Food and nutrition in the Netherlands.

World Review of Nutrition and Dietetics, vol. 22, pp. 1-39 (Karger, Basel 1975)

Food and Nutrition in the Netherlands C. DEN HARTOG1

Contents I. Introduction II. Nutrition and Health in the Netherlands A. OvernutritiQn and Heart Diseases B. Physical Development III. Nutrition of Population Groups A. Nutrition of Children 1.Infants and Pre-School Children 2. School Children and Adolescents B. Nutrition of Adults 1.Adults and Older Men 2. Women 3. Lactating Women 4. Students 5. Young Soldiers 6. Prisoners IV. Food Patterns and Food Habits A. General Information (Individual Intake and General Food Patterns) B. Special Food Products (Milk, Butter, Margarine) V. Nutrition Studies in the Netherlands VI. Conclusions and Summary References

1 7 7 13 14 14 14 16 18 18 20 20 22 23 23 26 26 31 33 34 35

I. Introduction

1 Emeritus Professor of Nutrition; President of the Nutrition Council of the Netherlands; President of the International Union of Nutritional Sciences.

Downloaded by: Université de Paris 193.51.85.197 - 1/10/2020 8:43:25 PM

In 1966, a survey of nutrition in the Netherlands was published in World Review of Nutrition and Dietetics (Vo1.6). Since that time, knοω-

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ledge of nutrition and health in the Netherlands has increased to a considerable extent. Economic co-operation in Europe, and particularly in the Benelux countries, has so far exerted little influence on the general nutrition patterns. The influence on legislation has been greater, but this will be discussed below. Inflation and the tension in the labor market have resulted in relatively high unemployment. The number of unemployed was 134,896 ín February 1973, i.e., 3.8 ο/ο of the male and 2.1 ο/σ of the female working population. Owing to good unemployment benefits, there is sufficient money available for adequate nutrition. So far, however, there has been no investigation into the current situation concerning the nutrition of the unemployed, in contradistinction to the slump years around 1930. Reviews Table Ι. Average consumption of calories, proteins, fats, and carbohydrates per member of the population in absolute figures

1936/38 1950/52 1955/57 1960/62 1964/66

kcal

Proteins, Fat,

Carbohydrates,

2725 2825 2850 2925 2955

81 80 79 78 80.5

371 379 363 363 351

102 110 120 130.5 136.5

Data from DE Wιν [1968].

Table 11. Age structure with regard to some age groups, since 1940

1940 1950/52 1960/62 1965/66

up to 5 years

65 years and older 20-60 years

%

%

%

9.5 12.0 10.0 9.8

7.0 7.8 9.2 9.6

52.1 51.2 48.6 48.9


Data from Central Bureau for Statistics [1967, 1972].

Food and Nutrition in the Netherlands

3

of the literature can be found in the studies by REITH and GORTER [1948]. In spite of the currently adequate old-age insurance system, the aged belong to the economically weaker groups. A Public Assistance Act provides the possibility for indigent aged to be admitted to homes for the aged or to nursing homes. On behalf of the Nutrition Council, DE Wu i [1968, 1972] has described the alterations of the food pattern in the Netherlands from 1936/38 to 1950/52, and in later 3-year periods until 1964/66. Table I lists the average consumption of calories, proteins, fats, and carbohydrates per member of the population. The relative significance is greater than the absolute significance, as these are statistical consumption data and we do not know what amounts

a increase b Decrease 1950 1955 1960 1965 1970 1950 1955 1960 1965 % 40 ,rgaríne

1970 40 °/°

30 25

30

20 18 16 14 12 19

8 7 6

meat tlyes

— butter

ta fs

κ

κ

bacon

•

5

cheese ,

4

flour

3 2.5

• milk products

s,η9

eggs

e6\

8 7 6 5 4 3 - 2.5

κ

nuts

2

ι

25 20 18 16 14 12 10

2 x/

fish

1.25 Boa

Ο

-1.25

cream

0.625

Fig.l. Percentage contribution of different food groups to the total amount of fat from food in the Dutch national food pattern 1950-1970. From DE Wui [1972].


0.5

4

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Oils and fats —Fish

g 50 -

40 -

30 -

20 -

10

-

' ΙΙΙΙιιι:"Ι

— Eggs

11111111111

Ι ~Ι

— Cheese

—Milk

ΙΙΙ

%

—Meat

ε w

E

ν

Φ

Netherlands

0-

z

R

η

C ø o

η

co C υ,

of the various foodstuffs are lost on the way to the consumer. Since the figures have always been obtained in the same way, we may attach considerable value to the trend these figures show. In evaluating the figures, the change of the age structure of the population since 1940 should be taken into account. Table II illustrates this clearly. The adult group between 20 and 60 years has decreased from 52 to 49 O/o, and the group of 65 years and older has increased from 7.0 to 9.6 u/o. For a number of foodstuffs, it has been determined what part they have played in the increase or decrease of the caloric, carbohydrate, and fat contents of the average Dutch nutritional intake. Figure 1 shows the percentage proportions of groups of foodstuffs in the average consumption of nutritive fats since 1938 and 1950.


Fig. 2. Consumption of animal protein in various countries (g/person/day), 1962-1963. From DEN HARTOG and MULLER [1965].


5

150

Essential

j fatty acids

140 130 120 110 100 90

Essential

80

, fatty acids

f

70 60

h

50 40

/ : / ••

Saturated fatty acids

Saturated ,4atty acids Total fat

30

/

20 10 o 10 20 30 40 1938 1947

1951

1955 1959

'63 '64 '65 '66 '67 '68

lt may be interesting to compare the various countries of Europe, both as regards the amount of animal proteins and as regards the source of this protein (1962-1963). No more recent data are available. ln the diet of the Dutch (1970), animal proteins account for 63 ο/ο of the total protein consumption. Since 1950, the consumption of carbσhydrates has decreased by 2.5 Ο/ο per 5-year period. ln the last 30 years, the consumption of fats has increased by an average of 5 0 /0 per 5-year period. The consumption of animal proteins increased by another 6 Ο/' in 1970; the fat consumption has increased by 6 °hi since 1960, and by 26 °hi since 1950, and now amounts to 136 g per day [DE Wui]. The proportion of carbohydrates has decreased by 6 °/ο [MULLER, 1972]. Milk supplies approximately 12-13 °hi of the average number of


Fig. 3. Percentage variations in the consumption of total fats and fatty acids since 1938.

6

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9 20 -

Total fat

19 18 17

-

16 15 14 13 12 11 10 98 7-

i Margarine

6-

Oil, dressing

/ ` ^ ~~`~ ; n

5 4

•• Other fats

Ít ---------

1-

0

1938 1947

ι ι

1951

ι ι ι ι

1955

1959

~ ................................. Dairy prod.

ι

ι ι

ι

'63 '64 '65 '66 '67 '68

calories; the calculated average caloric value is approximately 400-500 kcal, higher than is generally recommended for the population if the population structure is taken into account. Over 40 ο/ο of the calories are supplied by fats (1969). Of the 142 g of fats per day in 1968, 84 g were obtained from margarine, butter, slaughtered-animal fats, bacon, and edible oils, and approximately 60 g were hidden fats in milk, cheese, eggs, meat, biscuits, potato chips, etc. The ratios of poly-unsaturated fats and saturated fats since 1938 can be found in figure 3. The variations of consumption of essential fatty acids (g/day) are shown in figure 4 [DEN HARTOG and MULLER, 1970].


Fig. 4. Essential fatty acids (g/person/day), supplied by the diet. From DEN HARTOG and MULLER [1965].


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ΙΙ. Nutrition and Health in the Netherlands It is of obvious importance to determine the correlations between nutrition and health in the Dutch population. The American psychologists STEIN et al. [ 1972] have studied the question of whether or not permanent damage can be demonstrated in children bom in the `hunger winter' (1944-1945) in the starving West of the country. This investigation was carried out over 20 years after the period of starvation, and was based on psychological reports on conscripts born in the hunger winter as compared with groups born before and after that period. Studies of the intelligence at later ages failed to reveal any late sequelae of brain lesions in neonates due to protein deficiency of the pregnant women during the starvation period.

The ubiquitous phenomenon in increasing overfeeding and heart diseases in affluent countries also shows itself clearly in the Netherlands. The number of conscripts rejected for obesity per 10,000 per annum increased from 2.62 in 1949 to 35.39 in 1959. The number of overweight 8year-old school children increased in the large cities from 4.5 Ο /' to 8 Ο/ο (P 97.5 for skin fold triceps + scapula). Of a number of young men with an average age of 32.6 years, in one of the northern provinces, 70 Ο/ο took too little exercise and 40 Ο/ο were overweight. A total of 6,500 male workers in various large companies were examined for overweight by means of the Quartelet index (W/HE Χ 10). An index exceeding 270 was encountered in 15-25 Ο/ο of the men; the incidence increased with advancing age (see table ΙΙΙ). Overweight among school children was more frequent among the lower than among the higher socio-economic strata [BERGINK, 1970]. A nationwide study of 8-year-old children carried out in 1971 revealed that 5 Ο/ο of the boys and 6 Ο/o of the girls were obese. The mortality from cardiovascular diseases has increased considerably since 1950, especially in the younger age groups. In the age group between 35 and 39 years, this increase in 1967 amounted to approximately 447/o; in the age group between 40 and 44 years, it amounted to 379 /o, with the increase gradually growing less in the older groups. Ιn the age group between 60 and 64 years, the increase since 1950 has been approximately


A. Overnutrition and Heart Diseases

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136 Ο/o. Since a number of factors are involved in the causation of ischemic cardiopathy, it is difficult to consider nutrition separately in this respect, or at any rate to assess the extent of its influence. If the cholesterol level of the serum is applied as the criterion, the influence of nutrition on cardiopathy in the Netherlands is not very marked. An investigation of the correlation between nutrition and heart diseases, which has now been going on in Zutphen for 10 years (first reported in the World Review of Nutrition and Dietetics, in 1966), under the auspices of the Council of Nutrition and headed by VArτ BUCHEM, has yielded numerous data. In 1960, the population of this town included approximately 2,300 men ranging in age from 40 to 59 years, from among whom a group was selected at random. Of this representative group, 1,050 participated in the nutrition study in 1960, and 908 were subjected to medical examination. In 1960, 1961, and 1963, chemical analyses were made of food samples, and cholesterol tests of blood samples were made in KEYS' laboratories as well as in the investigator's own laboratory. Attendance at the medical examination every year is approximately 90 0/ο. Column 3 in table III lists the total numbers of men available for the experiment as well as the numbers of them who have died over the years. Table ΙΙΙ. Details of participation in the medical survey in the course of some years (a) Year of examination 1960 1961 1962 1963 1964 1965 1966 1967 1968 Total

(b) Entered into experiment 908 10

(e) Total of men available for experiment1

(d)

death

removal

908 918 906 888 867 860 843 825 815

— 3 10 18 5 16 16 10 16 94

— 9 8 3 2 1 2 1 4 30

(e)

Lost from experiment due to

(f) Rest (c [d+e])

908 906 888 867 860 843 825 814 794


1 Total number of men after the examination in the preceding year. The same number is mentioned under (f) for the preceding year.

9


Table IV. Average consumption of calories and nutrients per day for all men involved in the experiment in 1960 and 1965 Year of experiment Number of men Calories1 Vegetable protein Animal protein Total protein Fat Carbohydrates) Ca Fe Vitamin A Carotene Thiamine Riboflavin Nicotinic acid Vitamin C Vitamin D mg thiamine/1,000 kcal

kcal g g g g g mg mg mg mg mg mg mg mg I. U.

1960 906

1965 758

2943 39 51 89 141 330 ? ? 1.0 2.5 1.3 ? ? ? ? 0.44

2861 33 52 86 142 309 989 12.8 1.0 2.4 1.3 1.7 13.6 104 311 0.44

1 Not including those in alcoholic and/or non-alcoholic beverages.

Table V. Differences between 1960 and 1965 in the consumption of calories and nutrients by 755 men Calories Fats Carbohydrates

Proteins

55.6 % of the men on average consumed fewer calories; on average, 95 kcal less were consumed (standard deviation 663 kcal)) 52.7 % of the men consumed more fat; on average, 1 g more fat was consumed (standard deviation 43 g) 37.9 % of the men increased their carbohydrate consumption; on average, 23 g less carbohydrates were consumed (standard deviation 84 g) 39.2 % of the men increased their protein consumption; on average, 4 g less protein were consumed (standard deviation 20 g)


1 Standard deviations listed are the standard deviations of the distributions of the differences per person.

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2

Abell method of cholesterol determination.


In order to keep the number of tables limited, the Zutphen nutrition experiment is only reported in the form of the mean findings concerning calories and nutrients in 1960 and 1965 (table IV). Data concerning food consumption were obtained partly by measuring and weighing and partly by the dietary history method. Table V indicates the differences in calorie and nutrient consumption between 1960 and 1965. Table VI lists the percentages of calories derived from various sources of fat, protein, and carbohydrates. The age influenced the food consumption; the age group between 40 and 50 years consumed more fat, protein, and carbohydrates and, accordingly, more calories than the group between 50 and 60 years. The subjects examined were subdivided into three groups on the basis of their serum cholesterol level: 0-209 mg0/ο, 210-249 mgο/ο, and > 250 mg0/ο2. The proportions of calories consumed by these groups were studied for various nutrients (table VI). From the subsequent investigation, the following conclusions were drawn. The serum cholesterol of the entire group proved to have a positive correlation with the body weight/cm of height in 1960 but not in 1965. Both in 1960 and in 1965, it was found to have a negative correlation with the percentage of calories derived from carbohydrates and with the total number of calories. No connection was discovered between the serum cholesterol and the quantity of fat, or between the serum cholesterol and its poly-unsaturated fatty-acid content. More than half of the persons who had cardiac and vascular abnormalities before 1960 were among those who had the lowest caloric intake — a fact that may be connected with the medical treatment they were receiving. This is not true of those who developed cardiac and vascular abnormalities after 1960. No significant difference was found between the diets in 1960 of those who after 1960 had no cardiac and/or vascular abnormalities and those who developed such abnormalities after 1960. The caloric value and the sugar and carbohydrate contents of the diet of those who developed cardiac or vascular abnormalities after 1965 and decreased between 1960 and 1965. The average carbohydrate consumption and caloric value of the diets of a group of persons with low serum cholesterol values and without cardiovascular abnormalities were compared with the corresponding averages of three other groups of persons with a high serum-cholesterol level and/or cardiovascular complications, and were found to be sig-


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Table VI. Serum cholesterol and percentages of calories and nutrients from various foodstuffs (1960) — averages

Number of persons Vegetable protein Animal protein Fat from milk, butter, and cheese Total fats Carbohydrates Total calories Height, cm Weight, kg

0-209

210-249

> 250

unknown

254 5.3 6.8 9.3 42.4 45.5 3070 173 70.7

313 5.3 7.0 10.3 42.8 45.0 2939 173 73.0

289 5.1 7.4 11.0 43.3 44.2 2818 173 74.2

50 5.3 6.7 9.3 43.5 44.6 3040 175 73.2

nificantly higher. On average, the skin folds of the first-mentioned group were thinner. To ascertain the effect of diet on the incidence of atherosclerotic complications, it is important to know whether the diet and physical condition of the men who developed such complications had differed previously from these factors in the men who developed no complications. It should therefore be pointed out that, in 1960, no significant differences were found as regards either caloric values or consumption of protein, fat, carbohydrates, and sugar. Nor were there any significant differences in weight and height. It was also found that the diets in 1965 of those who developed atherosclerotic complications after 1965 and those who did not were no different as regards consumption of protein, fat, carbohydrates, and sugar or as regards caloric values. In three separate surveys, a negative correlation was found between the amount of calories consumed and the serum cholesterol content. In the medical part of the survey, the following results are given. Among patients whose serum cholesterol and triglyceride contents are high, myocardial infarctions are more common; but they have also occurred quite often in men, who in the preceding years, had presented a serum cholesterol content below 237 mg0 /o. It seems likely that the serum cholesterol content is affected by genetic factors. The serum uric acid content of the men with cardiovascular complications did not differ from that of the others.


Subdivision according to serum cholesterol level, mg%

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3

Abell method of cholesterol determination.


An extensive follow-up examination was carried out for sclerosis of the aorta and it was established inter alia that there is a phonocardiogram characteristic of persons with this disease, showing an asymmetrical protomidsystolic decrescendo murmur. The prognosis proved to be favorable. In the ECG follow-up examinations, extrasystoles were often found, particularly after exertion, and not infrequently an intraventricular block, with complete left bundle branch and complete right bundle branch block without complaints and without other abnormalities being encountered. `Ischemic' depression of the ST segment of the ECG often occurred without complaints and without other abnormalities, and was found to be partly due to sympathicotonia [VAN BUCHEM]. The fundus oculi was examined several times by ophthalmologists. An extensive investigation was made into the connection between abnormalities found and the patient's blood pressure, serum cholesterol content, and complications that had arisen. Various abnormalities of the fundus arteriolae, which are usually associated with hypertension, were found without hypertension but proved to be connected with the patient's age. In patients with an arcus cornea on both sides, the serum cholesterol content is higher, on average, in the lower age group. This is not the case when there is an arcus corneae on one side only. Thorough investigation of physical activity revealed that this had no correlation with the serum cholesterol content. There was a marked, positive correlation with diet but none with the thickness of the skin folds. No correlation was found between the serum cholesterol content and smoking, but a positive correlation was found with inhaling. One of the men examined had a very low serum cholesterol content, which was found to be due to a β-lipoprotein deficiency. A detailed examination was likewise made of the serum lipids (triglycerides, phosphatides, lecithin) and lipoproteins in at least 200 men, and of thrombocyte aggregation in all the men examined. The results are still being prepared. The cholesterol level of the blood is often high even in the young in the Netherlands, averaging 218 mgr/οs, as has been found in female students [KouwnxuovEN et al., 1971]. The same phenomenon was observed in young conscripts: in 180 young men, an average of 210 mgr/ο was found. It is interesting to note that during the weekend, when the young soldiers are at home, the triglyceride content of the blood increases con-


13

Table VII. Average serum cholesterol, total blood lipids, and adiposity index (Quetelet) by age among employees of various companies in the Netherlands, and percentages above the highest limit of 'normal' Cholesterol, mg/100 ml, %

Total lipids, mg/100 ml, %

Adiposity-index, W/H2 X 10, %

Age group, years

N

mean SE >300 mean SE >900 mean SE >900

35-39 40-44 45-49 50-54 55-59 60-64

180 1212 1333 1403 1403 918

245.7 263.8 263.5 273.0 271.3 266.5

3.72 1.57 1.31 1.39 1.44 1.75

11 % 23 % 22 % 28 % 28 % 24 %

812.6 13.05 28 % 244.8 1.75 16 % 841.4 5.39 33 % 249.1 0.86 18 % 840.7 7.09 34 % 249.2 0.84 22 % 849.7 4.39 35 % 251.6 0.79 24 % 829.6 4.04 32 % 253.2 0.78 28 % 804.9 4.93 24 % 250.6 1.01 25 %

siderably, owing to the consumption of large amounts of alcohol (beer) and sugar. A detailed examination of 6,500 male industrial workers, carried out by the `Commissie Opsporing en Preventie Ischaemische Hartziekten' (COPIH) (Committee for the Detection and Prevention of Ischemic Cardiophathies) and reported by DE WiJN, yielded the cholesterol levels listed in table VII. The mean cholesterol level in the blood of these healthy men at the age of 35-39 is 245 ο/ο4; at the age of 50-54, the mean level is 270 mgr/ο. Among the younger group, 11 ο/ο had levels over 300 mgr/ο4; at the age of 50-60, the figure was 28 (1 /o. The total lipid content of the blood at the age of 35-39 years was 812 mgr/ο, and at the age of 50 it was ± 850 mgr/ο. B. Physical Development A somatomet c study of Dutch youth, carried out by LUYKEN, DE and VAN WIERINGEN, has been in progress for a number of years. The subjects studied are boys and young males between 18 and 25 years, subdivided into 5 age groups. Six variables were measured for the purpose of characterization. Most suitable for the estimation of the `ideal' body

4 Huang method of cholesterol determination.


WIJN

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weight was the combination of height, shoulder width, chest width, and pelvic width. On this basis, tables were drawn up for persons between 8 and 25 years of age which, for a given height and chest width, allow an optimal estimation of the `normal' body weight to be expected. Within the scope of this paper, no detailed report of these investigations is possible; the reader is referred to the original publications. Comparison with American data shows that there is a considerable difference between the average body weight of young population groups in America and in the Netherlands. Tables published by PRYoR show that, for American 15-year-old boys (1960) with a chest width of 26.5 cm and a pelvic width of 27 cm, an average weight of 57 kg is to be expected for a height of 166 cm. The average weight of Dutch youths for the same criteria is 55 kg. Another example is that of youths aged 17 years with a shoulder width of 39 cm and a pelvic width of 27.5 cm, for whom an average weight of 69 kg was found for a height of 177 cm. Dutch boys aged 17 years with identical somatic dimensions have an average weight of 64.5 kg. VAN WIERINGEN [1972] has carried out a number of studies comparing growth in the present century with that in the middle of the last century. In 1965, 5-year-olds had increased in height by 14-15 cm, 10year-olds by 17-18 cm, adult men by 10-11 cm, and adult women from lower social strata by somewhat over 13 cm. Dutch children and adolescents are among the tallest in the industrialized world [vAN WτεRINGEN, 1972]. MULLER [1972b] has carried out an orientative somatometric and densitometric study of approximately 600 persons between 30 and 70 years of age. Its purpose was to determine alterations correlated with aging.

III. Nutrition of Population Groups

1. Infants and Pre-School Children In a preceding article in World Review of Nutrition of Dietetics published in 1966, the nutrition of infants in the Netherlands was discussed in detail. For the moment, we can only add that practically the entire nutrition of infants that are not breast-fed consists of industrially prepared infant foods. There is a tendency to use more so-called humanized milk.


A. Nutrition of Children

15

A committee of the Nutrition Council has drawn up the requirements which humanized milk must fulfil with respect to nutritive value and purity. To give an example: humanized milk must contain a minimum of 1.5 and a maximum of 2.2 g protein/100 ml, with a minimal proportion of whey proteins of 20 Ο/o. There are no stringent requirements concerning the milk fat; however, at least 4 Ο/ο of the calories must be supplied in the form of linoleic acid, which corresponds to 300-350 mg/100 ml milk. Not more than 50 Ο/ο of the calories must be supplied by the total quantity of fat. The Ca/P ratio in humanized milk must be 2:1. There are also requirements regarding carbohydrates, magnesium, sodium, potassium, chloride, iron, and various vitamins. No fluorine may be added to humanized milk. The trace elements should be identical to those in human milk. In all, 60 Ο/ο of the infants are seen regularly in the Netherlands Infant Welfare Centers; approximately 35 Ο/ο of the infants are still entirely breast-fed at the age of 3 months. The impression is gained that breastfeeding of infants increases in the higher and decreases in the lower economic strata. Among the children seen in the Welfare Centers, there are many that are too `fat' but no exact data are available. A competitive element among the mothers who visit these centers in groups with their infants may play a part. The ideal image of a baby is still the fat cherub that abounds in Ruben' paintings. Pediatricians are increasingly aware of the problems which obesity in infants causes at later ages. The proportion of overweight infants in the Netherlands is unknown, but it is believed to be high. There are not many data available concerning the nutrition of toddlers. In 1968, ΒΕΤΗΕ et al. published a report of a study of 500 toddlers in Almelo, a small town in the eastern part of the country. Data were processed concerning 397 of these toddlers, whose ages varied between 1 and 5 years. The study covered a period of 1 year, during which the children were examined three times. A nutrition survey and a somatic examination were carried out. The findings were expressed in the so-called Sacratama equation of Von Pirquet (s = sanguis; cr = crassitudo, t = turgor; m = musculature; i. e., for skin color, amount of subcutaneous fatty tissue, skin turgor, and musculature, respectively). The a in the Sacratama formula may be replaced by the vowels i, e, o, or u. These vowels have the following significance: í = very high; e = increased; a = normal; o = decreased; u = very low. The parameters determined were height and weight, Hb level, and dental and skeletal age. As regards dentition, no difference was found from that of American toddlers. At the ages of 1, 2,



DEN HARTOG

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2. School Children and Adolescents We know much more about the nutrition of school children than about that of toddlers, since school organization facilitates investigation. Toddlers, especially young ones, do not go to school, and the number of day nurseries is small. The welfare centers for pre-school children have no time for extensive nutrition studies.


and 3 years, more elements had erupted than was the case during World War II. The growth rate of the 397 children clearly exceeded that of the unselected group of children who had suffered from some infectious disease such as measles or whooping cough. The growth rate of girls at the age of 11/2-3 years exceeded that of the boys; the weight gain of the boys slightly exceeded that of the girls. In other respects, there were no differences from the children of Zürich and those of Boston, who are frequently used as standards. The skeletal age was expressed in Oxford Maturity Units (OMU). The age was determined according to Acheson's method. Up to and including the age of 31/2 years, the girls were ahead of the Oxford girls. As regards the Hb levels subnormal values were found in only 9 ο/ο of the cases in the unselected group. The toddler's diet was studied for 2 years. There were three main meals per day, one of them hot. Bread was often spread with sweet products; consequently, dental caries is very frequent among toddlers in general. It was found that when children were given bread together with cheese and meat, they ate only the cheese and the meat, to be followed by bread and butter with jam. Most of the toddlers ate too small in-between meals at 10 or 11 a. m. and 3 or 4 p. m. They drank milk, cocoa, or coffee. They also ate fruits, but `sweet' things predominated. In two subsequent tests, the mean caloric intakes of a boy aged 12 months was 1,052 and 1,471 kcal, respectively, and 1,108 and 1,395 kcal for a girl; at 60 months, these figures were 1,778 and 1,980 kcal for a boy and 1,301 and 1,477 kcal for a girl. The 1-year-old boys consumed 32.5 g proteins; the 4-year-olds, 44.2 g. For the girls, these values were 29.2 and 39.9 g, respectively. Iron intake amounted to 4.6 mg for 1-year-olds and to 6.6 mg for 31/2-year-olds; for the 5-year-olds, it was 6.0 mg. These figures are below those of the Recommended Dietary Allowances. As was to be expected, the thiamine uptake was also below the recommended amount, owing to the considerable consumption of sweet things and of white bread.

17

In 1970/71, an orientative study of the nutrition of 8-year-old school children was carried out, the fifth since 1959/1960. It was found that, in the city of Amsterdam, in a large proportion of the cases it was up to the children themselves what they wanted to eat. Their mothers were insufficiently or not informed about what the children actually consumed. Of the 739 children studied, 3 ο/ο received less than 20 g animal protein; the proportion of children receiving less than 400 mg calcium/day had increased since the previous investigation and amounted to approximately 13 0/0 ; approximately 27 ο/ο of the children received less than 0.75 mg vitamin Βs/day; milk consumption was on the decrease. It appears that the constant increase of skin-fold thickness has recently ceased. The differences between the sexes remained the same. It is difficult to gain a real insight into the nutrition of adolescents. It seems probable that many groups of adolescents are insufficiently fed. Adolescent psychology has been described often and extensively, so we shall omit this. Many of the adolescents are currently living in subcultures where they seek adventure, and do not wish to identify with adults or with the recent past. Many live only for today, and do not worry about the future. Nothing is known concerning their attitude with regard to their own nutrition. Since 1958, a few studies of the differences in nutrition between children from small and from large families have been carried out in two cities, viz., Leeuwarden in the north and Tilburg in the south of the country. These children have now grown into adolescence. The investigators examined the second child from the small family, the second child from the large family, and the fifth child from the large family, at a time when each was 8 years old. Naturally, this longitudinal investigation cannot be reported in detail, but a few main aspects may be mentioned. As previously stated, at the beginning of the study the children were 8 years old. At the time of the last study, when they were 16-18 years old, no systematic differences between the nutrition of the children from the large and from the small families were observed. The characteristic nutritional patterns and eating habits of the north and the south had persisted. Quantitatively, the nutrition was adequate or abundant; over the years, the average diet had had too high a caloric value and had contained too much fat; the average iron content had been too low for a number of girls, and in some cases this was true of calcium as well. The results of the health study have not yet been processed [VΑN Sc~iaικ and KENTER] .



DEN

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HARTIG

B. Nutrition of Adults

1. Adults and Older Men Over the period with which this report is concerned, little study has been made of adults. The study of the nutrition of men over 40 in correladon with cardiopathy has already been mentioned on page 8, and we shall not refer to it here. Farmers in a group doing hard physical labor in one of the polders were found to have a high caloric consumption, viz., 4,210 kcal in winter and 3,672 kcal in autumn [DALDERUP, 1967]. The serum cholesterol level was higher in winter than in autumn, viz., 274 and 242 mgo/ο, respectively (Abell method). The farmers' physical activity was slight in winter, and their body weight increased. Among those involved in the investigation, 25 Ο/ο used vitamin-D preparations. In this group, the average serum cholesterol level was 25 mgr/ο higher than in the other 75 Ο/ο participants, whose average age was the same. The proportion of fat in the diet was 37.8 calo/ο, the amount of milk fat was 16.3 calo/ο. In a group of 60 men between 71 and 92 years of age, data were collected concerning the basic metabolism (measured and calculated), blood pressure, anthropometric elements, smoking intensity, and food intake, as well as the levels of a number of serum components [DALDERUP et al., 1971b]. These men were living in two homes for aged people in Amsterdam. Their mean age was 81 years. The surprising findings can be summarized as follows. Old men have, on average, low serum lipid levels, which are similar to those of young adults, and low blood pressures. They have as much body fat as normal young women, eat what others eat as far as concerns quality, but much less in quantity than younger and active men. Those participating were a positive selection from the inhabitants of both homes and the

Smoking score

Number of subjects

Large particle fraction, mg%

0 1

16 18 17 5

4.7 5.3 7.5 8.8

2 3


Table VIII. Serum `large particle' fraction in relation to smoking


19

5

Will be published as a thesis in cooperation with the Nutrition Council.


values found for the various physiological data measured might be regarded, therefore, as favourable in general, although it is not known whether this must be seen as a `thanks to' or as a `notwithstanding'. Physical activity and smoking do not affect the serum lipid levels to such an extent as in younger age groups, although the effect of smoking on the serum `large particle' fraction remains demonstrable (table VIΙΙ). The blood lipid pattern is influenced by a negative calorie balance resulting in the consumption of own tissue for the daily caloric needs, and is consistent with a simulated high fat/low carbohydrate diet. Α new formula for the basal metabolic rate has been calculated, based on the data of a previous investigation and the present data. This improved formula (1971) reads: —82.9 — 2.0 age + 8.1 height + 3.7 weight; a slightly more accurate aequation (1971) in which skeleton volume is taken into consideration reads: —492.0 —1.5 age+ 10.2 height + 5.1 weight — 0,0023 skeleton index. The original article contains detailed tables of anthropometric data, basal metabolism, and results of chemical and nephelometric analyses of the serum that will be omitted here. The average calorie uptake in the two homes was 1,696 and 1,562, respectively, with 39.9-42.4 calo/o fat and 14.8-13 ca10/o proteins. The consumption of alcohol was slight, viz., 1.2, and 4.3 calo/o. Βτνκ et al. [1966] collected data on 756 men between 46 and 66 years concerning their activities in various occupations, during work as well as leisure. The group concerned consisted of men from Zutphen, to whom we have referred earlier (p. 8). These men, on an average, worked for 531 min/day; professional persons and shopkeepers had the longest hours. The caloric expenditure on rest days was less than on working days. For instance, in a group with an average body weight of 75.2 kg and a height of 174.1 cm, the mean total calorie expenditure on a working day amounted to 2,888 kcal (588 kcal in leisure hours), as against 1,698 and 1,466 kcal in leisure time on free Saturdays and Sundays, respectively. The average total calorie expenditure per day is reduced by the fact that less is eaten on free days; in the group mentioned, it was reduced to 2,748 kcal on the average. In Rotterdam, an investigation of nutrition and health is in progress amongst 300 aged persons [ΒοwLΕs]5. This is a longitudinal study

DEN HARTOG

20

with determination of, not only the food intake, but also of Hb, hematocrit, blood cells, iron levels, and iron-saturation percentages, as well as of the blood levels of thiamine, pyridoxine, vitamin A, and folic acid. If deficiencies are found in a sufficient number of these aged persons (7.5-15 ο/o), the question will be studied of whether or not this is due to incorrect diet and whether the deficiencies may be corrected by improved (possible enriched) nutrition or whether other causes will have to be looked for, such as abnormal absorption, metabolic disorders, etc. As is to be expected, the energy consumption of forestry laborers is high. Mechanization of labor has not altered this fact. Calorie consumption was measured by the method of Kofrany and Michaelis, and the weighing and measuring method was also used in order to determine the calorie uptake [KouwENHovEN et al., 1971]. On the whole, a reasonable balance was found between calorie uptake and calorie consumption, which amounted to 4,260 and 4,365, respectively. The proportions of fat, carbohydrate, and protein calories were 47.2, 41.8, and 10.9 0/o, respectively. The blood cholesterol level in these hard-working forestry laborers varied from 222 to 419 mg°/o.

3. Lactating Women Few studies have been made of lactating women. vaν Scuaικ et al. [1965], using the method of nutrition anamnesis, collected data concerning the nutrition consumed by 160 women during 1 week in the 2nd and 3rd month of the lactating period and during 1 week 7 months later, when the breast-feeding had ceased. The average consumption of calories, animal


2. Women BEIFDICTO [1968] studied the nutrition of 970 women aged between 30 and 50 years. The sample had not been selected at random. Generally, these persons ate three meals per day, except during weekends. In 79 0/ο of the cases, the family income was earned by the husband exclusively, in 9 °/o by the wife exclusively, and in 11 0/o of the families by husband and wife together. The body weights of the women examined varied from 45 to 108 kg; the caloric value of the food consumed varied from 900 to 5,100, with a mean of 2,420 kcal. The proportion of `sociability calories' (pastry, snacks, etc.) amounted to 19.4 0/o of the total; 25 0/o of the women ate two meals on Sundays. The avarage amounts of fats and proteins in the nutrition were 109 and 75 g, respectively.

U

Ca

Fat

g

total g

Proteins 0 .

20

CO CO Ν

7 CO r

ó óó .. .-. ~ Ν - - -

✓

-- --

Ν

CO \O

Ν

0.4 to 1.0 to 50 0.5 1.1

Ο

3

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η 'σ ΝD - 0'

recommended Increases recommended for lactation period

•

0.15

Ø

1.0

Ø

40

85 62 23

εν dí r rí .-ι

1.0 0.3

%

12 12

39 38

protein fat C cal mg cal

~ 2.2 1.4 0.7

B2 mg

bl' ν ~

1.3

B1 mg

%

0.76 0.69

Btl1,OOO cal from carbohydrate and proteins, mg ;-

700 20

14 (12) 0.74 12 (11) 0.58 1 (1) 0.17

Υ ~ bΓ'

1.4 0.9 0.6

CS

117 96 26

ω

88 68 22

bl'

Lactation period 160 2910 53 132 2346 37 After lactation period Difference between the 2 periods 132 575 17

CS

mg

A

Vitamins

α mg

Num-Calober ries g

b

an.

Fe

ξ ai

g

Period

IX. Mean nutritional nutritional values values during and and after period of of lactation [vni [VAN Scκπτκ, SCHAlK, 1965] 1965] Table ΙΧ.

0

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Food and Nutrition in the Netherlands 21

C')

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22

DEN HARTIG

protein, and thiamine was in accordance with the recommendations. The intake of calcium, iron, riboflavin, and vitamin C was relatively low. If 15 0/o less than the recommended values is accepted as the lower limit, only 16 0/o of the mothers fulfilled all requirements. After the lactation period, the nutrition changed for the better and was in closer agreement with the recommended amounts than during the lactation period. Table IX clearly illustrates this. 4. Students Students are not noted for a particularly regular life. This also applies to their nutrition. A physician at the University of Leyden [DEN HØ and VERMEY-SCHELTEMA, 1967] has studied the nutrition of 601 male and 359 female students, with special reference to the nutritional habits as well as to the protein consumption. A pronounced degree of anemia was encountered in the girls. The iron uptake could not be calculated from the data obtained: 82 0/o of the students lived in furnished rooms, 12.5 0/ lived at home and commuted, and 5.5 0/ lived with their families without commuting; 80-90 ο/ο of the students ate no breakfast, and 10 0/ο ate no lunch. Most hot meals included potatoes; 45 0/ consumed less than 200 g/day. Animal products such as meat, milk, and eggs were used in sufficient amounts; approximately 65 0/0 of the boys consumed more than 1.2 g protein/kg body weight, and 3 0/o less than 0.8 g/kg. For the girls, these figures were less favorable. Sugar consumption was very low, with 75 0/o of the students consuming less than 30 g sugar/day; 120 kcal per day, on the average, were derived from alcohol.

Table X. Normal military ration in g/caput/day bread potatoes meat without bone, meat products, chicken, fish eggs (number)1 cheese groceries milk

400 700 150 40 30 600

coffee cream butter, margarine, fat, etc. sugar fruit vegetables, average (prepared product) leguminous seeds

x 75 80 125 250 35


1 Substitutes for meat, i. e., milk.

23

5. Young Soldiers Until 1881, the army system was for every garrison to buy its own food and to arrange its own meals. Nowadays, the Defence Ministry determines the rations of military personnel, with a considerable degree of differentiation for the various army services. The normal military ration (1968) is shown in table X. Mostly, the amounts shown are maxima; on average, the actual consumption of bread is 250 g and for potatoes the figure is 500 g. Meat products (40 g) and cheese (40 g) can be substituted for each other in a ratio of 60-20. Recently, enlisted men have been entitled to a larger ration, with the following extras per day: bread 100 g, meat products 10 g, cheese, bread dressing, and margarine, 10 g each. The nutrient composition of the normal ration is: 3,300 cal, 109 g protein of which 54 g is animal protein, 127 g fat, 433 g carbohydrates, 1,300 mg calcium, 18 mg iron, 5 mg vitamin Α + carotene, 1.6 mg vitamin B1, 2.1 mg vitamin Β2, 22 mg nicotinic acid, and approximately 120 mg vitamin C. The actual amount of vitamin C is probably less as the result of cooking and keeping the food hot. The training ration contains over 4,000 calories and almost 130 g protein. Special rations are allotted to soldiers in hospitals, divers of the Pontonniers regiment (extra cocoa for every section), and night-flying personnel. The rations are more than ample; but the whole there is a great deal of waste, as demonstrated mostly by investigations in other countries. Α recent study among newly enlisted conscripts approximately 20 years of age showed that approximately 35 Ο/ο ate no breakfast, although this does not mean that the same 35 °/ο habitually missed breakfast. For lunch and the hot (evening) meal, these figures were 1 Ο/o and 15 o/o, respectively [Tiros and SØτs, 1972]. There is a tendency amongst military personnel to obtain a good part of their calories outside the barracks in the form of snacks, to an average of 1,200-1,700 kcal, of which 30-25 ο/ο is derived from beer. Except at weekends, the average calorie consumption of military personnel in training for the two groups examined was found to range from 3,900 to 4,700 kcal [Tλκs and SARIS, 1972], with the proportion of fat being between 34 and 38 u/ο. The amount of linoleic acid ingested was 16 g/day. Food consumption during the weekends was considerably less, between 3,100 and 3,200 kcal. The average blood cholesterol levels for a number of determinations varied between 204 and 210 mgο/o, the total lipids between 604 and 669 mgο/o.



DEN

24

HARTIG

1821 Protein

1920

1952

100%.

:~, a`s rï

•:.: i!:MSφç:

Animal protein

1001.

Γ

Fat

Ca

1957

100

.°®..-...

1001.

Fe

100"

Vitamin A

100".

Vitamin 13,

100 '!.

Vitamin 512

1001.

N¢toirnc acid

1001.

Vitamin C

Calories

".

i'v>':

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