In the last few decades, there has been an increase in the prevalence of nutrition-related non-communicable diseases, including obesity, cardiovascular diseases, and type 2 diabetes mellitus [1
]. It has been suggested that this could be the result of a nutrition transition characterised by changes in the dietary pattern towards an unbalanced and unhealthy diet [3
], accompanied by an unhealthy lifestyle that includes physical inactivity and sedentary behaviour [1
Adequate nutrition is one of the pillars of public health, and knowing the population’s nutritional situation, before designing national guidelines, it is essential to improve the nutrition of the population [4
]. Zinc, selenium, and vitamins A (retinol and carotenes), E and C, have in common biological functions involved in the antioxidant defence system, which have important implications for the prevention of inflammatory chronic diseases and in particular of cardiovascular illnesses.
Zinc is an essential trace element that participates in many metabolic processes as a catalytic, regulatory and structural component [5
]. It is a cofactor for more than 300 enzymes and it is part of the structure of 2500 transcription factors [6
]. It is also involved in the metabolic hormone regulation of growth and has key roles in gene expression regulation and the immune system. Selenium’s main biological role is associated with glutathione peroxidase (GPOX) and avoiding toxicity by selenoproteins [7
]; apart from its antioxidant function, these proteins are involved in spermatogenesis, brain development, and thyroid function [7
]. Vitamin A comprises retinol and the molecules that share its biological activity (retinoids), and those with provitamin A activity (carotenoids) [8
]. Vitamin A participates in many biological functions such as the visual cycle, cell differentiation, cell proliferation and apoptosis, maintenance of epithelial tissue, reproduction and embryogenesis, haematopoiesis, intercellular communication, antioxidant defence, and immune competence [9
]. Vitamin E is an effective antioxidant in the protection of unsaturated fatty acids and other easy oxidizable substances. This vitamin participates mainly in the stabilisation of biological membranes, the inhibition of platelet aggregation, the maintenance of the erythrocyte morphology and influences the activity of some enzymes [10
]. Vitamin C is an antioxidant with a high reducing power. This vitamin participates as a cofactor in many biochemical reactions namely in the synthesis of collagen, carnitine, and catecholamines. It is also involved in the metabolism of cholesterol [11
National diet survey, including a three-day food record, is the most common tool to evaluate the nutrient self-reported intake and the nutritional situation of the population. However, by using this kind of methodology, people tend to misreport their energy intake (EI), as it is mainly auto-reported [12
]. Consequently, the reported EI does not represent the usual intake giving an estimate EI that is not physiologically plausible [12
]. ANIBES (Anthropometry, Intake and Energy Balance in Spain) is a Spanish study that evaluates energy intake and expenditure, body composition and dietary patterns in a national representative sample. Previous articles have reported intake of energy [13
], the main macronutrients [14
] and several micronutrients [15
]. As part of the representative Spanish ANIBES study [17
], in the present article, we analysed the reported intake of zinc, selenium, and the vitamins A (retinol and carotenes), E, and C in the whole population, and in the plausible energy reporters separately (following EFSA harmonised approach to identify misreporting), and assessed the food that contributes to their sources of intake.
Recent studies have demonstrated that a well-balanced diet leads to an improved redox status, which affects positively to reduce the risk of non-communicable chronic diseases [25
]. The present article analyses the daily intake of the main micronutrients involved in the antioxidant defence system. Here, we show that the percentage of the Spanish population included in the ANIBES study not meeting the European recommendations for zinc, selenium, and vitamins A, E and C were 83%, 15%, 74%, 80% and 56%, respectively. Even when the plausible energy reporters were analysed separately, these percentages remained above 40%, except for selenium, where only 9% of the population showed inadequate intake.
In recent years, there has been controversy about the validity of the use of Memory-Based Dietary Assessment Methods (M-BMs), as these methods are indirect and have a pseudo-quantitative nature. Some authors believe that the data collected through them are inappropriate to calculate EI and have stated its inadmissibility in scientific research and for the formulation of national dietary guidelines, while other authors are opposed to these statements [26
]. Additionally, sometimes the estimated EI of part of the population is not always plausible physiologically [12
] because, for various reasons, people tend to underreport their food intake. To minimise all these methodological risks, the present study is based on the “Guidance on the EU Menu methodology” [28
], a guidance document published by EFSA to facilitate the collection of harmonised food consumption data from all EU Member States. Additionally, some objective tools to measure EI were used, such as tablets and digital cameras.
Spain has undergone dramatic socioeconomic changes since the 1960s. These changes include the increase in the immigrant population, the rural-urban migration, a rapid urbanisation process and the incorporation of women into the active workforce, factors that have influenced family life and home meals organisation. The increasing use of restaurants, catering and vending machines have also influenced food consumption. The Food Consumption Survey by the Ministry of Agriculture, Food and Environment (MAGRAMA), which has been conducted for over 20 years, evaluates the food consumption and dietary patterns in the Spanish population. The results of this survey have shown that the abovementioned social and economic changes have led to substantial modifications in food patterns in the last decades, moving the Spanish diet away from the traditional Mediterranean Diet pattern [29
Comparing the data obtained in the present study with the data obtained in the ENALIA (Encuesta Nacional de ALimentación en Población Infantil y Adolescente de España/National Dietary Survey in Spanish Children and Adolescents) [30
] for children and adolescents and with the ENIDE (Encuesta Nacional de Ingesta Dietética/National Dietary Intake Survey) [31
] for adults, we observed that the zinc intake was similar for male children (9.8 mg/day), adolescents (11.3 mg/day) and adults (10–12 mg/day) as well as for women (8.7 mg/day, 8.9 mg/day and 8–9 mg/day, respectively) when we consider only the ANIBES plausible energy reporters. The intake of this nutrient is inadequate in the three studies when comparing with the Spanish and European recommendations. A recent review from Mensink et al. in nine European countries (Belgium, Denmark, France, Germany, The Netherlands, Poland, Serbia, Spain, and the UK) [32
] reported that the intake of zinc in adolescents (11–17 years) ranged from 6.6 mg/day to 11.2 mg/day in girls, and from 8.4 mg/day to 14.7 mg/day in boys. The lowest values were observed in the UK while the highest were seen in Germany. Compared to the data obtained from the adolescents’ plausible energy reporters in the ANIBES study, both sexes reported intake was around the mean intake of the European countries included in the review.
Studies in different countries of Europe have reported the consumption of Zn in adults. In men, Germany [33
], Denmark [34
], Finland [35
], Italy [37
] and Sweden [38
] have reported mean intakes over 12 mg/day; Ireland [39
] and The Netherlands [40
] over 11 mg/day; and the United Kingdom (UK) [41
] over 10 mg/day. In women, Finland [35
] and Italy [37
] have reported mean intakes over 10 mg/day; Germany [33
], Denmark [34
] and Sweden [38
] over 9 mg/day; and Ireland [39
], The Netherlands [40
] and UK [41
] less than 8.6 mg/day. Comparing with the ANIBES plausible energy reporters data, the reported intake for both men and women was a bit lower than the European mean intake.
As expected, meat and meat products were the main sources of zinc for the ANIBES population, as well as for the ENIDE study [31
]. However, the other food groups’ contributions to the reported intake of zinc were in different order and proportions: in the ANIBES study, cereals and grains, milk and dairy products, fish and vegetables; and, in the ENIDE study [31
], pulses and nuts, fish, eggs, milk and dairies and cereals.
In all studied groups, the reported intake of selenium met almost the totality of the Spanish [20
] as well as the European recommendations [21
]. In children and adolescents (male and female), the reported selenium intake in the ENALIA study [30
] was higher than in the ANIBES study, even taking into account only the plausible energy reporters. However, comparing these data with data collected in European countries [32
], where the observed intake ranged from 29 mg/day for the Danish girls to 46 mg/day for the French boys, ANIBES reported intakes from adolescents (both sexes) was much higher in the total population (boys 85 mg/day and girls 71 mg/day) as well as in the plausible energy reporters (boys 102 mg/day and girls 84 mg/day).
In the whole adult population, the reported selenium intakes in both men and women were higher in the ANIBES study than in the ENIDE study [31
], and these differences increased when considering only the plausible energy reporters. The plausible energy reporter’s reported intake was inadequate in less than 7% in most of the age by sex groups according to the Spanish [20
] and European recommendation [21
]; only the older women groups had a higher percentage of inadequacy according to the European recommendations [21
]. Results from the ANIBES study indicate that the reported intake of selenium in the whole population as well as in the plausible reporters separately, in adults and elderly (men and women) was higher than in some European Countries, namely Denmark [34
], Finland [35
], Italy [37
], The Netherlands [40
] and Sweden [38
In contrast to the ENIDE study [31
], where fish was the main dietary source of selenium, in ANIBES, cereals and grains ranked first, followed by fish, but with a large difference in proportion compared to the ENIDE study [31
]. This disparity might be because the sampling of each study was made in different periods of the year. In the ANIBES study, meat and meat products and milk and dairy products ranked next, while, in the ENIDE study [31
], the food groups contributing to the selenium intake after fish were meat and meat products, cereals and eggs.
The reported intakes of vitamin A in the present study were lower than the Spanish [20
] and European [21
] recommendations, in both the whole population and the plausible energy reporters. Comparing the children and adolescents (male and female) groups with the ENALIA study [30
], the reported vitamin A intake was lower for ANIBES in both the whole population and plausible energy reporters separately. Data from EU countries [32
] indicates that Spanish boys (528 µg RE/day) and girls (420 µg RE/day) (data from the EnKid study) [42
] reported the lowest intake, while Poland for boys (1800 µg RE/day) and Germany for girls (1500 µg RE/day) reported the highest intakes. Comparing to the ANIBES study results, neither the whole population nor the plausible energy reporters’ data are higher than the mean observed intake from the European Countries.
In the adult group, the mean of the observed intake of vitamin A in the ENIDE study [31
] was around 730 µg RE/day; adult mean intake was 747 µg RE/day for males and 723 µg RE/day for females. Data from the ANIBES study for the whole population were lower (668 µg RE/day) than the one reported in the ENIDE study [31
]; however, taking the plausible energy reporter’s group alone, the mean intake (790 µg RE/day) was higher than the ENIDE study [31
]. Adult vitamin A intake data from European countries indicate that Germany [43
] and Poland [44
] (both sexes) have the highest intake, over 1800 µg RE/day for men and over 1215 µg RE/day for women. Other countries such as France [45
], the UK [47
] and Denmark [48
] reported intakes over 1000 µg RE/day for men and over 800 µg RE/day for women. Comparing these data with the data reported in the ANIBES study, the Spanish vitamin A intake in the adult’s population is much lower in the whole population as well as in the plausible energy reporters. Interestingly, the older adults whole population have vitamin A intakes similar to the adult group; however, considering only the plausible energy reporters, both men and women reported intakes over 1000 µg RE/day as in most European countries mentioned before.
Unlike the ENIDE study [31
], vegetables were the main source of vitamin A in the ANIBES study, preceding milk and dairy products, eggs, fruits and oil and fats. In the ENIDE study [31
], eggs were the main source of vitamin A intake, followed by vegetables, milk and dairy products, fish and fruits. Even though the first three groups of food were the same in both studies, the proportions that represent each one is very different.
The reported intakes of vitamin E in the ANIBES study for all studied groups in both the whole population and the plausible energy reporters were much lower than the Spanish [20
] and European [21
] recommendations. Comparing the observed data from the ENALIA study [30
], children and adolescents reported intake was higher in that study than in the ANIBES study in the whole population; however, these differences narrowed when considering only the plausible energy reporters. Mensink and co-workers’ [32
] review data indicate that the vitamin E intake in European adolescents ranged from 7.6 mg/day to 18.6 mg/day in boys, and from 6.4 mg/day to 16.4 mg/day in girls, with the lowest intakes observed in Spain (data from the EnKid study) [42
], while the highest were seen in Germany. The ANIBES study data indicates that Spanish intakes are still low compared with the data observed in the rest of the European countries included in the review.
The adult’s observed intake for vitamin E in the ENIDE study [31
] was around 14 mg α-TE/day, whereas in the ANIBES study it was half of that value (7 mg α-TE/day) for the whole population and 9 mg α-TE/day for the plausible energy reporters. According to the ENIDE study [31
], the adult population have an adequate intake of this nutrient. However, the data from the ANIBES study indicates that 80% of the whole adult population and 60% of the plausible energy reporters have inadequate intake of vitamin E. The European adult’s intake of vitamin E data indicates that Germany [33
] and The Netherlands [40
] have the highest observed intake for men (over 14.5 mg α-TE/day) and women (over 11.5 mg α-TE/day); followed by Italy [37
] and Ireland [39
] whose observed intakes were over 11 mg α-TE/day for men and women. Countries such as Portugal [49
], Sweden [38
] and Denmark [50
] have intakes around 8 mg α-TE/day for men and around 6 mg α-TE/day for women. In the ANIBES study, the adult’s whole population reported an intake of around 7 mg α-TE/day, the lowest among the European countries analysed here. However, taking into account just the plausible energy reporters, the reported intake is above 11 mg α-TE/day for men and almost 9 mg α-TE/day for women.
The main source of intake of vitamin E in both ENIDE [31
] and ANIBES studies were oil and fats; however, in the ENIDE study [31
], pulses, seeds and nuts ranked second, preceding fish, vegetables, eggs and fruits, which is very different from the ANIBES study, where vegetables ranked second, followed by fish, ready-to-eat-meals, and milk and dairy products and eggs.
The mean reported intakes for vitamin C in the ANIBES study was lower than the observed intakes in the ENALIA study [30
] for children and adolescents, and the ENIDE study [31
] for adults in the whole population and the plausible energy reporters separately. Data from the ENALIA study [30
] indicate that only a subgroup of female adolescents had an inadequate intake of vitamin C; however, in the ANIBES study, both children and adolescents of both sexes did not meet the Spanish or European recommendations. In the ENIDE study [31
], 100% of the adult population had an adequate intake of this vitamin. However, in the ANIBES study when we calculated the inadequate intake, we observed that 29% and 58% of the whole adult population did not meet the Spanish and European recommendations, respectively. Even considering only the plausible energy reporters, the recommendations were not met (19% and 45%).
In their review of the EU countries, Mensink et al. [32
] indicated that the vitamin C intake in adolescent boys ranged from 71 mg/day in The Netherlands to 203 mg/day in Germany, and in girls, from 69 mg/day in Spain (data from the EnKid study) [42
] to 201 mg/day in Germany. They comment that the Germany reported data doubled the data from any other country. Even taking into account the previous comment, ANIBES reported data was lower than those reported for the lowest intake, considering only the plausible energy reporters, the reported intakes are still lower.
Many European countries have reported the mean intake of vitamin C in adults. Germany [33
], Greece [49
] and Norway [49
] have reported intakes over 140 mg/day in men and women; Denmark [34
], Portugal [49
], Italy [37
], Ireland [39
] (men and women) and Finland (women) [35
] between 100 and 130 mg/day; and Finland (men) [35
], Sweden [38
] and UK [41
] (men and women) under 100 mg/day. The ANIBES reported intake of vitamin C for the adult’s whole population was around 84 mg/day and considering only the plausible energy reporters the intake was around 100 mg/day, both amounts lower than most of the European observed data.
Fruits and vegetables are the main source of vitamin C (70%) in the ENIDE study [31
] as it is in the ANIBES study albeit in the opposite order. In the ENIDE study [31
], fruits and vegetables were followed by non-dairy drinks and pulses and in the ANIBES study by milk and dairy products, and non-alcoholic beverages.
As discussed in previously published articles, the ANIBES study has several strengths, which include the careful design, protocol, and methodology used, conducted among a random representative sample of the Spanish population aged 9–75 years [14
]. It is the first Spanish study at national level that analysed the data for the whole population and the plausible energy reporters. The limitations of this study are its cross-sectional design, which provides evidence for associations but not causal relationships [24
] and the low retention data found after the analysis of misreporting. When we comparing our findings with other studies, we observed that a low percentage of the energy intake studies apply the misreporting methodology and among these studies, the variability of the underreporting is extensive. In studies that have used the 24-h recall method, misreporting goes from 4% to 67%, and in studies that have used the food record method, it goes from 8% to 49% [51
]. The usual range of misreporting seen in studies goes from 20% to 30%. As we can observe, our study shows a higher percentage of misreporting compared with most of the published studies on that issue. However, it is important to highlight two points: (1) Even with a lower total population that reported a plausible energy intake, we can assure that our data are reliable and reflect the true nutrient intake situation of the Spanish population. (2) Many studies about energy and nutrient intake, apart from national surveys, have an N lower than 500; in this respect, our N of plausible reporters is not negligible.