcomings
in dietary habits, particularly as demonstrated by an
increase in the share of calories derived from carbohydrates (including sugars) and fats. Fibre intake is
important to diabetics because of its beneficial effects
in lowering glycaemia and improving the blood lipid
profile [8]. Indeed, a high fibre intake was observed
in the current study for type 2 diabetics, together with
improved dietary habits which may have led to the
blood lipid profiles approaching normality - relative to
the non-diabetics. This may be reflected in the subject’s
conscious decision to eat smaller meals or dishes and
the need to keep to dietary recommendations during
adopting any dietary therapy for diabetics. Another
contributing factor could be that this condition develops
over a long period without symptoms, so that un-diagnosed diabetic persons seek treatment only when apparent
complications arise. Both type 2 diabetes and obesity
can occur independently, nevertheless an excess of body
mass will significantly increase the risk of diabetes, and
the incidence of hospitalisations [7, 21].
A twofold higher glucose concentration was noted in
the presented study for overweight diabetics compared
to controls ie. in 84% diabetics and only 16% controls.
Similar results were seen in a study by Tripathy et al.
[24] on diabetics with average fasting glucose levels
of 171 mg/dl compared to normal healthy subjects
of 73 mg/dl. Disorders in lipid metabolism are a recognised factor for the incidence of type 2 diabetes.
Under non-physiological conditions of high glucose
concentration, changes in the lipid profile occur, that are
most frequently manifested by high triglyceride levels,
low HDL-cholesterol and a normal –moderately high
LDL-cholesterol [3]. Moreover, obesity and an excess
of abdominal adipose tissue are linked with changes to
lipoprotein structure depending on the genes coding for
cholesteryl ester transfer protein (CETP). It has been
shown that a lack of, or a disorder in its function are
factors that affect HDL levels and the effectiveness of
reverse cholesterol transport [16]. A study by Fagot-Campagna et al. [4] found that 97% of diabetics had
at least one abnormal feature in their lipid profile.
Inflammation is recognised to play an important
role in type 2 diabetic pathogenesis. In overweight and
diabetic persons, hyperglycaemia and adipose tissue are
factors that induce chronic inflammatory reactions that
appear, amongst others, as an increase in acute phase
reaction proteins (such as CRP), which in turn affects
atherosclerosis development [6, 18]. The presented
study has demonstrated CRP levels higher than the
reference value in most subjects studied, with the dia-
137
betics being the most high. A study by Pisaczyk-Wiza
et al. [17] has likewise found that obese and diabetic
subjects had increased CRP concentrations which had
been used as a sensitive marker of inflammation. This
relationship was also observed in a Mexican study that
a protein marker of inflammation is a significant factor
affecting the development of type 2 diabetes and metabolic disorders in women [9].
CONCLUSIONS
1. An abnormal lipid profile in the studied subjects was
related to shortcomings in their dietary habits, particularly in the intakes of carbohydrates (including
sugars), as well as dietary fibre and fatty acids.
2. Raised serum CRP concentrations in those overweight persons suffering from type 2 diabetes may
indicate an inflammatory state arising from long-term hyperglycaemia.
3. Obtained findings illustrate the need for nutritional
education and for preventative studies on overweight
subjects to reduce the risk of complications resulting
from obesity and other conditions so accompanying.
Acknowledgement
The study was performed as a scientific project financed
by the by Faculty of Human Nutrition and Consumer
Sciences, Warsaw University of Life Science (SGGW),
Warsaw, Poland
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NUTRITIONAL VALUES OF DIETS CONSUMED BY WOMEN SUFFERING
UNIPOLAR DEPRESSION
Ewa Stefańska1*, Agnieszka Wendołowicz1, Urszula Kowzan2, Beata Konarzewska2, Agata Szulc2,
Lucyna Ostrowska1
Department of Dietetics and Clinical Nutrition, Faculty of Health Sciences, Medical University, Bialystok, Poland
2
Department of Psychiatry, Faculty of Medicine, Medical University, Bialystok, Poland
1
ABSTRACT
Background. Previous studies have shown that patients suffering from depression are more likely to adversely change their eating
habits (eg. through increases in appetite, comfort eating and compulsive eating), which may result in an abnormal nutritional status.
Objectives. To evaluate selected dietary habits, such as the number and type of meals consumed during a normal day and comparing dietary calorific values and nutritional content between women suffering unipolar depression to those without this condition.
Material and methods. Subjects were a group of 110 women aged 18-65 years consisting of a test group of 55 women undergoing treatment for unipolar depression at the Department of Psychiatry, Medical University of Bialystok and a control group
of 55 women, without depression, attending an Obesity and Diet Related Treatment Centre. A study questionnaire was used
to determine their eating habits along with other relevant data. The 24-hour diet recall method was used to obtain quantitative
data collected on 3 weekdays and 1 weekend day; results being averaged. The calorific values and nutrient content of selected
components, according to mealtimes, were evaluated using the Diet 5.0 computer programme.
Results. Those patients with depression showed that the 3 meals/day model dominated whilst the 4 meals/day model was predominant in the control group. The most frequently missed meals for both groups were afternoon tea and the mid-morning meal.
Abnormalities in the calorific intake and nutritional contents from various meals were observed in women suffering depression.
Conclusions. It seems appropriate to recommend that those women especially suffering from depression should consult
with dieticians about their changing dietary habits, particularly for achieving the proper calorific and nutritional values/
balance from their meals.
Key words: women, depression, nutritional value of meals
STRESZCZENIE
Wprowadzenie. Jak wykazały badania u pacjentów chorujących na depresję częściej występują zmiany zachowań żywieniowych (m. in. wzrost apetytu, pocieszanie się jedzeniem, kompulsywne jedzenie), które mogą być przyczyną ich
nieprawidłowego stanu odżywienia.
Cel. Celem pracy była ocena wybranych nawyków żywieniowych, w tym liczby i rodzaju zwyczajowo spożywanych
posiłków w ciągu dnia oraz porównanie wartości energetycznej i odżywczej posiłków w jadłospisach kobiet z depresją
jednobiegunową oraz kobiet nie chorujących na depresję.
Materiał i metody. Badania przeprowadzono w grupie 110 kobiet w wieku 18-65 lat. Grupę badaną stanowiło 55 kobiet
leczonych z powodu depresji jednobiegunowej w Klinice Psychiatrii Uniwersytetu Medycznego w Białymstoku. Grupa
kontrolna obejmowała 55 kobiet, u których nie rozpoznano depresji. W badaniach wykorzystano kwestionariusz ankiety
zawierający m.in. pytania dotyczące nawyków żywieniowych. Ocenę ilościową dziennych racji pokarmowych dokonano
przy użyciu 24-godz. wywiadu żywieniowego zebranego z 3 dni powszednich i 1 dnia weekendowego (wyniki uśredniono). Ocenie poddano (z uwzględnieniem podziału na posiłki) wartość energetyczną oraz zawartość wybranych składników
odżywczych wykorzystując program komputerowy Dieta 5.0.
Wyniki. Wykazano, iż w grupie pacjentek z depresją dominował model 3 posiłkowy, a w grupie kontrolnej 4 posiłkowy.
Najczęściej opuszczanym posiłkiem w obu grupach był podwieczorek i II śniadanie. Wykazano zaburzenia proporcji
w dostarczaniu energii z poszczególnych posiłków jak i nieprawidłowości w zakresie ich wartości odżywczej, zwłaszcza
w grupie kobiet z depresją.
Wnioski. Wydaje się słusznym zalecenie badanym kobietom, zwłaszcza chorującym na depresję konsultacje z dietetykiem
nad zmianą nawyków żywieniowych, a w szczególności nad prawidłowym komponowaniem pod względem wartości energetycznej i odżywczej wybranych posiłków.
Słowa kluczowe: kobiety, depresja, wartość odżywcza posiłków
*Corresponding author: Ewa Stefańska, Department of Dietetics and Clinical Nutrition,
Faculty of Health Sciences Medical University, Mieszka I 4b, 15-054 Bialystok, Poland,
phone/fax : +48 85 732 82 44, e-mail: estef@umb.edu.pl
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E. Stefańska, A. Wendołowicz, U. Kowzan et al.
INTRODUCTION
In recent years the incidence of depression has
been increasing, leading to many health complications
and thus constituting a serious public health problem
[17]. According to World Health Organisation (WHO),
unipolar depression was the leading cause of mental
illness in the nineties of the previous century and perhaps, together with cardiovascular diseases (CVDs),
they may become the most common illnesses in the
world by 2020 [6].
Research has shown that patients suffering from
depression are more likely to alter their eating behaviour
with changes in appetite and food preferences, including
avoiding certain foodstuffs and food groups, eating
too rarely or by eating high-calorie snacks in between
main meals [9, 16, 21, 22, 23]. Monitoring the diet of
patients suffering from depression can help to indicate
irregularities, which would thereby permit an appropriate adjustment to be made through the development
of both healthy eating habits and educational programs.
Currently there are no published studies on assessing
the nutritional values of foodstuffs consumed by people
suffering from unipolar depression.
The study was therefore aimed at evaluating and
comparing selected dietary habits in women with or
without unipolar depression. These included the number
and type of meals normally consumed during the day
and their dietary calorific and nutritional values.
MATERIALS AND METHODS
The survey group consisted of 110 women aged
18-65 years. Of these, the test group was 55 women
treated for depression at the Department of Psychiatry,
Medical University of Bialystok, whilst the control
group were 55 women patients who were first reported
at the Obesity Treatment Centre and Diet-Related Diseases and were not on a reducing diet. The study took
place between September and November 2012. The test
group included patients diagnosed with recurrent major
depressive disorder (according to ICD-10), lasting up to
5 years, where their current episode of depression did
not last longer than a month [24]. Furthermore, their
current treatment for depression consisted of one antidepressant from the following; paroxetine, sertraline,
venlafaxine, citalopram, mirtazapine, escitalopram and
a sedative drug used as needed.
The current course of the disease was assessed based
on data from interviews and available documentation.
Depressive symptoms were measured using the Hamilton Depression Rating Scale (version 17-point), and
Beck’s self-esteem scale [3, 10]. Patients participating
in the study were informed of its purpose and methodology. Each patient expressed written consent for such
consultations. The study was approved by the Bioethics
Committee of UMB No. RI-002/325/2011. A dietary
questionnaire developed in-house at the Department of
Dietetics and Clinical Nutrition, Medical University of
Bialystok was used to collect data. The questionnaire
contained, amongst others, questions about dietary
habits, including the number of commonly consumed
meals and any eating in-between.
The daily diets were quantitatively analysed using
the 24-hour diet recall, including 3 weekdays and 1
weekend day; results being averaged. Patients did not
take any additional vitamin and mineral supplements.
The daily diet (including mealtimes) were evaluated by
their calorific value and nutritional content of selected
nutrients, where in the latter case this was performed
using the Diet 5.0 computer programme as developed
by the Institute of Food and Nutrition in Warsaw, taking
into account nutrient losses during the cooking process
(Diet 5.0 package for planning and current assessment
of individual nutrition, Institute of Food and Nutrition license contract no. HBBxtpINI). In assessing the intake
of the selected nutrients, recommended nutrition standards for the Polish population were used as reference
[14]. The proportion of calories derived from each meal
were thence related to the recommended total calorific
intake according to Hasik and Gawęcki [11].
Statistical analysis consisted of calculating averages, standard deviations and percentages with results
being evaluated using StatSoft STATISTICA 10.0, by
the χ2 and t-test for independent variables. Significance
was adopted at the p <0.05 level.
RESULTS
The subjects groups’ characteristics are presented
Table 1. There were no significant differences between
the average age (45.8 years in women with depression
vs. 41.1 years in the control group), nor correspondingly
body height (162.8 cm vs. 162.1 cm), body weight (70.7
kg vs. 69.2 kg) and the average body mass index (26.8
kg/m2 vs. 27.0 kg/m2). The average points score on the
Hamilton depression scale for the depressed subjects
was 14.0 and 25.4 on the Beck scale. Mean disease
duration for 50% of the women was 4 years, for 17%
2-3 years, and for 33% it was less than 1 year. In this
group, episodes of depression were on average 2.7. A
single episode for depression was reported in 33% of
women, 2-4 episodes in 39%, more than 4 episodes
occurred in 28% of patients. The average points score
on the Hamilton depression scale for the control group
was 3.0 and 6.5 on the Beck scale. In the group of depressed women 11% received paroxetine, 26% sertraline
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141
The nutritional value of meals of women with unipolar depression
Table 1. General characteristics of subject groups
Variables
Age (years)
Body height (cm)
Body weight (kg)
Body mass index (kg/m2)
Underweight (%)
Normal weight (%)
Overweight (%)
Obese (%)
Waist circumference (cm)
Marital status (%)
Married
Single
Education (%)
Primary
Vocational
Secondary
University
Number of previous
depression episodes
HAM-D score
Beck score
Depressed
subjects
(n=55)
45.8 (12.2)
162.8 (5.4)
70.7 (14.5)
26.8 (5.3)
3.6
45.4
32.7
18.3
89.4 (9.0)**
Control group
(n=55)
41.1 (13.1)
162.1 (5.2)
69.2 (10.6)
27.0 (5.3)
0.0
47.3
40.0
12.7
83.7 (9.8)
63.6***
36.4
40.0
60.0
14.5
22.0
54.5
9.0
12.7
12.7
38.2
36.4
2.7(1.7)
-
14.0 (7.3)
25.4 (12.8)
3.0 (1.7)
6.5 (3.2)
Values for categorical variables are mean, (SD) or percentages of
subjects. For continuous variables, the independent t test was used;
for categorical variables, chi-square test was used
*:<0.05, **:p<0.01, ***:p<0.001
and venlafaxine, 9% citalopram, 12% mirtazapine and
16% escitalopram.
Waist circumference (WC) was however statistically higher in the depressed women’s group than controls
(89.4 vs. 83.7 cm) and likewise there were significantly
more married women in the depressed group than controls. No significant differences in levels of education
were observed between groups, however the test group
tended to have more women with primary, vocational
and secondary education but less with higher education
as compared with controls.
The number of meals, mealtimes and meal types
in both study groups are shown in Table 2, where there
were no significant differences in the aforementioned
between the test and control groups. Nevertheless, more
depressed women (36.4%) preferred eating the usual 3
meals a day whereas those without depression preferred to eat 4 meals daily (43.6%). It was also noted that
about 7% of the test women 4% of controls consumed
only 2 or fewer meals per day. Eating an optimal 5
meals a day was observed in 31% of women for both
compared groups. Nearly 90% of all the women studied
consumed three main meals, ie. breakfast, lunch and
dinner. The least frequent consumed meals in the two
treatment groups were: afternoon tea (consumed by 56%
of women with depression and 45% of women in the
control group) and the mid-morning meal (consumed
by 56% of women with depression and 69% of women
Table 2. Details of subjects’ dietary habits selected for
assessment
Variables
Number of meals
≤2
3
4
≥5
Type of meals
Breakfast
Mid-morning meal
Lunch
Afternoon tea
Dinner
Additional eating inbetween meals
Type of additional
snacks
Sweets
Fast food
Sandwiches
Fruit
Vegetables
Depressed subjects
n=55
n
%
Control group
n=55
n
%
4
20
14
17
7.3
36.4
25.4
30.9
2
12
24
17
3.6
21.8
43.6
31.0
51
31
55
31
50
48
92.7
56.3
100.0
56.4
90.9
87.3
49
38
50
25
49
41
89.0
69.0
90.9
45.4
89.0
74.5
28
1
11
8
0
58.3
2.0
23.0
16.7
0.0
17
2
10
12
0
41.4
4.9
24.4
29.3
0.0
without depression). Another detrimental aspect of the
observed eating behaviour was the custom of snacking
in-between meals as declared by 87% of women with
depression and 74% of women in the control group
(differences not significant); the main foodstuffs being
eaten were mostly sweets.
The average calorific values and content of selected
nutrients in the daily diets are reported in Table 3. The
diets of the depressed had both higher calorific values
and nutritional content. Statistically significant differences were observed between respectively the test group
and controls for the total daily calorie intakes (1660.1
kcal/day vs. 1431.6 kcal/day), total fat (59.6 g/day vs.
42.7 g/day), saturated fatty acids (SFA) (25.2 g/day vs.
16.9 g/day) and monounsaturated fatty acids (MUFA)
(22.8 g/day vs. 15.7 g/day). Moreover, higher dietary
contents were respectively seen in women with depression compared to controls of total protein (65.7 g/day
vs. 65.2 g/day), polyunsaturated fatty acids (6.3 g/day
vs. 5.9 g/day), cholesterol (248.7 mg/day vs. 216.1 mg/
day) and total carbohydrates (230.8 g/day and 212.5 g/
day), although these differences were not statistically
significant. The average daily intakes of dietary fibre
were too low from normal in both groups of 16.7g/day
(test) and 22.7g/day (controls), however these differences were insignificant. The percentage of total calories
from dietary protein in women with depression was
lower at 15.8% than the 18.2% in the controls; differences being significant. In contrast, the percentage of
dietary calories derived from total fat, saturated fatty
acids and monounsaturates was significantly higher in
women with depression compared with women in the
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Table 3. Average calorific values and content of selected
nutrients in subjects’ daily diets
Variables
Calories
(kcal/day)
Total protein
(g/day)
Animal protein
(g/day)
Total fat
(g/day)
SFA
(g/day)
MUFA
(g/day)
PUFA
(g/day)
Cholesterol
(mg/day)
Carbohydrates
(g/day)
Fibre
(g/day)
Protein
(% E)
Total Fat
(% E)
SFA
(% E)
MUFA
(% E)
PUFA
(% E)
Carbohydrates
(% E)
Depressed subjects
(n=55)
% of
Mean (SD)
Standard
1660.1
79.0
(611.5)*
65.7
109.5
(26.2)
41.1
137.0
(19.6)
59.6
85.0
(27.2)***
25.2
108.1
(12.9)***
22.8
81.4
(11.5)***
6.3
35.3
(4.3)
248.7
82.9
(196.2)
230.8
75.8
(88.5)
16.7
55.7
(7.4)
15.8
(3.0)***
31.3
(7.8)***
13.7
(2.0)***
12.4
(2.4)***
3.4
(1.4)
52.9
(7.7)
Control group
(n=55)
Mean
% of
(SD)
Standard
1431.6
68.2
(410.6)
65.2
108.7
(21.9)
43.5
145.0
(20.8)
42.7
61.0
(18.1)
16.9
72.5
(9.6)
15.7
56.1
(7.4)
5.9
31.5
(3.4)
216.1
72.0
(156.1)
212.5
69.8
(68.9)
22,7
75.7
(27.7)
18.2
(5.2)
26.8
(7.2)
10.6
(3.0)
10.0
(2.0)
3.7
(1.4)
55.0
(8.1)
SD-standard deviation
%E -percentage of calories
For continuous variables the independent t-test was used
*:<0.05, **:p<0.01, ***:p<0.001
control group and respectively amounted to 31.3%,
13.7%, 12.4% vs. 26.8%, 10.6%, 10.0%.
The percentage of calories derived from dietary
polyunsaturated fatty acids was however similar in both
groups; being 3.4% in women with depression and 3.7%
in the control group. Likewise, there was no significant
differences between the test and control groups in the
percentage of calories derived from carbohydrate intake;
respectively 52.9% vs. 55%.
A breakdown of the calorific content for each meal
declared to be consumed by both subject groups, along
with recommended reference values are presented in
Figure 1. This demonstrated that in the depressed women, the calorific content of breakfast and afternoon
teas is too low but too high for lunch when compared to
recommendations. A significant proportion of calories
however derived from snacking in between meals for
both the depressed women (11%) and controls (7%).
In fact in the former group, these additional calories
exceeded those derived from the mid-morning meal
and afternoon tea and were mainly provided by carbohydrates and dietary cholesterol (Table 4).
The nutritional values of breakfast eaten by both
subject groups was similar, however in the depressed
women’s group, the intake derived from of total fat
and saturated fatty acids was higher than controls. In
the former group, the daily diet had significantly less
fibre than controls. Significantly lower dietary calorific
values and the intakes of total protein and carbohydrates
were also seen for the mid-morning meal in women with
Table 4. Calorific and nutritional values of meals consumed
by subjects
Variables
Calories (kcal)
Total protein (g)
Animal protein (g)
Total fat (g)
SFA (g)
MUFA (g)
PUFA (g)
Cholesterol (mg)
Carbohydrates (g)
Fibre (g)
Calories (kcal)
Total protein (g)
Animal protein (g)
Total fat (g)
SFA (g)
MUFA (g)
PUFA (g)
Cholesterol (mg)
Carbohydrates (g)
Fibre (g)
Calories (kcal)
Total protein (g)
Animal protein (g)
Total fat (g)
SFA (g)
MUFA (g)
PUFA (g)
Cholesterol (mg)
Carbohydrates (g)
Fibre (g)
Calories (kcal)
Total protein (g)
Animal protein (g)
Total fat (g)
SFA (g)
MUFA (g)
PUFA (g)
Cholesterol (mg)
Carbohydrates (g)
Fibre (g)
Depressed subjects
(n=55)
Mean (SD)
Breakfast
321.6 (158.3)
11.9 (7.1)
8.1 (6.0)
14.1 (10.4)**
7.2 (5.0)***
5.0 (4.3)
1.2 (0.9)
45.1 (47.8)
38.3 (17.3)
2.4 (1.8)***
Mid-morning meal
137.2 (179.9)**
5.0 (7.2)*
3.3 (5.4)
5.2 (8.4)
2.5 (4.3)
1,9 (3.2)
0.4 (0.7)
15.7 (24.1)
18.6 (24.1)*
1.4 (2.4)
Lunch
577.1 (184.8)***
25.5 (8.9)
15.6 (7.7)
14.7 (9.3)**
5.0 (3.4)***
6.7 (4.7)**
1.8 (1.7)
71.9 (33.1)
91.6 (34.5)***
7.7 (3.1)
Afternoon tea
109.5 (159.7)
3.6 (6.3)
1.6 (3.9)
2.9 (5.6)
0.9 (2.0)
0.9 (1.8)
0.4 (0.6)
9.9 (7.7)
18.5 (28.0)
1.5 (1.8)
Control group
(n=55)
Mean (SD)
291.8 (126.4)
13.1 (6.5)
8.3 (5.0)
10.4 (6.2)
4.4 ( 3.4)
3.9 (2.4)
1.3 (0.9)
48.0 (86.7)
40.8 (19.0)
3.9 (2.4)
211.1 (203.9)
8.5 (10.3)
5.9 (8.3)
6.4 (6.9)
2.8 (3.3)
2,3(2.9)
0.8 (1.9)
17.2 (18.6)
31.6 (34.3)
2.2 (3.0)
427.8 (186.2)
26.6 (13.1)
18.9 (12.1)
10.0 (8.7)
3.2 (2.8)
4.1 (4.2)
1.6 (1.7)
88.4 (100.9)
62.9 (34.2)
6.9 (4.0)
132.0 (154.3)
3.0 (4.9)
1.6 (3.9)
3.3 (6.4)
1.7 (3.4)
1.2 (2.5)
0.4 (0.7)
8.2 (7.2)
22.2 (24.9)
1.3 (1.5)
Nr 2
Dinner
Calories (kcal)
339.3 (203.8)*
264.5 (184.3)
Total protein (g)
13.8 (9.6)
11.9 (10.0)
Animal protein (g)
9.7 (8.4)
7.9 (8.8)
Total fat (g)
14.7 (12.6)**
8.2 (9.0)
SFA (g)
6.5 (6.0)
3.5 (4.0)
MUFA (g)
4.9 (4.2)**
2.8 (3.4)
PUFA(g)
2.0 (0.2)
1.4 (1.3)
Cholesterol (mg)
85.5 (38.4)
47.4 (37.5)
Carbohydrates (g)
40.4 (25.8)
38.3(27.6)
Fibre (g)
2.5 (1.7)
3.3 (2.8)
Snacks in-between meals
Calories (kcal)
177.2 (201.0)*
104.4 (108.5)
Total protein (g)
4.8 (7.2)*
2.2 (3.6)
Animal protein (g)
2.8 (5.9)*
0.9 (2.2)
Total fat (g)
7.8 (10.7)*
3.5 (1.1)
SFA (g)
2.9 (1.1)
1.6 (1.7)
MUFA (g)
3.1 (4.8)*
1.3 (2.6)
PUFA (g)
0.9 (1.9)
0.4 (0.9)
Cholesterol (mg)
20.6 (13.4)*
6.9 (7.8)
Carbohydrates (g)
22.8 (16.3)
16.7 (15.0)
Fibre (g)
1.3 (1.9)
1.0 (1.6)
SD-standard deviation
For continuous variables the independent t-test was used
*:<0.05, **:p<0.01, ***:p<0.001
depression compared to controls. In contrast, significantly higher dietary calories at lunchtime, in the depressed
women’s group, were observed to be derived from total
fat, saturated fatty acids, monounsaturated fatty acids
or total carbohydrates compared to the controls. There
were no significant differences between the two subject
groups in dietary calorific intake nor nutritional content
for the afternoon tea. At dinnertime, the women with depression demonstrated had significantly higher dietary
calorific values and intakes of total fat and monounsaturated fatty acids compared to controls. Furthermore,
the depressed women’s group more frequently adopted
the adverse habit of snacking between meals, which
provided significantly more calories, total protein, (including animal protein), total fat, monounsaturated fat
and dietary cholesterol in their diets compared to the
women without depression.
143
DISCUSSION
Studies have reported that the usual diets of persons
suffering from depression may differ from the principles
of rational nutrition [9, 23]. The presented study has
shown no significant differences in both the number of
meals normally eaten and their type between the two
groups of subject women. However the test group ie.
depressed women, tended to have more afternoon tea
and snacks in-between meals. Whilst the presence of
the former in a daily diet is beneficial, attention should
be drawn to their doubtful nutritional value, in that
these are mainly carbohydrate meals, with small amounts of protein. In addition, the diets of women with
depression demonstrated that the nutritional value of
in-between meal snacking exceeds that of nutritional
foodstuffs consumed during afternoon tea and mid-morning meals, which is also not consistent with the
principles of proper nutrition. The current study showed
that the most popular snacks were sweets eaten by almost 50% of subjects from the two compared groups.
Jeffery et al. [15] reported that depressive symptoms
were significantly and positively correlated between
the consumption of high-calorie sugary snacks with
a high-calorie consumption but negatively correlated
with non-sweet food.
Other studies have shown that the most common
women’s meals skipped were the morning ones and
that other mealtimes varied according to the afternoon,
evening and night-time hours of one day [19]. Friedrich
demonstrated that from the modelling of modern women’s lives, then this shows a lower consumption of
breakfast before going to work. Reasons determined
were a decreased appetite early in the morning and not
enough time for preparing breakfast [7].
According to some research, having the total calorific intake from the daily diet spread over 5 meals is
most appropriate for human body health. This 5-meal/
day model should include: breakfast providing 25%,
Figure 1. Energy content (%) breakdown per meal determined in both subject groups along with recommended reference
values
144
mid-morning meal -10%, lunch -30%, afternoon tea
-15% and dinner -20% of the total calorific daily food
intake [11]. The presented results however differ from
these cited recommendations and it should be stressed
that the habit of snacking in-between meals provided
11% of the diet’s total calorific daily intake for women
with depression and 7% in the control group. An even
greater amount of calories coming from in-between
snacks, compared to the current study, was reported by
Carels et al. and Zizza et al. [4, 25], which respectively
gave 15% and 22% values of the total calorific intake of
the daily diet. Moreover, these were mostly derived from
carbohydrate-fat products, a finding also confirmed by
the presented study.
It was found that, on average, the calorific value
of diets in women with depression was significantly
higher when derived from total fat, saturated fatty acids
and monounsaturated fatty acids compared to controls.
Other studies by Grossniklaus et al. and Konttinen et
al. respectively however, demonstrated higher calorific
values of 1899.8 kcal/day and 2224.0 kcal/day) [9, 16],
but lower values were found in studies by Jacka et al.,
Murakami et al., Park et al., respectively; 1642.0 kcal/d;
1575.0 kcal/d; 1524.5 kcal/d [13, 20, 21].
The presented study found that dietary protein intake from depressed women were insignificantly different
to controls and was similar to the values obtained in
other studies [5, 9, 21]. However, our study demonstrated an abnormal ratio between the intakes of animal and
vegetable derived protein, with a predominance of the
former. Dietary fat contents were significantly higher
in women with depression. Higher dietary fat intakes
in depressed women of 72.0 g - 90.0 g/day than those
obtained in the present study were observed in other
studies [5, 9]. Further studies on depressed women found similar levels of dietary cholesterol to the current
study as follows; 217.7 mg/day in Grossniklaus et al.
[9] and 268.8 mg/day in Parks et al. [21]. Total dietary
carbohydrate was found to be lower in the presented
study compared to others [2, 5, 9], with generally low
total carbohydrate intake in both groups together with
low dietary fibre. Even lower fibre intakes (ie. than
the <16 g/day of the current study), has been reported
[9, 21]. Studies have demonstrated that this situation
may arise from insufficient food intake in depressed
patients from those foodstuffs rich in fibre such as raw
fruit and vegetables, whole-grain cereals or dried leguminous seeds [1, 2, 5, 9, 15, 16, 23, 25]. Furthermore,
a prospective cohort GAZEL study has shown that the
intake of selected groups of foodstuffs such as fruit,
vegetables and fish were associated with a reduced risk
of subsequent episodes of depression [18].
Studies have shown that the diets of those suffering
depression often have an inappropriately excessive
composition of fatty acids, especially SFA [23]. Howe-
Nr 2
ver, a proper dietary intake of fatty acids, particularly
unsaturated fatty acids of omega-3-acid, EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) may
have beneficial effects for treating patients suffering
from depression. A study by Lakhan found that a high
consumption of fish, as a source of unsaturated fatty
acids, correlates with fewer patients suffering from
mental disorders within the population [17]. Here, it
was suggested that a 1 – 2 g daily intake of omega-3
was sufficient for healthy people, whilst consuming
9.6 g appears to be safe and adequate for patients with
mental disorders [17]. The antidepressant effect of EPA
may be due to its conversion to prostaglandins, leukotrienes and other compounds required for normal brain
function. Another theory suggests that EPA and DHA
affect signal transduction in brain cells by activating
peroxisomal proliferator-activated receptors (PPARs),
inhibiting G-proteins and protein kinase C, as well as
calcium, sodium, and potassium ion channels [17].
It has been demonstrated that depression caused by
monoamine deficiency (acting as a pathophysiological
substrate) leads to decreased levels of neurotransmitters
serotonin, norepinephrine and dopamine in the central
nervous system. Synthesis of serotonin or 5-hydroxytryptamine (5 HT) has been found to be dependent
on the availability of the dietary precursor serotonin-tryptophan [12]. High-carbohydrate and low-protein
meals may affect mood by increasing the synthesis of
this 5-hydroxytryptamine as compared to low carbohydrate and high protein meals [8]. Much research has
indicated that patients feel more calm, relaxed after a
snack rich in carbohydrates compared to protein-rich
and low-carbohydrate meals. This may therefore also
explain why the studied subjects took frequent recourse
to those foodstuffs providing carbohydrates [8].
CONCLUSIONS
1. There were statistically insignificant differences between the two groups of subjects in both the number
and types of meals throughout the day, as well how
many snacks were eaten in-between meals, although
this unhealthy habit tended to be more common in
the depressed women.
2. Despite both subject groups having afternoon tea,
the doubtful nutritional value of this actual meal
rendered it unhealthy, especially for the depressed
women.
3. The composition of diets for those women suffering
from depression was incompatible with dietary recommendations regarding calorific intakes.
4. Compared to controls, the diets of women with
depression had significantly higher calorific values
and contents of total fat, SFA and MUFA as well as
Nr 2
the percentage of calories derived from total fat, SFA
and MUFA.
5. It is recommended that women suffering from depression should consult with dieticians for improving
their dietary habits, particularly for achieving the
correct calorific and nutritional values/balance for
their meals.
Acknowledgement
This study was performed as a project of the Faculty
of Health Sciences, Medical University, Bialystok (No.
123-16595P).
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AWARENESS OF FACTORS AFFECTING OSTEOPOROSIS OBTAINED
FROM A SURVEY ON RETIRED POLISH SUBJECTS
Natalia Ciesielczuk, Paweł Glibowski*, Jolanta Szczepanik
Faculty of Food Science and Biotechnology, University of Life Sciences in Lublin, Poland
ABSTRACT
Background. Osteoporosis is a growing problem facing modern society and currently poses one of the most serious health
challenges. It is a progressive skeletal disease characterised by low bone mineral density whose development depends on
multiple factors. These principally include increasing age, nutrition, physical activity, endocrine changes, lifestyles, general
health condition and taken drugs.
Objectives. To assess how much subjects (aged >50 years) are aware of the dangers in contracting osteoporosis along with
the effects that lifestyle and dairy product consumption can have on this condition developing.
Material and methods. A questionnaire, designed in-house, was used to survey a group of 150 randomly selected individuals aged above 50 years. This was performed in June 2012. Questions were on socio-demographics, milk and dairy
product consumption, physical activity as well as assessing knowledge about osteoporosis that included issues such as its
incidence, prevention and morbidity.
Results. Osteoporosis was established in 60.7% subjects of whom 69.2% were women. Only 9.3% never consumed any
dairy products. Physical activity of some kind was undertaken by 77.3% subjects. Within the last year, 38.0% reported
having fractures of whom 46.0% had osteoporosis and 25% were healthy. Respondents were aware that consuming dairy
products is beneficial to bone health and this awareness was higher among those with osteoporosis. Physical activity was
also recognised to be important in preventing this condition.
Conclusions. Subjects suffering from osteoporosis had twice as many more fractures than healthy subjects.
Key words: osteoporosis, milk, dairy products, calcium
STRESZCZENIE
Wprowadzenie. Osteoporoza jest coraz większym problemem współczesnego społeczeństwa. Jest to choroba szkieletu,
która charakteryzuje się niską gęstością mineralną kości. Jest ona bardzo poważnym wyzwaniem w obecnych czasach,
ponieważ na jej rozwój wpływa wiek a także odżywianie, aktywność fizyczna, zaburzenia hormonalne, styl życia, ogólna
kondycja zdrowotna a także przyjmowane leki.
Cel badań. Celem badań była ocena świadomości zagrożenia osteoporozą oraz wpływu stylu życia i spożywania przetworów
mlecznych na jej występowanie u osób w wieku powyżej 50 roku życia.
Materiał i metody. Badania zostały przeprowadzone na podstawie ankiety własnego autorstwa w czerwcu 2012 roku.
Badaną grupą było 150 losowo wybranych osób w wieku od 50 lat wzwyż. Ankieta zawierała pytania dotyczące sytuacji
socjo-demograficznej ankietowanych oraz wiedzy i zagadnień dotyczących osteoporozy, przyczyn jej występowania, zapobiegania, zachorowalności a także spożywania mleka i przetworów mlecznych oraz aktywności fizycznej.
Wyniki. 60,7% badanych miało osteoporozę, a 69,2% chorych stanowiły kobiety. Tylko 9,3% badanych nie spożywała
produktów mleczarskich. 77,3% respondentów stosowało jakiś rodzaj aktywności fizycznej. 38,0% deklarowało, że w ciągu
ostatniego roku wystąpiło u nich złamanie, przy czym 46% wśród nich miało osteoporozę i 25% wśród zdrowych. Uczestniczący w badaniach byli świadomi, że spożywanie produktów mlecznych ma korzystny wpływ na kościec, jednak większą
świadomość miały osoby z osteoporozą. Aktywność fizyczna była częstą praktyką wśród respondentów, wskazywana jako
ważna część profilaktyki osteoporozy.
Wnioski. Nadal niewystarczająca wiedza na temat osteoporozy u osób powyżej 50 roku życia i powinna być poszerzana, co
mogłoby wpłynąć na zmniejszenie liczby złamań u takich osób, które są niemal dwukrotnie częstsze niż u osób zdrowych.
Słowa kluczowe: osteoporoza, mleko, przetwory mleczne, wapń,
*Corresponding author: Paweł Glibowski, University of Life Sciences in Lublin, Faculty of Food Science and Biotechnology,
Department of Milk and Hydrocolloids Technology, 8 Skromna Street, 20-704 Lublin, Poland,
phone: +48 81 462 33 49, fax +48 81 462 33 54, e-mail: pawel.glibowski@up.lublin.pl
148
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N. Ciesielczuk, P. Glibowski, J. Szczepanik
INTRODUCTION
Healthy and rational nutrition is essential for the
proper development of human physical and mental
fitness [12]. Inadequate nutrition may lead to a deterioration of health and emergence of lifestyle-related
diseases [26]. Due to an aging population, osteoporosis
has become an increasing health problem [22]. The
World Health Organisation (WHO) defines osteoporosis as ‘an epidemic of the XXI century’, which along
with obesity, diabetes and cardiovascular disease, is a
serious and growing clinical problem associated with
the process of aging. Because developing this disease
depends on many factors like ageing (along with the
increase in bones loss density and strength), nutrition,
physical activity, endocrine changes, lifestyles, general
health condition, as well as taken drugs, it nowadays
poses one of the most serious health challenges [8,
33]. According to the WHO definition, osteoporosis is
a systemic skeletal disease, characterised by low bone
mineral density and abnormal bone micro-architecture,
which in consequence leads to fragility and increased
susceptibility to fractures [24]. It is a serious disease
that develops slowly over many years and it is often
diagnosed too late. Due to current medical advances,
a reduction in the risk and incidence of fractures has
been demonstrated as well enabling an increase in bone
mineral density. The restoration of normal body weight
is also important [25].
The main factors affecting maximum bone mass and
strength are genetic predisposition and dietary habits
acquired from childhood and adolescence. Nutrients
supplied regularly and in sufficient quantities (especially calcium and protein), together with physical activity,
contribute in achieving a maximum bone mass [3]. The
main risk factor for human osteopaenia (a condition
where bone mineral density is lower than normal) and
osteoporosis is Vitamin D deficiency. This deficiency
is the cause of increased secretion of parathyroid hormone (PTH) and reduced calcium absorption from the
gastrointestinal tract, which contributes to a reduction
of bone mass [16]. The value of the peak bone mass
achieved, is dependent on genetic determinants, nutrition, physical activity and environmental pollution (for
e.g. lead adversely affects the bioavailability of nutrients
that includes calcium) [29].
Osteoporosis is a disease affecting both sexes,
however due to the late start of losing bone mass and
a milder course with no sudden changes in hormonal
activity, osteoporosis develops less often in men than
in women [17]. Diagnosis of osteoporosis proposed
by the WHO is based on the measurement of bone
mineral density [9]. In Poland, there have been a few
studies on osteoporosis conducted on the elderly [10,
28], however to the best of our knowledge, there are
no studies on Polish men and women (aged above 50
years) regarding their knowledge of osteoporosis. For
this reason, the study aim was to investigate awareness
about osteoporosis among retired subjects aged above
50 years and analysing their lifestyle and dairy products
consumption.
The study was based on an in-house designed questionnaire, and carried out in June 2012. The target
group was 150 randomly selected individuals aged
above 50 years. Subjects were divided into gender. The
questionnaire asked respondents about socio-demographics and their knowledge on osteoporosis issues that
included its occurrence, prevention, morbidity as well
as their consumption of milk and dairy products and
any undertaken physical activity. The questionnaire
consisted of 23 questions, including 3 multiple choice
ones and 20 that were single choice.
RESULTS
Subjects consisted of 92 women and 58 men. Socio-demographic details are presented in Table1.
Table 1. Socio-demographics of studied subjects
Characteristic
Age range
Location
Education
Financial
situation
Variants
50-60 years
60-70 years
70-80 years
>80 years
Village
City; to 20 thousand inhabitants
City; 20-50 thousand inhabitants
City; > 50 thousand inhabitants
Primary
Vocational
Secondary
Higher
Bad
Average
Good
Very good
Not know
Percentage
of total
30.0
40.0
20.7
9.3
44.0
29.3
20.0
6.7
21.2
17.3
33.3
26.0
14.7
22.7
38.0
23.3
1.3
Of the 150 subjects surveyed, 91 (60.7%) had
osteoporosis, among which 22.0% had been diagnosed
with osteoporosis at the age of 50-60, 11.3% at 40-50
years, 9.3% at 60-70 years and 8.0% at up to 30 years as
well as 3.3% of people over 80 years, 70-80 years and
30-40 years. In most cases, a genetic influence could be
probably discerned, as more than 50% subjects declared
Nr 2
149
Awareness of osteoporosis in the retirement age
Table 2. Surveyed incidence of osteoporosis types broken down according to gender and age
Type of osteoporosis
Idiopathic
Involutional
Senile
Post-menopausal
Derivative
< 30 years
10 W
1W
1M
-
30-40 years
1W
1M
1W
1W
1M
Ages at which the disease was diagnosed
40-50 years
50-60 years
60-70 years
1W
1W
1M
2W
4W
3W
4M
7M
6W
16 W
2W
3W
4W
3W
3M
3M
3M
70-80 years
2W
1W
2M
Over 80 years
1W
2M
W- woman, M- man
15.3% in those with senility and 7.3% were stricken by
idiopathic-osteoporosis. The lowest morbidity among
respondents (4.0%) concerns involutional-osteoporosis.
Milk and dairy products had been consumed by
80.0% of respondents in their youth. Almost 11% never
consumed any dairy products and a little over 9.0% said
they couldn’t remember. At the present time, 45.3% of
respondents declared consuming dairy products several
times a week, 30.0% every day, 12.0% once a week,
33,9%
3.3% several times a month and 9.3% never at all. A
35%
significantly higher consumption of dairy products was
30%
recorded for osteoporotic individuals compared to the
25%
group as a whole. It was found that 31.0% of patients
20%
14,5%
14,5%
consume milk and dairy products daily, 56.0% several
13,0%
15%
times weekly, 4.4% once weekly and 1.1% several
8,1%
8,1%
6,5%
10%
times a month. However only 4.0% (4/91 osteoporotic
1,6%
5%
subjects) did not consume dairy products, which inc0%
luded a single subject in the osteoporotic group that
suffered fracture (2%). This, therefore indicates a high
awareness in the benefits of consuming such kinds of
food. Among those respondents who did not get sick,
Figure 1.Close relatives of the respondents who were dia- 18.0% (11/59) never ate dairy products, whilst 20.0%
gure 1. Close relatives of the
respondents
who were diagnosed
gnosed
with osteoporosis
(%) with osteoporosis (%) of healthy subjects (3/15) who had fractures never consumed milk nor its products. The most important dairy
that osteoporosis had been diagnosed in some of their
family members (Figure 1). In addition, 6 osteoporotic
subjects (6.6%) were diagnosed with the primary type
of this disease. Osteoporosis is a disease that affects people of all ages and both women and men. In our study,
69.2% of those suffering were women. The incidence
of the osteoporosis types, according to gender and age,
is shown in Table 2.
Subjects were found to well recognise and define
osteoporosis, where more than 90% gave correct definitions and furthermore, 37.0% were able to provide
reasons for its occurrence. In this latter group, 25 subjects (44.7%) reported low bone mineral density as a
reason, 18 (32.1%) believed it to be calcium and vitamin
D deficiency, 12 (21.5%) indicated an abnormal bone
mass, and only one respondent (0.7%) pointed to age.
When given the opportunity to select up to three
answers, as to the basic factors influencing osteoporosis
development, respondents mostly selected old age, a
genetic predisposition and menopause (Figure 2).
Subjects were aware of the fact that osteoporosis
develops more often in women (73.3%), than men
(19.3%), or in children (7.3%). The main type of
osteoporosis found was the postmenopausal variety
affecting more than 17% of the female subjects. Secondary osteoporosis was observed in 16.7% respondents,
23,4%
25,0%
20,0%
20,0% 19,3%
16,3%
15,0%
10,0%
5,0%
8,9%
4,9%
7,3%
0,0%
Figure 2. Factors affecting the development of osteoporosis
in the opinion of respondents (%)
Figure 2. Factors affecting the development of osteoporosis in the opinion of respondents (%)
150
products found to be consumed were milk, curds, and
cottage cheese (Figure 3).
30,0%
Nr 2
25,8%
24,5%
25,0%
20,0%
15,1%
15,0%
11,9%
6,9%
10,0%
3,3%
5,0%
5,7%
2,5% 3,4%
0,0%
Figure 3. Types of dairy products consumed by respondents (%)
gure 3. Types of dairy products consumed by respondents (%)
Amongst those that knew about calcium, 55.9% believed that such requirements should be 1200 mg/day, and
44.1% - 1500 mg/day. Over 49% of subjects indicated
vitamin D to be a nutrient that supports the absorption
of calcium from the gastrointestinal tract with the others
being ignorant of this fact. Calcium deficiencies were
made up for by 54.0% taking supplements, whilst the
remainder did not use these type of products. The majority of respondents derived information on osteoporosis
from their GP (General Practitioner) and the Internet.
Another important source was also from the family,
radio and television (Figure 5).
35,0%
30,0%
25,0%
20,0%
15,0%
10,0%
5,0%
0,0%
30,2%
25,9%
Physical activity was considered to be important in
16,0%
preventing osteoporosis by 81.0% of subjects, whereas
11,7%
6,9%
16.0% said otherwise and less than 3.0% answered that
5,5%
4,9%
they didn’t know. The respondents were found to be
0,0%
fairly active physically, where 26.0% said they took
walks, 24.7% did exercises, 18.7% went swimming,
16.7% preferred other types of activities and 14.0%
said they were passive. Regarding being aware of the
importance of physical activity, then 28.0% said they
Figure 5.Information sources for respondents concerning
undertook this daily, 26.0% a few times weekly
Figure 5.and
Information sources for respondents concerning osteoporosis (%)
osteoporosis (%)
23.3% a few times a month; unfortunately 22.7% were
not involved in any sport/exercises at all.
52.0% of respondents were medically examined on
Fractures are an inevitable consequence of osteopooccurrence
of osteoporosis; the others did not particirosis. The reduced strength of bone tissue due to the
pate
in
such
examination. Furthermore, access to such
lower mineral density results in decreased resistance to
damage as compared to those persons with normal bone examinations is sufficient for less than 23% of responmineral density. It was found that 38.0% subjects had dents, while others declare that it is not sufficient. It was
fractures in the last year, where the wrist, forearm and found that 31% (15/59) of the subject group suffering
hip bone were broken most frequently (Figure 4). Of from osteoporosis that did not have fractures, didn’t
the 91 osteoporotic subjects, 42 (46.0%) had fractures practice sport while 27% (13/49) of these did so daily.
over the last year, whilst 15/59 (25%) healthy subjects However, 27.0% (12/44) of healthy persons who didn’t
have fractures within the last year were observed not
suffered fractures.
practice any sports at all, but 34.0% (15/44) practiced
it every day. It is worth noting that the results for these
40,0%
35,4%
two groups (i.e. osteoporotic and healthy) are very si35,0%
milar. In those osteoporotic subjects suffering fractures,
30,0%
only 10.0% (4/42) didn’t practice any sport at all and
25,0%
likewise in healthy subjects who suffered fracture, only
20,0%
18,5%
20,0%
9.0% (4/44) abstained from any sport.
15,0%
9,2%
10,0%
6,1%
4,6%
5,0%
0,0%
Wrist
Hip bone Femur
Spine
Forearm
Leg
6,1%
Arm
Figure 4. Fractures occurred to the surveyed within a year (%)
Figure 4. Fractures occurred to the surveyed within a year (%)
More than 47.0% of respondents answered that they
knew what helps to prevent osteoporosis, but 63.0% didn’t know the importance of daily calcium requirements.
DISCUSSION
Milk and dairy products are necessary foodstuffs in
the daily diet of every person. They provide many essential nutrients, of which calcium is the most important.
Nowicka and Panczenko-Kresowska [23] indicate that
the calcium deficiency caused by low intakes of milk,
give rise to bone abnormalities. According to Coudray
[5], insufficient intakes of milk and dairy products by
Nr 2
children and adolescents leads to a failure in achieving
peak bone mass, and in the case of adults, effects the
bone tissue remodelling disorder and fosters the loss of
bone mass. Furthermore, van Staveren et al. [32] has
indicated that an adequate dietary supply of this group
of food products helps in preventing osteoporosis. Besides dairy products, drinking water can also be quite
an important source of calcium in the diet as reported
by Madej et al. [20], with a 15 % of the daily calcium
intake derived from drinking water.
The Polish WOBASZ study (Multicenter National
Study of Population’s Health Status) from 2002-2005
showed that current consumption of milk and dairy
products is surprisingly low. Similar results of such
a decline were obtained by Bouamra-Mechemache et
al. [2]. The presented survey on the randomly selected
subjects however, do not confirm this as demonstrated
by the quite high consumption of milk and dairy products. Furthermore, the frequency in consuming this type
of food products were also satisfactory. The reason for
this is probably the dietary habits acquired in childhood.
Fischer et al. [11] showed that milk and dairy products
are perceived as a major group of foods needed for the
growth and development of children and adolescents.
A large assortment and wide availability of milk
and dairy products on the market allows consumers to
choose those which match their preferences. According
to Henning et al. [14], development of the dairy industry
has had a positive influence on the variety and quality
of such available products. Kozłowska-Wojeciechowska
[19] showed that 51% men meet the daily demand for
milk and dairy products but only 41% women do so.
This difference is not so apparent in the current study,
as both, male and female subjects were found to regularly consume dairy products. Our study showed that
respondents know how important calcium and vitamin
D are. This quite high awareness of the recommended
calcium intake could be due to the high predominance
of osteoporosis in the surveyed group. MarcinkowskaSuchowierska and Sawicka [22] reported that the daily
requirement for calcium for older people is 1200 mg/
day, which is consistent with Tang et al. [30], who
proved that a calcium intake of 1200 mg/day alone
or in combination with vitamin D, reduces the risk of
osteoporotic fractures. Marcinkowska-Suchowierska
et al. [22] also recommends calcium intake levels of
1200 mg/day and 800-1000 IU/day of vitamin D. Such
calcium recommendations (1200 mg/day) for women
and men above 50 and 65 years old respectively, can
be found in the latest Nutritional Standards established
for the Polish population [33]. However, the adequate
intake for vitamin D (cholecalciferol) for the same group
is 15 µg/day (600 IU) [15].
Subjects recognised that an older age, genetic predisposition, stimulants, drug abuse, poor socio-econom-
151
ic and environmental pollution are factors influencing
the development of osteoporosis. Indeed, according to
Tanriover et al. [31] and Handa et al. [13], the main
factors affecting the development of osteoporosis are
age and gender. Center and Eisman [4] point out that
genetic factors and environmental conditions also have
an impact on this illness. Eastell [9] agrees with the
aforementioned factors, but also considers the impact
of drugs and other diseases.
The incidence of osteoporosis (over 60 %) in the
presented study is quite striking and it probably results
from the relatively small group of respondents taken.
Some estimations report that in Poland, osteoporosis
affects 30% of women and 8% of men above 50 years
age. According to Koduganti et al. [18], women are
more prone to osteoporosis, but men also suffer. The
National Osteoporosis Foundation estimates that in
people over 50 years age, the risk of bone fractures
due to osteoporosis increases up to 50% in women
and 25% in men. Zdziemborska et al. [34] reported
that osteoporosis occurs in one third of women aged
60-70 years and two thirds of women aged 80 years
and above. The results of our study also agree with
these data, as over 73% indicated that women suffer
from osteoporosis more often. In addition, respondents identified the age of above 50 years as being the
threshold when osteoporosis occurs.
Czerwinski and Kumorek [6] consider that the
incidence of osteoporotic fractures varies across populations, not only in relation to age, gender and race,
but also to the region of the world and socio-economic
conditions. Data on fractures are alarming, because
every year the numbers are increasing. Worldwide,
osteoporosis causes more than 8.9 million fractures
annually. In Europe, there were 3,119,000 osteoporotic fractures in people aged over 50 years in 2000.
Moreover, it is estimated that in 2050 there will be 4.5
million hip fractures, while in 2000 there were only
1.6 million [27].
Badurski et al. [1] suggests that the main goal of
treatment is to prevent the risk of osteoporotic fractures.
It should include reducing the impact of risk factors for
fractures and improve bone density with the use of drug
therapy. According to the respondents, osteoporosis
tests are necessary and desirable, but equal access to
them is not sufficient because of the still small scale of
publicising the consequences of this disease.
CONCLUSIONS
1. Respondents were well aware that consuming dairy
products has a beneficial effect on bone health; with
this awareness being higher among persons afflicted
with osteoporosis.
152
2. Physical activity is indicated as a preventative measure against osteoporosis and was often adopted
by respondents.
3. The incidence of fractures in people older than 50
years suffering from osteoporosis was almost twice
as frequent as in healthy people.
4. It appears that common knowledge and education
of people over 50 years old regarding osteoporosis
is still insufficient.
Conflict of interests
The authors declare no conflict of interests.
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RESPONSIVENESS TO THE HOSPITAL PATIENT NEEDS IN POLAND
Lucyna Gromulska1*, Paweł Goryński2, Piotr Supranowicz1, Mirosław Jan Wysocki1
Department of Health Promotion and Postgraduate Education, National Institute of Public Health – National Institute of
Hygiene, Warsaw, Poland
1
ABSTRACT
Background. The health system responsiveness, defined as non-medical aspect of treatment relating to the protection of
the patients’ legitimate rights, is the intrinsic goal of the WHO strategy for 21st century.
Objective. To describe the patients’ opinions on treatment they received in hospital, namely: admission to hospital, the role
of patient in hospital treatment, course of treatment, medical workforce attitude, hospital environment, contact with family
and friends, and the efficacy of hospital treatment in respect to responsiveness to patient’s needs and expectations (dignity,
autonomy, confidentiality, communication, prompt attention, social support, basic amenities and choice of provider).
Material and methods. The data were collected in 2012 from 998 former patients of the randomly selected 73 hospital in
Poland.
Results. Dignity: Over 80% of patients experienced kindness, empathy, care and gentleness, and over 90% of them had
the sense of security in hospital, met with friendliness during the admission to hospital and never encountered inappropriate comments from medical staff. Autonomy: About 80% of patients accepted the active role of patients in hospital, they
perceived they had influence on procedures related to hospitalization and course of treatment, and they felt medical staff
responded to their requests and concerns. Over 90 % of them had opportunity to communicate their concerns to medical
staff and to discuss the course of treatment. On the other hand, the explanation of the reason for the refusal to meet their
requests was given to only 23 % of the patients interested. Confidentiality: 70-80 % of patients declared the respect for privacy and confidentiality during collecting the health information and during medical examinations, and were not examined
in presence of other people. Nevertheless, only 23% of patients examined so were asked of their consent. Communication:
About 90% of patients declared they trusted their physician, received from him explanation regarding the course of treatment and information about further treatment after discharge from hospital, but physicians devoted the time and attention to
only 70% of them. Prompt attention: Over 90% of patients perceived simplicity of the formalities of admission to hospital,
and short waiting for treatment and additional tests in hospital (but only 50% received explanation of reason if they waited
long). Nevertheless, 10% of them % of them perceived they waited for admission to hospital too long, and over 20% for
admission to a ward as long. Social support: The unlimited direct and phone contact with family and friends was declared
by 96% of patients. Basic amenities: The high percentage of patients assessed positively the marking in hospital (97%) and
cleanliness of linen (89%), followed by the general indoor appearance room in which patient stayed, lack of noise (70-80%),
hospital meals, furniture (60-70%), availability of personal hygienic articles (50-60%), cleanliness of hospital room, toilet,
showers and bathtubs, and availability of soap (40-50%). Choice of provider: Only 41% of patients declared that they had
influence on choice of the hospital.
Conclusion. Responsiveness of Polish hospital patient needs is similar to that of the OECD countries of the lowest health
system responsiveness. Compared to the Central European countries, the responsiveness in Polish hospitals is lower than
that of Czech Republic and only slightly higher of those of Slovenia, Slovakia and Hungary.
Key words: responsiveness, patient rights, hospital
STRESZCZENIE
Wprowadzenie. Wrażliwość systemu opieki zdrowotnej na potrzeby pacjenta, definiowana jako niemedyczny aspekt leczenia odnoszący się do ochrony praw należnych pacjentom, stanowi samoistny cel strategii Światowej Organizacji Zdrowia
na 21-szy wiek.
Cel badań. Zebranie i przedstawienie opinii pacjentów o leczeniu, które zapewniono im w szpitalu, mianowicie: przyjęcie do
szpitala, rola pacjenta w czasie leczenia szpitalnego, przebieg leczenia, postawa personelu medycznego, środowisko szpitalne,
kontakt z rodziną i znajomymi oraz skuteczność leczenia szpitalnego, w odniesieniu do wrażliwości na potrzeby i oczekiwania
pacjenta (godność, autonomia, poufność, komunikacja, niezwłoczna pomoc, wsparcie społeczne i wybór szpitala).
*Corresponding author: Lucyna Gromulska, Department of Health Promotion and Postgraduate Education, National Institute of
Public Health – National Institute of Hygiene, Chocimska Street 24, 00-791 Warsaw, Poland,
phone +48 22 54 21 203, fax +48 22 54 21 375, e-mail: lgromulska@pzh.gov.pl
156
L. Gromulska, P. Goryński, P. Supranowicz et al.
Nr 2
Materiał i metody. Dane zebrano od 998 byłych pacjentów z losowo wybranych 73 szpitali w Polsce.
Wyniki. Szacunek: Ponad 80% pacjentów dostrzegało życzliwość, współczucie, troskę i delikatność, a ponad 90% miało
poczucie bezpieczeństwa, spotkało się z uprzejmością podczas przyjęcia do szpitala i nie spotkało się z niewłaściwymi
uwagami ze strony personelu medycznego. Autonomia: Około 80% pacjentów akceptowało aktywną rolę pacjenta w szpitalu, postrzegało, że mają wpływ na działania związane z pobytem w szpitalu i przebiegiem leczenia i reagowanie przez
personel medyczny na ich prośby i wątpliwości. Ponad 90 % miało możliwość przekazywania personelowi medycznemu
swoich wątpliwości i omawiać przebieg leczenia z lekarzem. Z drugiej strony, wyjaśnienie powodów odmowy spełnienia ich
próśb przekazało tylko 23% zainteresowanych pacjentów. Poufność: Chociaż 70-80% pacjentów deklarowało respektowanie
prywatności i poufności w czasie zbierania informacji o zdrowiu i w czasie badań medycznych, a także nie byli oni badani
w obecności innych osób, jednakże o zgodę proszono tylko 23% pacjentów badanych w ten sposób. Komunikacja: Prawie
90% pacjentów odczuwało zaufanie do lekarza, otrzymywało od niego wyjaśnienia o przebiegu leczenia i informacje o dalszym leczeniu po wypisaniu ze szpitala, ale lekarz poświęcał swój czas i uwagę tylko 70% z nich. Szybka pomoc: Chociaż
ponad 90% pacjentów postrzegało łatwość załatwiania formalności związanych z przyjęciem do szpitala i czas czekania
na zabiegi i dodatkowe badania postrzegało jako krótki (ale jeśli długo czekali, to tylko 50% otrzymywało wyjaśnienia
o przyczynie), jednakże prawie 10% czekających na przyjęcie do szpitala i ponad 20% czekających na przyjęcie na oddział
postrzegało czas oczekiwania jako długi. Wsparcie społeczne: Brak ograniczeń w kontaktowaniu się z rodziną i znajomymi
poprzez wizyty i rozmowy deklarowało 96% pacjentów. Podstawowe udogodnienia: Wysoki odsetek pacjentów ocenił pozytywnie oznakowania w szpitalu (97%) i czystość pościeli (89%), a w następnej kolejności: wygląd wnętrza szpitala, salę
w której przebywa pacjent, brak hałasu (70-80%), posiłki, mebli (60-70%), zapewnienie papieru toaletowego, ręczników
papierowych i suszarek do rąk (50-60%), czystość sali szpitalnej, toalet, pryszniców i wanien oraz dostępność mydła (4050%). Wybór usługodawcy: 41% pacjentów zadeklarowało, że mieli możliwość wyboru szpitala.
Wnioski. Wrażliwość na potrzeby pacjentów szpitalnych w Polsce jest podobna do notowanej w państwach OECD o najniższej wrażliwości systemu zdrowia. W porównaniu do państw Europy Środkowej wrażliwość jest niższa niż w Republice
Czeskiej i tylko nieco wyższa niż w Słowenii, na Słowacji i na Węgrzech.
Słowa kluczowe: wrażliwość na potrzeby pacjenta, prawa pacjenta, szpital
INTRODUCTION
The concept of responsiveness being, in addition
to health outcomes and fair financial contribution, the
intrinsic goal of the health system performance assessment was formulated at the beginning of 21st century
in WHO strategy aimed at improving health quality and
equity [6]. Health system responsiveness is defined as
non-medical aspect of treatment relating to the protection of the patients’ legitimate needs and expectations in
the way guaranteed to him/her by the human rights and
patient rights in particular. It consists of eight domains.
Dignity refers to respectful treatment by health care
staff, the right to ask questions and provide information
during consultations and treatment, and privacy during
examination and treatment. Autonomy means the right
of an individual to be informed about his/her disease
and alternative treatment options, to be consulted about
treatment, and to express the informed consent in the
context of testing and treatment. Confidentiality involves
conducting the consultations with the patients in a manner
that protects their privacy and safeguards the confidentiality of information provided by the patient, information
relating to an individual’s illness in particular, except
in cases where such information needs to be given to a
health care provider, or where explicit consent has been
gained. Communication refers to clarity of information,
careful listening to the patient’s questions and explaining
things to be understood. Prompt attention means that
patients should be entitled to rapid care in emergency,
and they should be entitled to care within reasonable
time even in non-emergency health problems or surgery,
so waiting lists should not cover long periods. Quality
of basic amenities relates to clean surroundings, regular
procedures of cleaning and maintenance of hospital
buildings, adequate furniture, sufficient ventilation,
clean water, toilets and linen, and healthy food. Access
to social support during hospitalization should allow
for regular visits by relatives and friends and enable
religious practices that do not prove an obstacle to hospital or hurt the sensibilities of other patients. Choice
of care provider means being able to freely choose a
physician and an institution to provide health care [8].
Responsiveness research from the perspective of
patients is broadly similar to that of patient’s satisfaction, however they differ in their approach; the latter
puts emphasis on increasing the efficacy of medical
treatment, whereas the interest of this first mainly relates
to ethical issues of treatment [1].
Since 2011, the analysis of factors influencing the
opinions of treatment in Polish hospital granted by the
Ministry of Science and Higher Education has been
carried out in the Department of Health Promotion
and Postgraduate Education of the National Institute
of Public Health – National Institute of Hygiene in
Warsaw (Poland).
Nr 2
Responsiveness to hospital patient needs in Poland
The aim of present paper was to describe the patients’ opinions on treatment they received in hospital,
namely, admission to hospital, the role of patient in
hospital cure, course of treatment, medical staff attitude,
hospital environment, contact with family and friends,
and the efficacy of hospital treatment, in respect with
responsiveness to patient’s legitimate needs and expectations (dignity, autonomy, confidentiality, communication, prompt attention, social support, basic amenities
and choice of provider).
Data collection
The hospitals where respondents were recruited,
were randomly chosen from the register of Polish hospitals, and 73 public hospitals, proportionally to the
number of patients hospitalised in the provinces (voivodeships), were qualified. The study was conducted
among the patients of the internal medicine wards after
obtaining the permission of the patients themselves and
the hospital directors. Two thousand nine hundred and
twenty patients being at hospital from April to September 2012 had agreed to participate in the study and provided the contact details. The data were collected from
1000 former patients in December 2012, i.e. after 3 – 9
Table 1. Sample characteristics
Demographic factors
Total
Gender
male
female
Aged
18-29
30-44
45-64
65-79
80 and more
Education
elementary
vocational
secondary
post-secondary/incomplete higher
higher
Occupational activity
employed
unemployed seeking work
unemployed not seeking work
pensioners
Marital status
married/in permanent cohabitation
divorced
widowed
single
Place of residence
town
village
n
998
%
100
451
547
45.2
54.8
56
129
466
300
47
5.7
12.9
46.6
30.0
4.7
209
258
310
58
153
21.1
26.1
31.4
5.9
15.5
287
39
63
606
28.8
3.9
6.3
60.9
647
54
186
108
65.0
5.4
18.6
10.8
581
417
58.2
41.8
157
months after discharge from hospital, and 998 correctly
completed questionnaires were used for analysis. The
sample characteristics is presented in Table 1.
Questionnaire
The developed questionnaire was based on the
WHO responsiveness definition and modified to suit
the Polish health system conditions. The questions were
grouped into seven themes: admission to hospital, the
role of patient in hospital care, treatment course, medical staff, hospital environment, contact with family
and friends, and the efficacy of hospital treatment.
The admission to hospital covered: health status at the
time of admission to hospital, procedure of admission,
choice of hospital, actual and perceived waiting time
for admission to hospital, actual and perceived time of
waiting in hospital to be admittted on a ward, simplicity
of arranging the formalities of admission to hospital,
staff attitude to the patient and to accompanying persons during admission. The role of patient in hospital
covered: general opinion concerning the active role of
the patient in the hospital, patient’s influence on a course of treatment, discussing and agreeing a course of
treatment with the patients, opportunity to communicate
the concerns to medical staff, reporting the requests
and concerns by medical staff and explanation of the
reason for the refusal of fulfilling the request. Course
of treatment covered: sense of security during the stay
in hospital, respect for privacy and confidentiality when
collecting health information, respect for privacy and
confidentiality during of medical examinations, presence of unauthorized people during medical examinations
or patient-doctor conversations, patient’s consent to the
presence of other people during medical examinations or
patient-doctor conversations, inappropriate comments
from the hospital staff, waiting for treatment or additional tests, explanation of the reason of the long waiting
for treatment or additional tests, lack of gentleness of
the medical staff during treatment and wearing rubber
gloves by the medical staff during treatments. Medical
staff assessment covered: kindness of the hospital staff
referring to the patients, empathy and care of medical
staff towards the patients, confidence to the physician
attending, time and attention devoted to patients by the
physician, explanation of the course of treatment given
by physician, giving the information to the patient about
further treatment after discharge from hospital, medical
staff assistance in daily activity, quick help from nurses
and assessment of the appearance of the medical staff.
Hospital environment covered: the interior of the hospital, marking applied in hospital, room in which patient
resides, hospital furniture, cleanliness of hospital room,
linen, toilet, showers and bathtubs, availability of toilet
paper, soap, paper towels and hand dryers, noise and
hospital meals. Contact with family and friends cove-
158
Nr 2
red: regulation of hospital visits, phone contact with
family and friends and nuisance of guest visits to other
patients. The efficacy of hospital treatment covered:
actual and perceived length of stay in hospital, perceived
improvement in health status after hospital treatment
and recommending the hospital to family and friends.
The usefulness of the questionnaire was validated
in the pilot study on 25 patients.
Statistical analysis
The SPSS program was applied for establishing the
database and statistical analysis. According to the WHO
recommendations for responsiveness measuring [10],
the ordinal variables (except those of two categories)
were converted into three-categorised (positive, moderate, negative response), and the prevalence of positive
responses (percentages) was set up as a measure of
responsiveness in respect to the item creating the domain (i.e. dignity, autonomy, etc.). Responsiveness of
a domain was calculated as the mean of percentages of
positive responses to the items forming given domain,
and the total responsiveness was the mean of percentages of positive responses to all items.
RESULTS
Admission to hospital
The referred planned admissions to hospital were
more frequent than those due to emergency or sudden
deterioration in health (Table 2). Only two of five patients declared the possibility to choose a hospital. Two-thirds of the patients waited for admission to hospital
no longer than 7 days, nevertheless, over 10% had to
wait more than 30 days, in that, almost 10% as long as
90 days or more. Also two-third of the patients defined
the waiting time as short, while almost 10% perceived
that they waited long. Only every fourth patient waited
at hospital for admission to a ward up to 15 minutes,
and the same proportion of them waited 16-30 minutes,
while almost 30% of the patients had to wait one hour, in
that, almost 7% as long as four hours and longer. Almost
half of the patients described the waiting time as short,
however, it was long for every one in five patient, as
expected. The vast majority of the patients perceived
the arranging the formalities of admission to hospital
as simple, and assessed positively the hospital staff
attitude to patients and accompanying persons during
admission to hospital.
The role of patient in hospital
Most of the patients recognised the need for the
active role of patients in the hospital, while every tenth
patient was of the opposite opinion (Table 3). Majority
of them experienced the influence on the procedures
Table 2. Admission to hospital
Factors examined*
Health status at the time of admission to
hospital
walking unaided
moving with the help of other person or walker
not walking and conscious
unconscious
Procedure of admission
emergency, sudden deterioration in health
planned admission to hospital with referral
transfer from another hospital
Hospital selection (CP)
self-choice
impossibility of self-choice
Waiting time for admission to hospital
up to 7 days
7-30 days
30-90 days
>90 days
Perceived waiting time for admission to
hospital (PA)
short or did not wait at all
middling
long
Waiting time at the hospital to admit on a ward
up to 15 min.
16-30 min.
31-60 min.
61-120 min.
121-240 min.
>240 min.
Perceived waiting time to admit on a ward (PA)
short
middling
long
Simplicity of arranging the formalities of
admission to hospital (PA)
yes
no
Staff attitude to the patient during admission to
hospital (D)
positive
negative
Staff attitude to the accompanying persons
during admission to hospital (D)
positive
negative
n
%
733
164
79
22
73.4
16.4
7.9
2.2
433
523
20
43.5
52.5
2.0
200
285
41.2
58.8
180
80
25
11
61.9
26.3
8.2
3.6
318
130
46
64.4
26.3
9.3
231
219
170
113
85
59
26.3
25.0
19.3
13.0
9.7
6.7
318
130
46
49.3
28.0
22.7
880
69
92.7
7.3
933
19
98.2
2.0
655
17
97.5
2.5
* Domains of responsiveness in parentheses: D – dignity, A – autonomy, Cy – confidentiality, Cn – communication, PA – prompt
attention, SS – social support, BA – basic amenities, CP – choice
of provider.
relating to stay in hospital and a course of treatment,
however, the opponents were frequent in the latter. The
vast majority of the patients discussed and agreed a
course of treatment with medical staff and had opportunity to communicate their concerns to them. Every
fourth of the patients reported requests and concerns
and almost 80% of them received satisfactory reaction
from medical staff. Nevertheless, only every fifth was
given an explanation for the refusal of their request.
Nr 2
159
Table 3. The role of patient in hospital treatment
Factors examined*
Opinion concerning the active role of the
patients in the hospital (A)
yes
sometimes
no
Patient’s influence on the procedures related to
staying in hospital (A)
often
sometimes
rarely or never
Patient’s influence on a course of treatment (A)
yes
sometimes
no
Discussing and agreeing a course of treatment
with the patients (A)
yes
no
Opportunity to communicate the concerns to
medical staff (A)
yes
rarely or never
Reporting the requests and concerns by patients
yes
no
Responding to the patient’s requests and
concerns by medical staff (A)
satisfactory
incomplete
getting rid
Explanation of the reason for the refusal of
fulfilling the request (A)
always
sometimes
never
n
%
753
115
85
79.0
12.1
8.9
346
92
454
81.2
13.3
5.5
734
101
104
78.2
10.8
11.0
943
40
95.9
4.1
867
79
91.6
8.4
274
724
27.5
72.5
218
31
25
79.6
11.3
9.1
13
22
21
23.2
39.3
37.5
of provider.
Treatment course
The vast majority of the patients experienced the
sense of security during the stay in hospital, while
those who felt insecure were 2% (Table 4). Also, the
most of the patients experienced respect for privacy
and confidentiality when collecting health information
and in time of medical examination, nevertheless, every
sixth and every eighth patient, respectively, was treated with little respect. One-third of the patients were
examined in the presence of unauthorised people, and
only every fourth of them were asked of their consent
to such presence. Although only 4% of the patients
encountered inappropriate comments from the hospital
staff. The vast majority of the patients waited shortly
for treatment or additional tests, but the explanation of
the reason of waiting was given to only the half of those who waited long. Most of the patients were always
treated with gentleness , while almost 3% perceived the
lack of gentleness of the medical staff during treatment.
Wearing the rubber gloves by medical staff during
treatments is mandatory, therefore, it is worrying that
almost 5% of the patients reported that the gloves were
not always worn.
Table 4. Course of treatment
Factors examined*
Sense of security during the staying in hospital (D)
yes
sometimes
no
Respect for privacy and confidentiality when
collecting health information (Cy)
yes
sometimes
no
Respect for privacy and confidentiality in the
time of medical examinations (Cy)
yes
sometimes
no
Medical examinations or health talks in the
presence of other people (Cy)
no
yes
Consent on the presence of other people during
medical examinations or health talks (Cy)
yes
no
Inappropriate comments from the hospital staff (D)
was
not was
Waiting for treatment or additional tests (PA)
short
long
Explanation of the reason for the long wait for
treatments or additional tests (PA)
given
not given
Lack of delicacy from the medical staff during
treatment (D)
never
sometimes
often
Wearing rubber gloves by the medical staff
during treatments
always
sometimes
never
n
%
953
24
20
95.6
2.4
2.0
569
70
140
72.3
9.9
17.8
748
55
11
81.8
6.0
12.2
679
298
69.5
30.5
218
745
22.6
77.4
957
40
96.0
4.0
914
63
93.5
6.5
31
32
49.2
50.8
881
72
26
90.0
7.3
2.7
935
41
5
95.3
4.2
0.5
* Domains of responsiveness in parentheses: D – dignity, A –
autonomy, Cy – confidentiality, Cn – communication, PA – prompt
of provider.
Medical staff
The majority of patients experienced kindness,
sympathy and care from medical staff, and only few of
them (5,5% and 2,7%) were treated otherwise. (Table
5). The attending physician was mostly described positively in answers to the questions about confidence,
explanation the course of treatment, provision of the
information about further treatment after discharge
from hospital and, to a lesser extent, time and attention
160
Nr 2
devoted to patients. Nevertheless, one in twenty patients
did not confide in their physician, and one in ten patients
was not given enough attention explanation of the treatment, nor was he informed about the future treatment.
Medical staff assisted in daily activity three-quarters
of patients, but one in thirty patients who needed assistance did not received it. Two-thirds of patients always
received the prompt help, however, every tenth of the
patients experienced it rarely or never. The appearance
(neat, clean) of the medical staff was positively assessed
by the majority of patients.
Table 5. Medical staff
Factors examined*
Kindness of the hospital staff referring to the
patients (D)
always gentle
mainly
rarely or never
Sympathy and care to the patients from
medical staff (D)
very careful
moderately
little
Confidence to the physician attending (Cn)
yes
to a limited extent
no
Time and attention devoted by the physician to
patients (Cn)
always paid attention to the patients
mostly
rarely or never
Explanation by the physician agreeing the
course of treatment (Cn)
yes
no
Providing by physician the information about
further treatment after discharge (Cn)
yes
no
Medical staff assistance in daily activity (PA)
yes
no
not need help
Quick help from the nurses/orderlies if need (PA)
always
often
rarely or never
Assessment of appearance of the medical staff
(PA)
always neat and tidy
mostly
rarely or never
n
%
810
133
55
81.2
13.3
5.5
839
121
27
85.0
12.3
2.7
894
47
54
89.8
4.7
5.5
703
171
118
70.9
17.2
11.9
884
110
88.9
11.1
913
80
91.9
8.1
753
31
212
75.6
3.1
21.3
556
251
74
63.1
28.5
8.4
921
60
14
92.6
6.2
1.4
of provider.
Hospital environment
The high percentage of patients were satisfied with:
the marking in hospital (97%) and cleanliness of linen
(89%), the interior of the hospital and patients’ room,
lack of noise (70-80%), hospital meals, furniture (6070%), availability of toilet paper and paper towels or
hand dryers (50-60%), cleanliness of hospital room,
toilet, showers and bathtubs, and soap (40-50%) available (Table 6).
Table 6. Hospital environment
Factors examined*
The interior of the hospital (BA)
positive
moderate
negative
Marking applied in hospital (BA)
adequate
inadequate
Patients’ room (BA)
spacious
middling
narrow
Hospital furniture (BA)
positive
moderate
negative
Cleanliness of hospital room (BA)
definitely clean
acceptably
dirty
Cleanliness of linen (BA)
changed according to the patient needs
not changes
Cleanliness of toilet (BA)
definitely clean
acceptably
dirty
Availability of toilet paper (BA)
always
sometimes
never
has own paper
Availability of soap (BA)
always
sometimes
never
has own soap
Availability of paper towels or hand dryers (BA)
always
sometimes
never
Cleanliness of showers and bathtubs (BA)
definitely clean
acceptably
dirty
Noise nuisance (BA)
no
sometimes
yes
Hospital meals (BA)
positive
moderately
negative
n
%
742
173
83
74.3
17.3
8.4
955
28
97.1
2.9
740
181
77
74.1
18.1
7.8
649
212
137
65.0
21.2
13.8
487
492
17
48.9
49.4
1.7
84
98
89.6
10.4
466
450
67
47.4
45.8
6.8
572
164
152
99
58.0
16.6
15.4
10.0
446
146
223
171
45.2
14.8
22.6
17.4
488
184
276
51.5
19.4
29.1
403
498
58
42.0
51.9
6,1
709
168
121
71.1
16.8
12.1
565
247
24
67.6
29.5
2.9
of provider.
Nr 2
161
Contact with family and friends
The vast majority of patients declared they had
opportunity to contact family and friends in person, or
by phone (Table 7). Only every twelfth patient reported
the nuisance of guest visits to other patients.
Table 7. Contact with family and friends
Factors examined*
Regulation of hospital visits (SS)
unlimited
limited
Phone contact with family and friends (SS)
possible
impossible
Nuisance of guest visits to other patients
no
yes
n
%
945
39
96.0
4.0
877
37
96.0
4.0
920
77
92.3
7.7
of provider.
The efficacy of hospital treatment
Over the half of patients stayed in hospital fot 2-7
days, and almost half of them stayed in hospital longer
(Table 8). Those of one-day stay were few. From the
patient perspective, the length of staying in hospital was
adequate to their health needs, for the most of them,
while every eighth patient perceived it as too short and
every fifteenth as too long. The three-quarters of patients
perceived improvement in their health due to hospital
treatment, whereas every fifteenth did not note a positive
result. The majority of patients would recommend the
hospital where they were treated to family and friends.
The dissatisfied patients were almost 8%.
Table 8. The efficacy of hospital treatment
Factors examined
Length of staying in hospital
1 day
2-7 days
more than 7 days
Perceived length of staying in hospital
adequate
too short
too long
Perceived improvement in health status after
hospital treatment
yes
hard to say
no
Recommending the hospital to family and friends
yes
sometimes
no
n
%
13
540
438
1.3
54.5
44.2
799
118
57
82.0
12.1
5.9
778
154
66
78.0
15.4
6.6
848
74
76
85.0
7.4
7.6
Responsiveness
The unweighted means of the responsiveness domains calculated by summing the percentages of positive
responses divided by the number of items of the domain
were shown in Table 9. The social support presented the
highest mean prevalence, followed by dignity, communication, autonomy, prompt attention, basic amenities,
confidentiality and choice of provider. The mean of over
80% indicates the provision of patients legitimate needs
and expectations (social support, dignity and communication), while that under 70% shows no respect for
patient’s rights (choice of provider, confidentiality and
basic amenities).
Table 9. Unweighted means of the responsiveness domains.
Domains
Dignity
Autonomy
Confidentiality
Communication
Prompt attention
Social support
Basic amenities
Choice of provider
Total
no. of
items
7
7
4
4
5
2
13
1
mean of positive
responses (%)
92
76
62
85
70
96
64
41
43
73
range (%)
81 – 98
23 – 96
23 – 82
71 – 92
49 – 94
96
42 – 97
41
23 – 98
DISCUSSION
Dignity
The WHO ranking of patients’ perceived importance of responsiveness domains was developed using
the data from the international study on 117 549
participants from 65 countries. Dignity got the second
rating of the importance and its mean was 14.8 points
(in Poland – third rating and 13.7 points). The highest
rating was noted in Egypt, Lebanon and Chile, while the
lowest in Luxemburg, France and New Zealand [10].
The study on the health system responsiveness from
the perspective of patients conducted on the sample
of 27 521 inpatients from 16 OECD countries showed
that the average prevalence of positive responses concerning dignity was 86% (range 61-97%). The higher
responsiveness (>90%) was reported in Sweden, United
States, United Kingdom, Canada, Luxemburg, France
and New Zealand, while the lower (<70%) in Greece
and Portugal [9]. The average percentage of positive
responses related to dignity in the study conducted on
inpatients from 5 Central European countries (Croatia,
Czech Republic, Hungary, Slovakia and Slovenia) was
78% and ranged from 65% (Croatia) to 82% (Czech
Republic) [11]. Our findings confirmed the high responsiveness to Polish hospital patients in respect to
dignity is comparable to that of the OECD countries of
the highest prevalence, and much higher of that of the
Central European countries. In our study, the items of
the questionnaire related to dignity presented the low
diversity. Over 80% of patients experienced kindness,
162
empathy, care and gentleness, and over 90% of them had
the sense of security in hospital, met with friendliness
during admission to hospital and never encountered
inappropriate comments from medical staff.
Autonomy
Autonomy got the sixth most important domain of
responsiveness in the WHO study mentioned above
and its mean was 11.7 points (in Poland – fifth rating
and 12.0). The highest rating was reported in Austria,
Netherlands, Switzerland, Sweden, China and Denmark, while the lowest in Egypt, Romania and Georgia
[10]. The study of 16 OECD countries showed that the
average prevalence of positive responses concerning
autonomy was 72% (range 44-84%). The higher responsiveness (>80%) was reported in New Zealand, United
States, Luxemburg, Sweden and United Kingdom, while
the lower (<70) in Greece, Italy, Spain and Portugal
[9]. In the study of the Central European countries, the
average percentage of positive responses related to
autonomy was 54% and ranged from 32% (Croatia) to
63% (Hungary) [11]. Our findings demonstrated that the
responsiveness to the Polish hospital patients in respect
to autonomy is slightly above the mean for the OECD
countries and considerably higher than the mean for
the Central European countries. Particular items of the
questionnaire related to autonomy presented the high
diversity. About 80% of patients accepted the active role
of patients in hospital, they stated that they had influence
on procedures related to staying in hospital and course
of treatment, and they were given response to their requests and concerns from medical staff. Over 90% of
patients had opportunity to communicate their concerns
to medical staff and to discuss the course of treatment
with the physician. On the other hand, the explanation
of the reason for the refusal to address their requests was
given to only 23 % of the patients interested.
Confidentiality
Confidentiality got the fourth rating in the WHO
study and its mean was 12.4 (in Poland - sixth rating and
a mean of 12.0). The highest rating was reported in Iceland, Germany, France, Belgium and Egypt, while the
lowest in Lithuania, Indonesia and Romania [10]. The
study of 16 OECD countries showed that the average
prevalence of positive responses related to confidentiality was 82% (range 68-92%). The higher responsiveness
(>90%) was reported in Ireland, Canada and United
States, while the lower (70) in Italy and Portugal [9].
The average percentage of positive responses related to
confidentiality was 70% and ranged from 54% (Croatia)
to 78% (Czech Republic) [11]. Our findings demonstrated that the responsiveness to the Polish hospital patients
in respect in terms of confidentiality is comparable with
Nr 2
that for the OECD countries of the lowest prevalence
and lowest than the mean for the Central European countries. The items of the questionnaire composing the
domain of confidentiality presented the high diversity.
Although 70-80 % of patients declared they experienced
respect for privacy and confidentiality during collecting
the health information and during medical examinations,
and were not examined in presence of other people,
nevertheless, only 23 % of those examined were asked
of their consent.
Communication
Communication got the third rating in the WHO
study and its mean was 14.0 (in Poland – fourth rating
and a mean of 12.7). The highest rating was reported
in Republic of Korea and Indonesia, while the lowest
in Venezuela and Portugal [10]. The study of 16 OECD
countries showed that the average prevalence of positive responses concerning communication was 82%
(range 49-89%). The higher responsiveness (>85%)
was reported in Sweden, New Zealand, France, United
States and Finland and dramatically low (<50%) in Greece [9]. The average percentage of positive responses
related to communication in the study of 5 Central was
72% and ranged from 56% (Croatia) to 80% (Slovakia)
[11]. Our findings demonstrated that responsiveness to
Polish hospital patients in respect to communication is
slightly higher than the mean for OECD countries and
considerably higher than that of the Central European
countries. The items of communication presented moderate diversity. About 90% of patients felt they could
confide in their physician, received from him explanation regarding the course of treatment and information
about further treatment after discharge from hospital,
but physicians devoted sufficient time and attention to
only 70% of them.
Prompt attention
Prompt attention was rated as first in the WHO
study and its mean was 18.0 (in Poland - also the first
and a mean of 19.5). The highest rating was reported
in Indonesia and Italy, while the lowest in Lebanon and
China [10]. The study of 16 OECD countries showed
that the average prevalence of positive responses concerning prompt attention was 77% (range 61-85%). The
higher responsiveness (>80%) was reported in Germany,
Netherlands, Luxemburg, United Kingdom, Ireland
and Finland, while the lower (<70%) in Greece [9].
The average percentage of positive responses related
to prompt attention in the study of 5 Central European
countries was 58%, and ranged from 43% (Croatia) to
74 % (Czech Republic) [11]. Our findings demonstrated
that the responsiveness to the Polish hospital patients
in respect to prompt attention is comparable to that of
Nr 2
the OECD countries of the lowest responsiveness and
higher than the mean for the Central European countries, however, lower than that of Czech Republic. The
items of prompt attention demonstrated high diversity.
Over 90% of patients experienced simplicity of arranging the formalities of admission to hospital and short
waiting for treatment and additional tests in hospital
(but only 50% received explanation for undergoing
these procedures. 64% of the respondents declared they
waited shortly for admission to hospital, and only 50%
for admission to a ward.
Social support
Social support got the eighth rating in the WHO
study and it mean was 6.3 (in Poland also eight rating
and 4.7). The highest rating was reported in Canada and
Kyrgyzstan, while the lowest in Republic of Korea ,
Hungary, Netherlands and Sweden [10]. The study of 16
OECD countries showed that the average prevalence of
positive responses concerning social support was 88%
(range 74-96%). The higher responsiveness (>90%)
was reported in Netherlands, Canada, Sweden, United
Kingdom and Luxemburg, while the lowest <80%) in
Portugal, Greece and Italy [9]. The average percentage
of positive responses related to social support in the
study of 5 Central European countries was 80% and
ranged from 61% (Croatia) to 93% (Hungary) [11]. Our
findings demonstrated that responsiveness to Polish hospital patients in respect to social support is comparable
to that of the OECD countries of the highest prevalence
and higher than that of the Central European countries
(except Hungary). The items of social support presented
complete identity. The unlimited contact with family
and friends by visits or phone declared 96% of patients.
Basic amenities
Basic amenities got seventh rating in the WHO
study and it mean 10.6 (in Poland also seventh rating
and 11.3). The highest ratings was reported in Turkey,
Indonesia, Nigeria and Kyrgyzstan, while the lower in
Canada and France [10]. The study of 16 OECD countries showed that the average prevalence of positive
responses concerning basic amenities was 74% (range
59-88%). The higher responsiveness (>80%) was reported in Ireland, Germany and United Kingdom, while
the lowest (<70%) in Italy, Greece and Portugal [9].
The average percentage of positive responses related
to quality of basic amenities in the study of 5 Central
European countries was 60% and ranged from 44%
(Croatia) to 80% (Czech Republic) [11]. Our findings
demonstrated that responsiveness to Polish hospital
patients in respect to basic amenities is comparable to
that of the OECD countries of the lowest prevalence
and comparable with the mean for the Central European countries, but considerably lower of that in Czech
163
Republic. The items of the quality of basic amenities
presented high diversity. The high percents of patients
assessed positively the marking in hospital (97%) and
cleanliness of linen (89%), followed by the appearance
inside the hospital, room in which patient resides, lack
of noise nuisance (70-80%), hospital meals, furniture
(60-70%), availability of toilet paper and paper towels
or hand dryers (50-60%), cleanliness of hospital room,
toilet, showers and bathtubs , and soap available for
patients(40-50%).
Choice of provider
Choice of provider got the fifth rating in The WHO
study and its mean was 12.3 (in Poland - the second
rating and a mean of 13.9). The highest rating was
reported in United States, Estonia, Latvia, Cyprus and
Czech Republic, while the lowest in Nigeria, India and
Indonesia [10]. The study of 16 OECD countries showed
the average prevalence of positive responses concerning choice of provider was 87% (range 60-97%). The
higher responsiveness (>90%) was noted in Belgium,
France, New Zealand, Canada United States and United
Kingdom, while the lowest in Finland (60%) [9]. The
average percentage of positive responses related to
choice of provider in the study of 5 Central European
countries was 64% and ranged from 54% (Croatia) to
79% (Czech Republic) [11]. Our findings demonstrated
that responsiveness to Polish hospital patients in respect
to choice of provider is much lower than both: that of
the OECD countries of the lowest prevalence and of the
Central European countries (41% of patients declared
that they had possibility to choose hospital), however,
the underestimation due to only one item used for measuring should be taken into account.
Total responsiveness
The overall mean of positive responses of the total
responsiveness for 16 OECD countries was 81% (range
62-88%). The higher responsiveness (>85%) was noted
in United Kingdom, Ireland, Luxemburg, New Zealand,
United States and Sweden, while the lower (<75%) in
Greece, Portugal and Italy [9]. The overall mean for
responsiveness for 5 Central European countries was
67% and ranged from 51% (Croatia) to 76% (Czech
Republic) [11]. The study conducted by us showed that
the overall mean of responsiveness of Polish hospital
patient needs is similar to that of the OECD countries
of the lowest health system responsiveness. Compared
to the Central European countries, the responsiveness
is lower than that of Czech Republic and only slightly
higher of those of Slovenia, Slovakia and Hungary. Our
findings are consistent with the common opinion on
the healthcare in Poland confirmed by the population-based surveys [2, 7]. It should be noted, however, that
164
presented results are opposite to those of the patient
satisfaction studies, which have permanently demonstrated the positive (even to 100% [3]) evaluation of
medical services received in hospitals [4, 5]. The latter
are undoubtedly very beneficial for hospitals when they
apply for accreditation, but seem to be less sensitive
to the actual patient interaction with health system.
The use of the responsiveness measuring allows us to
demonstrate authentic situation of the hospital patients
in Poland.
CONCLUSIONS
Our findings showed that the responsiveness to
Polish hospital patient needs is similar to the OECD
countries of the lowest health system responsiveness.
Compared to the Central European countries, the responsiveness is lower than that of Czech Republic and
only slightly higher of those of Slovenia, Slovakia and
Hungary. In particular:
1. the hospital patients legitimate needs and expectations were met sufficiently regarding the social
support, dignity and communication;
2. the health system responsiveness was somewhat
worse regarding the autonomy and prompt attention;
3. the patients’ rights were not respected enough regarding quality of basic amenities, confidentiality and
choice of health providers.
Acknowledgements
The study was performed as the scientific project nr
N N404 168540 ‘Analysis of factors influencing the
opinions on treatment in Polish hospitals’ financed by
National Science Centre, Poland.
The authors would like to thank Bożena Moskalewicz,
PhD and Elżbieta Buczak-Stec, MSc, for their invaluable contribution in the project.
The authors declare no conflict of interest
Nr 2
REFERENCES
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2012;66(1):149-155.
8. Valentine N.B., Lavalee R., Liu B., Bonsel G.J., Murray
C.J.L.: Classical psychometric assessment of the responsiveness instrument in the WHO multi-country study on
health and responsiveness. In: Murray C.J.L., Evans D.B,
eds.: Health system performance assessment: debates,
methods and empiricism. Geneva, WHO, 2003, 597-629.
9. Valentine N.B., Ortiz J.P., Tandon A., Kawabata K., Evans
D.B., Murray C.J.L.: Patient experiences with health
services: population survey from 16 OECD countries.
In: Murray C.J.L., Evans D.B., eds.: Health system performance assessment: debates, methods and empiricism.
Geneva, WHO, 2003, 643-652.
10. Valentine N.B., Salomon J.A.: Weights for responsiveness
domains: analysis of country variation in 65 national sample surveys. In: Murray C.J.L., Evans D.B., eds.: Health
system performance assessment: debates, methods and
empiricism. Geneva, WHO, 2003, 631-642.
11. Vitrai J.: Inequalities in health system responsiveness:
joint World Health Survey report based on data from
selected Central European countries. Geneva, WHO,
2007.
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[ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE]
Volume 65
2014
Number 2
CONTENTS
REVIEW ARTICLES
Flavonoids – food sources and health benefits.
A. Kozłowska, D. Szostak-Węgierek .................................................................................................................................. 79
Diacetyl exposure as a pneumotoxic factor: a review.
B. Starek-Świechowicz, A. Starek ...................................................................................................................................... 87
ORIGINAL ARTICLES
Development and validation of a method for determination of selected polybrominated diphenyl ether congeners
in household dust.
W. Korcz, P. Struciński, K. Góralczyk, A. Hernik, M. Łyczewska, K. Czaja, M. Matuszak, M. Minorczyk,
J. K. Ludwicki ................................................................................................................................................................... 93
Variations of niacin content in saltwater fish and their relation with dietary RDA in Polish subjects grouped by age.
M. Majewski, A. Lebiedzińska ......................................................................................................................................... 101
Evaluating adult dietary intakes of nitrate and nitrite in Polish households during 2006-2012.
A. Anyżewska, A. Wawrzyniak ......................................................................................................................................... 107
School pupils and university students surveyed for drinking beverages containing caffeine.
M. Górnicka, J. Pierzynowska, E. Kaniewska, K. Kossakowska, A. Woźniak ................................................................ 113
The use of vitamin supplements among adults in Warsaw: is there any nutritional benefit?
A. Waśkiewicz, E. Sygnowska, G. Broda , Z. Chwojnowska ........................................................................................... 119
Energy and nutritional value of the meals in kindergartens in Niš (Serbia).
K. Lazarevic, D. Stojanovic, D. Bogdanović .................................................................................................................. 127
Comparing diabetic with non-diabetic overweight subjects through assessing dietary intakes and key parameters
of blood biochemistry and haematology.
K. Gajda, A. Sulich, J. Hamułka, A. Białkowska ............................................................................................................ 133
Nutritional values of diets consumed by women suffering unipolar depression.
E. Stefańska, A. Wendołowicz, U. Kowzan, B. Konarzewska, A. Szulc, L. Ostrowska .................................................... 139
Awareness of factors affecting osteoporosis obtained from a survey on retired Polish subjects.
N. Ciesielczuk, P. Glibowski, J. Szczepanik .................................................................................................................... 147
Responsiveness to the hospital patient needs in Poland.
L. Gromulska, P. Goryński, P. Supranowicz, M.J. Wysocki ............................................................................................ 155
Instruction for authors ................................................................................................................................................. 165
Abstracts and full texts: http:// www. pzh.gov.pl/roczniki_pzh/

roczniki państwowego zakładu higieny - Wydawnictwa NIZP-PZH

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