Danish University Colleges Development of a healthy New Nordic Diet Mithril, Charlotte Elisabeth

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Danish University Colleges

Development of a healthy New Nordic Diet

Mithril, Charlotte Elisabeth

Publication date:

2013

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Citation for pulished version (APA):

Mithril, C. E. (2013). Development of a healthy New Nordic Diet. [PhD, University of Copenhagen]. Københavns Universitet.

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CHARLOTTE MITHRIL Development of a healthy New Nordic Diet DEPARTMENT OF NUTRITION, EXERCISE AND SPORTS

FACULTY OF SCIENCE · UNIVERISITY OF COPENHAGEN PHD THESIS 2013 · ISBN 978-87-7611-646-0

CHARLOTTE MITHRIL

Development of a healthy New Nordic Diet

fac u lt y o f s c i e n c e

u n i ve r s i t y o f co pe n h ag e n

Development of a healthy

New Nordic Diet

PHD THESIS · 2013

CHARLOTTE MITHRIL

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Development of a healthy

New Nordic Diet

Charlotte Mithril PhD thesis

2013

Development of a healthy

New Nordic Diet

PhD thesis · 2013

Charlotte Mithril

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Development of a healthy New Nordic Diet PhD Thesis by Charlotte E. Mithril

2013

Supervisors

Professor Lars Ove Dragsted

Department of Nutrition, Exercise and Sports University of Copenhagen

Denmark

Professor Arne Astrup

Department of Nutrition, Exercise and Sports University of Copenhagen

Denmark

Adj. Professor Claus Meyer Meyers Madhus A/S Denmark

Department of Nutrition, Exercise and Sports Faculty of Life Sciences, University of Copenhagen Rolighedsvej 30

DK‐1958 Frederiksberg C, Denmark

ISBN 978‐87‐7611‐646‐0

Printed by SL grafik, Frederiksberg C, Denmark (www.slgrafik.dk)

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Preface and acknowledgement

The present PhD thesis is part of the OPUS research project and is conducted in collaboration with Meyers Madhus and Department of Human Nutrition, Faculty of Science, University of Copenhagen. It is a part of Work Packages 1 within the OPUS project and the primary workplace has been Meyers Madhus where the development of the New Nordic Diet including the development of recipes has tak‐

en place.

OPUS is an acronym of the Danish title of the project 'Optimal well‐being, development and health for Danish children through a healthy New Nordic Diet' and is supported by a grant from the Nordea Foundation, Denmark, in cooperation with Øresund Food Network. The OPUS project runs from 2009 till 2013 and the main objective is to establish a multi‐disciplinary research centre to develop a healthy and palatable new food and eating concept ’The New Nordic Diet’, and to examine how such a diet can affect mental and physical health.

I owe thanks to many people who have been involved in this project:

To my supervisors Lars Ove Dragsted, Claus Meyer and Arne Astrup for giving me the opportunity to conduct this research ‐ thank you Claus for your never ending passion and inspiration, and thank you Lars and Arne for guiding me in this (for me) sometimes confusing scientific world; to my former col‐

leagues in WP 1 Mathias Holt and Emil Blauert ‐ it has been a hard, educational and fun journey; to all my former colleagues at Meyers Madhus for your support and friendship; to my former colleagues at the OPUS project ‐ best of luck to you all; to the participants at the OPUS congress held in June 2009 and the WP 1 advisory boards for your valuable input; to all the employees at NordicFoodLab for great inspiration and cooperation; to my colleagues at IHE for the support and help with all the practical stuff; to Inge Tetens, Anja Biltoft‐Jensen and Karin Hess Ygil at DTU food for your professional cooper‐

ation (and patience); to my roommates at the end of the project at Abilgaardhuset ‐ I wish you all the best; to Elling Bere for being a great source of inspiration and in a way one of the fathers of the New Nordic Diet; to my friends and family for always supporting me whatever I do; to my love and to Mi‐

amaja for always reminding me of what is important in life.

Charlotte Mithril, June 2013.

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List of papers

This thesis is based on the following manuscripts:

Paper I Mithril C, Dragsted LO, Meyer C, Blauert E, Holt MK and Astrup A.

Guidelines for the New Nordic Diet.

Public Health Nutrition 2011; doi:10.1017/S136898001100351X [E‐pub ahead of print].

Paper II Mithril C, Dragsted LO, Meyer C, Tetens I, Biltoft‐Jensen A and Astrup A.

Dietary composition and nutrient content of the New Nordic Diet.

Public Health Nutrition 2012; doi:10.1017/S1368980012004521 [E‐pub ahead of print].

Paper III Mithril C & Dragsted LO.

Safety evaluation of some wild plants in the New Nordic Diet.

Food and Chemical Toxicology 2012;50:4461–4467.

Paper IV Andersen MS, Reinbach HC, Rinnan Å, Barri T, Mithril C and Dragsted LO.

Discovery of exposure markers in urine for Nordic meals and foods by UPLC‐qTOF‐MS untargeted metabolomics.

Metabolomics 2013; doi:10.1007/s11306‐013‐0522‐0 [E‐pub ahead of print].

The papers are referred to in the text as Paper I‐IV and are reproduced in full in chapters 5‐8.

C Mithril’s contribution to the papers

Paper I C Mithril developed the guidelines for the New Nordic Diet together with LOD, CM, EB, MKH and AA and was responsible for writing the manuscript.

Paper II C Mithril developed the dietary composition of the New Nordic Diet together with LOD, CM, IT, ABJ and AA and was responsible for writing the manuscript.

Paper III C Mithril performed the safety evaluation of four wild plants in the New Nordic Diet to‐

gether with LOD and was responsible for writing the manuscript.

Paper IV C Mithril designed and validated the meals together with MKH and LOD and designed the divided 24 h urine collection. C Mithril was not involved in the data collection or metab‐

olomic analysis of the study.

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Summary

Many of the diseases today are diet‐related, and recommendations for a healthy diet are one of the main challenges for public health today. At the same time, concern for the environment and the planet's health has developed to be an equally important challenge, and the circumstances call for an update of our food culture. Dietary recommendations have not yet been successful in reversing the obesity epidemic, and one of the reasons for this could be that palatability and gastronomic potential are not taken into account in current dietary recommendations. It has been suggested that dietary recommendations should be more tailored to regional conditions which could help to preserve cultur‐

al diversity in eating habits, and in addition contribute to more environmentally friendly food con‐

sumption.

Both gastronomists and nutritionists are beginning to believe that there is a shared route to creating regional diets and an opportunity to develop a healthy diet that bridges gastronomy, health and sus‐

tainability. This forms the basis for the multidisciplinary, 5 year research project, OPUS (Optimal well‐

being, development and health for Danish children through a healthy New Nordic Diet), which aims to define and test a New Nordic Diet (NND). The hypothesis is that an optimal diet composition, based on healthy, palatable meals, may not only contribute to the prevention of excessive weight gain, obesity, and other health disorders, but may also improve quality of life, learning ability, and mental and physi‐

cal performance in children.

In the development of the NND the following principles have been crucial: Health, gastronomic poten‐

tial, Nordic identity, and sustainability. These principles led to the formulation of three overall guide‐

lines forming the basis of the NND as compared to the current average Danish diet: (i) More calories from plant foods and fewer from meat; (ii) More foods from the sea and lakes; and (iii) More foods from the wild countryside. These guidelines were used to develop a list of dietary components charac‐

terizing the NND: Fruit and vegetables (especially berries, cabbages, root vegetables and legumes), fresh herbs, potatoes, plants and mushrooms from the wild countryside, wholegrain, nuts, fish and shellfish, seaweed, free‐range livestock (including pigs and poultry), and game. For dietary compo‐

nents already included in the Danish Food‐based Dietary Guidelines (DFDG) and with substantial evi‐

dence for their health promoting properties, they are naturally included in the NND in at least the same amount as in DFDG; e.g. fruit, vegetables, potatoes, wholegrain, nuts, fish and shellfish. The rec‐

ommended intake of the other dietary components in the NND (e.g. fresh herbs, plants and mush‐

rooms from the wild countryside, seaweed, meat and game) is based on the scientific arguments for their health promoting properties together with considerations for acceptability, safety, availability, and the environmental sustainability.

An evaluation of the nutritional content of the NND was performed based on the overall dietary com‐

ponents in the NND compared with data from the Nordic Nutrition Recommendations (NNR) and the intake in the average Danish diet with regard to both macro‐ and micronutrients. Overall, the average

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daily intake of macro‐ and micronutrients in the NND meets NNR with small adjustments based on evidence of their health promoting properties. In addition, a safety evaluation of selected NND foods (wild plants) was performed for ensuring a non‐risk intake of these in the NND using the concept of Substantial Equivalence (SE) when data on the level of acceptable daily intakes was not known. It was concluded, that most compounds with a possible risk of adverse effects found in the plants seemed within similar levels as other common food plants, but further evaluation and analysis are necessary, before a daily intake of wild plants can be generally regarded as safe.

Finally a thematic variation over three lunch meals, each with fish, meat or vegetable protein sources and a model for a weekly meal structure applying similar variations have been made, to aid in the pro‐

cess of turning the NND guidelines and dietary components into meals. The model is made with ut‐

most concern for acceptability in relation to the Danish population's current everyday kitchen and dining culture, taking the principles of the NND into account. This model has subsequently been ap‐

plied successfully for two large OPUS intervention trials.

The NND is a suggestion for a regional diet with concern for health, gastronomic potential, Nordic identity, and sustainability. In the two intervention studies performed within the OPUS project, one in overweight adults and one in school children, it will be examined how such a diet can affect the nutri‐

tional, mental and physical health. As we get the results from these studies we learn more about how to develop it further. It is suggested that regional diets like the NND, could be created anywhere in the world using the same principles and guidelines.

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Sammenfatning (Danish summary)

I dag er en væsentlig del af årsagerne til vor tids sygdomme kostrelaterede. Anbefaling af en sund kost er derfor en af de vigtigste udfordringer for folkesundheden. Samtidig er bevaring af naturen og hen‐

synet til miljøet og planetens sundhed blevet en ligeså vigtig udfordring, og omstændighederne kalder på en opdatering af vores madkultur. Kostanbefalinger har endnu ikke haft held til at vende fedmeepi‐

demien, og en af grundene til dette kan være, at der ikke tages hensyn til velsmag og gastronomisk potentiale i de nuværende kostanbefalinger. Det er blevet foreslået, at kostanbefalingerne bør være mere skræddersyede til regionale forhold, der kan bidrage til at bevare den kulturelle mangfoldighed i spisevaner, og derudover bidrage til mere et miljøvenligt fødevareforbrug.

Både gastronomer og ernæringseksperter er begyndt at tro på, at der er en fælles vej til at skabe en regional kost og en mulighed for at udvikle en sund kost, der bygger bro mellem gastronomi, sundhed og bæredygtighed. Dette danner grundlaget for det tværfaglige, 5 årige forskningsprojekt, OPUS (Op‐

timal trivsel, udvikling og sundhed for danske børn gennem en sund Ny Nordisk Hverdagsmad), som sigter mod at definere og afprøve en Ny Nordisk Hverdagsmad (NNH). Hypotesen er, at en optimal kostsammensætning, baseret på sunde, velsmagende måltider, ikke kun bidrager til at forebygge vægtstigning, fedme og andre sundhedsproblemer, men også kan forbedre livskvalitet, indlæringsev‐

ne, og mental og fysisk præstationsevne hos børn.

I udviklingen af NNH har følgende principper har været afgørende: Sundhed, gastronomisk potentiale, nordisk identitet, og bæredygtighed. Disse principper førte til formuleringen af tre overordnede ret‐

ningslinjer, der danner grundlag for NNH sammenlignet med den nuværende gennemsnitlige danske kost: (i) Flere kalorier fra vegetabilske fødevarer og færre fra kød; (ii) Mere mad fra havet og søerne;

og (iii) Mere mad fra de vilde landskaber. Disse retningslinjer blev brugt til at udarbejde en liste over råvarer der karakteriserer NNH: Frugt og grøntsager (især bær, kål, rodfrugter og bælgfrugter), kryd‐

derurter, kartofler, planter og svampe fra de vilde landskaber, fuldkorn, nødder, fisk og skaldyr, tang, kød fra fritgående husdyr (herunder svin og fjerkræ), og vildt. For råvarer, der allerede indgår i de danske kostanbefalinger og med betydelig evidens for deres sundhedsfremmende egenskaber, indgår de i NNH i mindst den samme mængde som i kostrådene, fx frugt, grøntsager, kartofler, fuldkornspro‐

dukter, nødder, fisk og skaldyr. Det anbefalede indtag af de andre råvarer i NNH (fx krydderurter, planter og svampe fra de vilde landskaber, tang, kød og vildt) er baseret på de videnskabelige argu‐

menter for deres sundhedsfremmende egenskaber sammen med overvejelser omkring acceptabilitet, sikkerhed, tilgængelighed, og bæredygtighed.

En evaluering af næringsindholdet i NNH blev udført på baggrund af råvarerne i NNH sammenlignet med data fra de Nordiske Næringsstofanbefalinger (NNR) og indtaget i den gennemsnitlige danske kost med hensyn til både makro‐og mikronæringsstoffer. Generelt var resultatet, at det gennemsnitlige daglige indtag af makro‐ og mikronæringsstoffer i NNH fulgte NNR med små justeringer hvor doku‐

mentation for deres sundhedsfremmende egenskaber. Derudover blev en risikovurdering af udvalgte

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NNH råvarer (vilde planter) udført, for at sikre et risikofrit indtag af disse i NNH. Vurdering blev fore‐

taget ved brug af metoden om ’Substantial Equivalence’ (SE) når data om niveau for acceptabelt dag‐

ligt indtag ikke var kendt. Det blev konkluderet, at de fleste stoffer fundet i de vilde planter med en mulig skadelig effekt, kunne findes i lignende niveauer i andre almindelige fødevarer, men yderligere evaluering og/eller analyse er nødvendig, før en daglig indtagelse af vilde planter generelt kan betrag‐

tes som risikofrit.

Endelig blev der udarbejdet en tematisk variation over tre frokostmåltider med enten fisk, kød eller vegetabilier som proteinkilde, samt en model for en ugentlig måltidsstruktur med samme variations‐

muligheder for at hjælpe med at omforme retningslinjerne og råvarerne i NNH til måltider. Måltids‐

strukturen er lavet med størst mulig hensyn til acceptabilitet i forhold til den danske befolknings nu‐

værende daglige måltidskultur, og med principperne for NNH taget i betragtning. Modellen blev efter‐

følgende benyttet med succes i to store OPUS interventionsstudier.

NNH er et forslag til en regional kost med hensyn til sundhed, gastronomisk potentiale, nordisk identi‐

tet, og bæredygtighed. I de to interventionsstudier udført i OPUS projektet, et med overvægtige voksne og et med skolebørn, vil det blive undersøgt, hvordan en sådan kost kan påvirke den ernæringsmæssi‐

ge, mentale og fysiske sundhed. Når vi får resultaterne fra disse studier, vil vi lærer mere om hvordan NNH kan udvikles yderligere. En regional kost som NNH burde kunne skabes overalt i verden ved brug af de samme principper og retningslinjer.

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Abbreviations

ADD Average Danish diet ADI Acceptable daily intake CVD Cardiovascular disease

DFDG The Danish food‐based dietary guidelines EDI Estimated daily intake

E% Percentage of total energy FA Fatty acids

GHG Greenhouse gas LCA Life‐cycle assessment NND New Nordic Diet

NNR The Nordic nutrition recommendations

OPUS Optimal well‐being, development and health for Danish children through a healthy New Nordic Diet

PCB Polychlorinated biphenyls PEMs Potential exposure markers

PDCAAS Protein digestibility corrected amino acid score SE Substantial equivalence

TMAO Trimethylamine N‐oxide WP Work packages

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1 Introduction

The World Health Organization (WHO) states that obesity is one of the greatest public health challeng‐

es of the 21st century (1). In Denmark, as well as in the rest of the World, the prevalence of overweight and obesity among both children and adults has increased dramatically over the last 60 years, and the numbers continue to rise at an alarming rate, particularly among children (1‐3). Overweight has been estimated to affect up to one fourth of children in Europe (4). An inappropriate diet, in combination with a lack of physical activity, is believed to be the main element in the development of childhood obesity. In addition to causing various physical disabilities and psychological problems, excess weight drastically increases the risk of developing a number of diseases, including cardiovascular disease (CVD), cancer and type 2 diabetes. Studies also indicate that inappropriate diet affects cognition, learn‐

ing and behaviour (5,6).

Recommendations for a healthy diet are one of the main challenges for public health today. It seems that we have developed a preference for foods that are rich in fat and sugar, which makes the chal‐

lenge of recommending a healthy diet even more difficult. Combining health and palatability is crucial in this task – just think what it would mean for the society if the food we preferred also was the health‐

iest. Concern for the environment and the planet's health has developed to be an equally important challenge, since food production is estimated to count for 20‐30% of the total emissions of greenhouse gases (GHG) (7). All the above circumstances call for an update of our food culture.

The traditional Mediterranean diet has for many years been a role model for healthy diets and has proven to reduce the risk of CVD, type 2 diabetes and certain cancers (8‐10). Attempts to promote the Mediterranean diet outside the Mediterranean countries has been tried, but it can be questioned whether such a specific regional diet can be recommended all over the world. Many of the foods are not suitable for growing in other climates and require greenhouses and long distance transport on the expense of the environment, or cannot be produced in large enough quantities to meet the demands of the world. The adoption of the Mediterranean diet worldwide would also lead to loss of local food cultures and might not be the preferred diet for all. There seems to be a need for stronger regionally‐

based food cultures that possess the health benefits of the Mediterranean diet and can be accepted by the local population as being palatable. Such regional tailoring may help to preserve cultural diversity in eating habits and in addition may contribute to more environmentally friendly eating.

The emerging mutual understanding by both gastronomists and nutritionists that there is a shared route to creating regional diets offers an opportunity to develop a healthy diet based on regional food that bridges gastronomy, health and sustainability. This forms the basis for the multidisciplinary, 5 year research project, OPUS (Optimal well‐being, development and health for Danish children through a healthy New Nordic Diet), which aims to define and test a New Nordic Diet (NND). The hypothesis is that an optimal diet composition, based on healthy, palatable meals, may not only contribute to the

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prevention of excessive weight gain, obesity, and other health disorders, but may also improve quality of life, learning ability, and mental and physical performance in children(5,11).

2 Aim of thesis

The purpose of this thesis is to describe the development of the NND. The hypothesis is that it is possi‐

ble to develop a healthy, environmentally friendly and palatable diet that can play an important role in promoting health and preventing disease in Denmark. Since this is a theoretical thesis, it will not be possible to evaluate the effect of the NND on the human body based on this specific contribution, but a theoretical evaluation of the pros and cons of the NND will be performed and accessible results from Nordic diet studies will be discussed.

The studies and tasks include:

 Establishment of a new system of dietary guidelines living up to the NND paradigm.

 Identification of a list of dietary components that lives up to the NND guidelines. A theoretical positioning of the dietary components of the NND against the current average Danish diet and the Nordic Nutrition Recommendations (NNR) / Danish Food‐based Dietary Guidelines (DFDG).

 An evaluation of the nutritional content of the NND based on the overall dietary components in the NND compared with data from NNR and the intake in the average Danish diet with regard to both macro‐ and micronutrients.

 A safety evaluation of selected NND foods for ensuring a non‐risk intake of the selected foods in the NND.

 Development of specific NND dishes and menus that can gain complete recognition as being palatable, healthy and acceptable by chefs, nutrition‐ and health experts, and the consumers.

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3 Background

The traditional Danish diet

The early Danish diet was based on the foods that could be captured, collected or grown in the local area. Based on archaeological findings from the early Danish history it has been established that nuts, berries, wild plants and roots, grains, mussels, deer, stork, aurochs and pike were some of the common eaten foods in the stone age (12). In the Middle Ages the households became more or less self‐

sufficient and the meals were mainly based on soups, stews, porridge, bread and beer, and until the end of the 1800 century the main ingredients in the meal was grain, milk, meat, vegetables (especially cabbage) and eggs (13,14).

With the industrialization, and the invention of e.g. the stove and the meat grinder, the meals changed.

Potatoes, root vegetables and coffee were introduced to the diet, and meat became more accessible and in particular pork and larger birds such as ducks and geese were typical (12). People moved from the rural areas to the cities and the concept of a lunch box was introduced with e.g. rye bread and liver pate. Potatoes became a food served almost every day, though they for many years were regarded as unfit for human food, probably because the potato for many years only was known as a raw food (12,14).

Economic crisis, food shortages and ingenuity marked the first half of the 1900 century with war and depression. Food shortage, high prizes and rationing resulted in a decrease in the intake of meat, and the basic foods became bread, potatoes and vegetables like cabbage and root vegetables (12). After 1950 the economy improved and Denmark went from an agricultural to an industrial country, and the women joined the labour market. A major change in the everyday meals was seen due to what could be called ‘the industrialized kitchen’ characterized by the introduction of mass produced industrial prod‐

ucts (12). The intake of meat increased drastically and became the defining part of the meal, while vegetables became a garnish (12). Potatoes were still a part of the everyday meal and fermented dairy products were introduced. The revolutionary series of recipes from “Karolines Køkken” (Caroline’s Kitchen) was introduced in 1962 and distributed to all households (15). They were published by the Danish Dairy Board and were intended as an educational tool for Danish housewives to teach them to use dairy products. New and exotic dishes and new methods of preparation were introduced in the cookbooks, and they became ground‐breaking for the Danish kitchen, as the dishes spread like wildfire around the country and became a common reference at the dinner table.

In 1972 Denmark became a member of the European Union resulting in easier access to a wide range of foods from all over the world. Especially foods from the Mediterranean countries were popular with products like French cheese and wine, Italian sausages, pasta, pizza and canned tomatoes, but also fast food from USA with e.g. hamburgers became popular (12). Even though the Danish food culture has

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been highly influenced by the access to foods from all over the world, many of the dishes eaten in the Danish homes today are still traditional Danish dishes like meatballs, meatloaf, chicken and stews, but with the introduction of Italian dishes like pizza and lasagne (12).

During the recent years a new era in the Danish food culture has emerged. There is an increasing awareness of the limited resources of the nature and the importance of food with regard to health (both mentally and physically). Organic food production is increasing (16), and we are after having been inspired by other food cultures for the past years, now turning towards our own local foods again, to see if we maybe could learn something from the traditional Danish diet. Dietary recommen‐

dations have become a widespread phenomenon in mass media, and there is a great demand for in‐

formation and inspiration of how to eat a healthy diet.

National dietary recommendations The Nordic Nutrition Recommendations

The official nutritional guidelines in Denmark as well as in the other Nordic countries are based on the Nordic Nutrition Recommendations 2004 (NNR) (17). NNR are the result of a joint Nordic co‐

operation between experts from the five Nordic countries. The recommendations are based on the existing scientific knowledge and are updated at a regular basis as new information becomes available.

NNR gives overall recommendations for intake of dietary fat, carbohydrate, protein, vitamins and min‐

erals, and is intended to be used as guidance in planning diets for groups, as basis for education and information about diet and nutrition, as basis for food and nutrition policy, and as reference for the assessment of dietary surveys (17).

Table 1 provides an overview of the recommended average daily intake of protein, fat, carbohydrates, salt and alcohol as percentage of total energy intake recommended by NNR (17). Table 2 presents an overview of the average daily intake of micronutrients recommended by NNR(17). All figures are based on the energy‐adjusted intake per 10 MJ for groups of individuals 10‐75 years of age, with a het‐

erogeneous age and sex distribution (for alcohol the age group is 18‐75 years).

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Table 1 Overview of the average daily recommended intake of protein, fat, carbohydrates, salt and alcohol as percentage of total energy intake by NNR^a. All figures are for groups of individuals 10‐75 years of age, with a heterogeneous age and sex distribution (for alcohol the age group is 18‐75 years).

Macronutrient Recommended intake NNR^a

Protein (E%) 15

Fat (E%) 30

Saturated FA (E%) ≤ 10

Monounsaturated FA (E%) 10‐15

Polyunsaturated FA (E%) 5‐10

Carbohydrates (E%) 55

Dietary fibre (g/day) 25‐35

Refined sugars (E%) ≤ 10

Salt (g/day) 6‐7

Alcohol (E%) ≤ 5

a NNR, 2004

Table 2 Overview of the average daily intake of micronutrients recommended by NNR^a. All figures are based on the energy‐

adjusted intake per 10 MJ for groups of individuals 10‐75 years of age, with a heterogeneous age and sex distribution.

Micronutrient Recommended intake NNR^a

Vitamin A (RE) 800

Vitamin D (µg) 10

Vitamin E (α‐TE) 9

Thiamin (mg) 1,2

Riboflavin (mg) 1,4

Niacin (NE) 16

Vitamin B6 (mg) 1,3

Folate (µg) 450

Vitamin B12 (µg) 2

Vitamin C (mg) 80

Calcium (mg) 1000

Phosphorus (mg) 800

Potassium (g) 3,5

Magnesium (mg) 350

Iron (mg) 16

Zinc (mg) 11

Copper (mg) 1

Iodine (µg) 170

Selenium (µg) 40

a NNR, 2004

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NNR is based on the current nutrition situation in the Nordic countries and aims at providing a basis for planning a diet that covers the primary needs for nutrients, i.e. meeting the physiological needs for growth and function, as well as providing conditions for a generally good health and reducing the risk of diet‐related diseases. NNR applies primarily to groups of healthy people. For sick people and for groups with special needs (e.g. obese people) the dietary composition should be adapted to their spe‐

cific requirements. The composition of the diet is generally allowed to vary from meal to meal and from day to day, and the figures in NNR applies in principle to an average diet over a longer period, i.e.

a week or more. The recommended intake refers to the quantities eaten. Therefore, loss of nutrients caused by preparation etc. should be taken into account when planning a diet based on the recom‐

mendations.

The latest edition of NNR was published in 2004, but a 5th revised edition is expected in 2013, and a draft proposal was presented at the 10th Nordic nutrition conference in Reykjavik, Iceland in June 2012 (18). According to the draft proposal, most of the recommendations from the 4th edition (2004) remain unchanged in the new edition, but more emphasis is put on the quality of fat and carbohy‐

drates and their dietary sources. Specific recommendations for the total intake ranges for carbohy‐

drates and fats are not given in the new edition; instead recommendations include ranges for the dif‐

ferent fatty acids (FA), dietary fibre and added sugars. NNR 2012 focuses on the whole diet, and a diet following NNR 2012 should be associated with lower risk of most diet‐related chronic diseases, and covers a diet with plenty of fibre‐rich plant foods (e.g. dark green leafy vegetables, cabbages and on‐

ions, beans and peas, root vegetables, fruit and berries, nuts and wholegrain cereals), with frequent consumption of fish and seafood, with low fat dairy products and vegetable oils preferably used, and with a limited salt intake (18). In contrast, according to NNR 2012, the risk of chronic diseases and weight‐gain in the population will increase with frequent consumption of food products low in essen‐

tial nutrients and fibre and high in energy, like sugar‐sweetened beverages, sweet bakery products or confectionary, refined cereals and solid fats (e.g. butter) (18). A high consumption of processed and red meats (i.e. beef, pork and lamb), may also enhance the risk of adverse health effects and chronic disease in the population (18). NNR 2012 also considers factors like production characteristics, sea‐

sonal food supply and origin when selecting food items, stating that a diet that supports health could also be sustainable from an environmental and ecological perspective (18).

The Danish Food‐based Dietary Guidelines

For a person without a professional background within nutrition it can be difficult to use NNR for diet planning. Therefore a set of comprehensive guidelines, the Danish Food‐based Dietary Guidelines (DFDG), has been formulated by the Danish Nutrition Council (19). DFDG consist of the following eight dietary guidelines:

1. Eat fruit and vegetables ‐ six a day

2. Eat fish and fish products several times a week

3. Eat potatoes, rice or pasta and wholegrain bread ‐ every day

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4. Cut down on sugar 5. Cut down on fat

6. Eat a varied diet and maintain a normal weight 7. Drink water when you are thirsty

8. Be physically active ‐ at least 30 minutes a day

For selected dietary components with comprehensive evidence for their health promoting properties, specific average amounts recommended to be eaten per day has been set and are henceforward re‐

ferred to as DFDG (19‐21). These are fruit, vegetables, wholegrain, potatoes, nuts, fish and shellfish, meat, and dairy products. A list of the recommended intake of each is presented in table 3.

Table 3 Overview of the average daily recommended intake of dietary components according to DFDG^a‐c. All figures are based on the energy‐adjusted intake (per 10 MJ) of all persons aged 4‐75 years.

Dietary components Recommended intake DFDG

(g/day)

Fruit 300^a

Vegetables 300^a

Wholegrain 75^a

Potatoes 140^a

Nuts 30^b

Fish and shellfish 29‐43^a

Meat 100^c

Dairy products 525^a

a Astrup et al.,2005

b Ministry of Food, Agriculture and Fisheries, 2010

c Ovesen, 2002

Living according to DFDG should ensure the recommended intake of vitamins, minerals and other es‐

sential nutrients by NNR, and should also reduce the risk of lifestyle diseases like CVD, type 2 diabetes and cancer and prevent weight gain (19‐21). Most of the Danish population can benefit from living according to DFDG. Exceptions are children under 3 years, slow eating elderly and persons with an illness that has specific dietary demands (19).

The present Danish diet

Despite the efforts made on recommending a healthy diet, the major determinants of the burden of disease today are still diet‐related (22). In Denmark, as well as in the rest of the World, the prevalence of overweight and obesity among both children and adults has increased markedly in recent decades (2,3). Figures suggest that in Denmark up to 47% of the adult population is overweight (BMI ≥ 25) and approximately 13% of the adult population is obese (BMI ≥ 30) (23). For Danish children the preva‐

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lence of overweight and obesity is estimated to be 15‐20% and the trend is similar in our neighbouring countries Sweden, Norway and Germany (24).

Obesity increases the risk of a wide range of serious medical complications including CVD, insulin re‐

sistance, type 2 diabetes, gall bladder disease, osteoarthritis, asthma and several cancers (25). The reasons for the increasing prevalence of overweight and obesity in Denmark, as well as in the rest of the world, are many, but unhealthy food choices and a decrease in the level of physical activity are assumed to be the main reasons. The Danish diet and food culture has during the past decades gone through large changes. Agricultural and technological development, international cultural exchanges, food imports and exports, and the introduction of processed and industrialized foods have changed the eating habits in Denmark, and thereby also influenced the prevalence of overweight and obesity in the Danish population. The intake of meat in Denmark is among the highest in the world, while the intake of fish and shellfish, fruit, vegetables and dietary fibre is too low compared to DFDG (19).

The National Food Institute at DTU Food has since 1985 performed regular surveys of the dietary composition of the Danish diet. In the following the composition of the average Danish diet anno 2003‐

2008 is presented (26).

Dietary components

In table 4 is presented an overview of the average daily intake of dietary components in the Danish population in relation to the average daily intake recommended by DFDG (when recommendation exists) (19‐21,26,27). Compared with the recommended intake from DFDG, the average intake of fruit, vegetables, potatoes, nuts, and fish and shellfish is too low, whereas the intake of meat is high com‐

pared with the intake considered adequate (table 4).

Table 4 Overview of the average daily intake of dietary components in the Danish population^a,b in relation to the average daily intake recommended^c‐e. All figures are based on the energy‐adjusted intake (per 10 MJ) of all persons aged 4‐75 years.

Dietary components Average intake in the

Danish population^a,b (g/day)

Recommended intake DFDG

(g/day)

Fruit 240 300^c

Vegetables 181 300^c

Potatoes 106 140^c

Wholegrain 36 75^c

Nuts 1 30^d

Fish and shellfish 22 29‐43^c

Meat 143 100^e

Dairy products 522 525^c

a Pedersen et al., 2010

b Biltoft‐Jensen, 2009

c Astrup et al., 2005

d Ministry of Food, Agriculture and Fisheries, 2010

e Ovesen, 2002

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When comparing the data from the latest dietary survey with the former national dietary survey in 2000‐2002 (not presented here), the intake of fruit and vegetables has increased, whereas the intake of potatoes has decreased (26,28). Since the survey in 2000‐2002 there have not been large changes in the intake of meat, fish and shellfish, and dietary fibre despite national initiatives for promoting a higher intake of both fish and shellfish, and wholegrain (26,28).

Macronutrients

In the adult population, the average diet provides 14% of energy from protein, 33% from fat and 48%

from carbohydrate (table 5) (26). Among the adults energy contribution from alcohol amounts to a mean of 6% of the total energy intake, but the intake distribution is highly skewed (26). The recom‐

mended energy distribution according to NNR is 15% from protein, 30% from fat, 55% from carbohy‐

drate and maximum 5% from alcohol (17). The content of saturated FA is 14 E% for adults compared to the recommended level of max. 10 E%, while the level of mono‐ and polyunsaturated FA is 12 and 5 E% respectively compared to the recommended level of 10‐15 and 5‐10% (table 5) (17,26). The Dan‐

ish population has an average intake of 23 g/day of dietary fibre compared to the recommended intake of 25‐35 g/day, and about 25% of the adults in the Danish population consume more added sugars than the recommended maximum of 10 E% (26). Intake of salt is 7.3 and 9.8 g/day for females and males, respectively (26). The corresponding recommended levels are 6 and 7 g/day (17).

Table 5 Overview of the average daily composition and intake of macronutrients in the Danish population as percentage of total energy intake^a in relation to the average daily composition recommended by NNR^b. All figures are for groups of individ‐

uals 10‐75 years of age, with a heterogeneous age and sex distribution (for alcohol the age group is 18‐75 years).

Average composition of the diet in the Danish population^a

Recommended intake NNR^b

Protein (E%) 14 15

Fat (E%) 33 30

Saturated FA (E%) 14 ≤ 10

Monounsaturated FA (E%) 12 10‐15

Polyunsaturated FA (E%) 5 5‐10

Carbohydrates (E%) 48 55

Dietary fibre (g) 23 25‐35

Refined sugars (E%) 11 ≤ 10

Salt (g/day) 7‐10 6‐7

Alcohol (E%) 6 ≤ 5

b NNR, 2004

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Micronutrients

The content of micronutrients in the average diet is generally sufficient compared with NNR (table 6) (17,26). For vitamin A, riboflavin, niacin and B12, vitamin C, calcium, phosphorus and iodine the con‐

tent are abundant. For vitamin E, thiamine, B6 and magnesium, zinc, selenium and potassium the con‐

tent is acceptable. Whereas the content of vitamin D is too low in all age groups, and the folate and iron content is insufficient for many females in fertile age (26).

Table 6 Overview of the average daily intake of micronutrients in the Danish population^a in relation to the average daily composition recommended by NNR^b. All figures are based on the energy‐adjusted intake per 10 MJ for groups of individuals 10‐75 years of age, with a heterogeneous age and sex distribution.

Nutrients Average composition

of the diet in the Danish population^a

Recommended intake NNR^b

Vitamin A (RE) 1149 800

Vitamin D (µg) 3,3 10

Vitamin E (α‐TE) 7,6 9

Thiamin (mg) 1,4 1,2

Riboflavin (mg) 1,8 1,4

Niacin (NE) 31 16

Vitamin B6 (mg) 1,6 1,3

Folate (µg) 341 450

Vitamin B12 (µg) 5,5 2

Vitamin C (mg) 123 80

Calcium (mg) 1226 1000

Phosphorus (mg) 1559 800

Potassium (g) 3,6 3,5

Magnesium (mg) 365 350

Iron (mg) 10,8 16

Zinc (mg) 11,7 11

Copper (mg) ‐ 1

Iodine (µg) 216 170

Selenium (µg) 46 40

b NNR, 2004

Overall, it seems that even though the Danish diet is slowly improving on a number of areas, there is still a long way before the diet meets the recommendations for a healthy and nutritious diet composi‐

tion. The average intake of fruit, vegetables, potatoes, nuts, fish and shellfish in the Danish population is too low compared to the recommended intake by DFDG, while the content of meat is high compared to the estimated adequate intake. The intake of fat, sugar and salt in the Danish diet is still too high, whereas the intake of dietary fibre is too low compared to DFDG.

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The New Nordic Cuisine

Over the past 10 years a completely new cuisine has been discovered and developed in Scandinavia:

The New Nordic Cuisine. It started with the opening of the restaurant Noma in 2003, a restaurant where the food and menu would be based solely on Nordic foods. Not many people believed in the concept at that time, but the restaurant turned out to be one of the greatest success stories in the his‐

tory of Nordic restaurants, and have in 2012 been rated The World’s Best Restaurant for the third year in a row (29). In November 2004 a Nordic Kitchen Symposium was held at Noma where some of the most outstanding chefs of the Nordic region together with food writers and other food professionals gathered to discuss the potential for developing a new Nordic food culture. The meeting resulted in a 10‐point manifesto, Manifesto for the New Nordic Kitchen, outlining how best to develop the new Nor‐

dic cuisine, and it is today considered a milestone in the Nordic culinary movement (figure 1) (30). The manifesto defining the criteria and references for a New Nordic Cuisine forecasted, that it was possible to establish a cuisine that not only bridges the gap between palatability and health, but also protects the environment of plants and animals, the biodiversity and the amenity value of nature, and the wel‐

fare of the Earth in general (30). The manifesto was in 2005 adopted by the Nordic Council of Minis‐

ters as the ideology of the New Nordic Food programme, with the aim of establishing the Nordic cui‐

sine as a part of the gourmet world map (31). And so it has. Restaurants and chefs focusing on Nordic food are now rated among the best in the world (29,32), and the ideologies and methodologies behind the New Nordic Cuisine holds qualities that can serve as model for the rest of the world. The New Nor‐

dic Cuisine has proven to be just as unique and just as intriguing as other famous kitchens by the use of local foods and new preparation techniques e.g. molecular gastronomy, and the same could likely be done in many other countries.

In Southern Europe, there is a long tradition of small business enterprises that make use of special local climatic circumstances ‐ the terroir ‐ and especially of the local biodiversity, to fabricate products that are unique, specifically because they communicate their geographic origin through their flavour, appearance and history. In the North, however, before 2003 we had very few of these kinds of enter‐

prises and the large agricultural producers made it difficult to distinguish the terroir dimension in the different produce.

Apart from the great gastronomic potential in eating regionally produced food, it is also potentially more environmentally sustainable. Transport of food from production to consumer can be minimized by increased consumption of local produce, thus minimizing some of the negative effect on the envi‐

ronment. Stressing regionality, use of seasonal produce, and use of foods from the wild countryside could be of benefit to the environment. The New Nordic Cuisine has therefore also a potential with regard to a more sustainable food production in the Nordic countries.

In the Manifesto for the New Nordic Kitchen, it is stated in item 4 that “we seek to unite the demand for palatability with modern knowledge about health and well‐being” (30). However, until recently the New Nordic Cuisine has predominantly been at the highest gastronomic level, and most people cannot af‐

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ford to visit these restaurants. Both gastronomists and nutrition experts now understand that in order to reach the whole population and especially the segments who suffer most from nutritionally related lifestyle diseases, and who normally do not exhibit an interest in gastronomic cooking, we have to cre‐

ate a new everyday diet that bridges gastronomy and health, without forgetting the traditional food culture. Since sustainability is also an important aspect of food production and ‐culture today, the fu‐

ture everyday diet should also focus on sustainability by e.g. being based on regional food products and taking food production into account.

Manifesto for the New Nordic Kitchen

As Nordic chefs we find that the time has now come for us to create a New Nordic Kitchen, which in virtue of its good taste and special character compares favourable with the standard of the greatest kitchens of the world.

The aims of New Nordic Cuisine are:

1. To express the purity, freshness, simplicity and ethics we wish to associate with our region.

2. To reflect the changing of the seasons in the meals we make.

3. To base our cooking on ingredients and produce whose characteristics are particularly excellent in our cli‐

mates, landscapes and waters.

4. To combine the demand for good taste with modern knowledge of health and well‐being.

5. To promote Nordic products and the variety of Nordic producers – and to spread the word about their under‐

lying cultures.

6. To promote animal welfare and a sound production process in our seas, on our farmland and in the wild.

7. To develop potentially new applications of traditional Nordic food products.

8. To combine the best in Nordic cookery and culinary traditions with impulses from abroad.

9. To combine local self‐sufficiency with regional sharing of high‐quality products.

10. To join forces with consumer representatives, other cooking craftsmen, agriculture, the fishing, food , retail and wholesale industries, researchers, teachers, politicians and authorities on this project for the benefit and advantage of everyone in the Nordic countries.

Signed by the following chefs:

Hans Välimäki, Finland Erwin Lauterbach, Denmark René Redzepi, Denmark Leif Sørensen, Faroe Islands Fredrik Sigurdsson, Iceland Hákan Örvarsson, Iceland Mathias Dahlgren, Sweden Eyvind Hellstrøm, Norway Rune Collin, Greenland Roger Malmin, Norway Gunndur Fossdal, Faroe Islands Michael Björklund, Åland Islands Figure 1 Manifesto for the New Nordic Kitchen (30).

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The New Nordic Diet

So far, dietary recommendations have not been successful in reversing the obesity epidemic, and there are probably several reasons for this. Nutrition experts often face a sceptical attitude from the con‐

sumers when promoting healthy diets, and a Danish study has demonstrated that the lack of sufficient focus on the gastronomic properties of the recommended diet leads to increased drop‐out during a course of weight maintenance following a weight loss program in obese individuals (33). In addition, recent studies have shown that current dietary recommendations may not be effective for the control of body weight and the prevention of weight gain and obesity (34,35). Research bridging palatability and health in diets is therefore a very important discipline. Furthermore, it has been suggested that dietary recommendations should be more tailored to regional conditions (36). As described in the previous chapter, such regional tailoring may help to preserve cultural diversity in eating habits and contribute to more environmentally friendly consumption. It seems that sustainability is becoming yet another major public health challenge (37), and healthy diet promotion should therefore also take environmental sustainability into account.

OPUS

The goal of the 5 year research project OPUS is an interdisciplinary collaboration between gastrono‐

my, nutrition science, sociology and sensory science to develop a new healthy, palatable, environmen‐

tally friendly diet through a meal system called the NND. The OPUS project is divided into seven Work Packages (WP’s):

WP 1: Definition and development of a New Nordic Diet WP 2: Acceptability of the New Nordic Diet

WP 3: Dietary intervention with supermarket model WP 4: Acute effects of impaired sleep on energy balance

WP 5: Free healthy meals in schools ‐ a dietary intervention in Danish schools WP 6: Core laboratory facilities for clinical biochemistry and appetite hormones WP 7: Dissemination and communication

In two large intervention studies (WP 3 and WP 5) it will be examined how such a diet can affect the mental and physical health.

The first intervention study (WP 3) is a six month, randomised, controlled dietary intervention trial of the NND vs. the Average Danish Diet (ADD) in adults, using the ‘supermarket model’ in which the sub‐

jects receive all foods free of charge in order to achieve optimal dietary adherence. Approximately 200 young adults (18‐50 years old) with central obesity, of whom at least 2/3 also have one or more com‐

ponents of the metabolic syndrome, will participate. Both diets can be consumed ad libitum, i.e. there is no calorie restriction, but a careful monitoring of whether the participants eat in accordance with the diet they were set to follow was performed. Participants received a cookbook, attended a cooking

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course in their respective diet, and had close supervision by dieticians and chefs during the study pe‐

riod to aid in the process.

The primary outcome is to detect relevant differences in body weight of the subjects between the two diets, e.g. changes in body weight (kg), body fat percentage (assessed by DXA), dietary compliance, drop‐out rate and risk factors for type 2 diabetes and CVD.

The second intervention study (WP 5) is a randomised, dietary cross‐over study with approximately 1100 children from 3rd and 4th grades (8–11 years old) at nine Danish municipal schools. Classes are assigned to two three‐month periods with free school meals based on either the NND or their usual packed lunch (control). Approximately 40‐45% of their energy intake should be covered by the inter‐

vention diet.

Dietary intake, nutrient status, physical activity, cardiorespiratory fitness, sleep, growth, body compo‐

sition, early metabolic and cardiovascular risk markers, illness, absence from school, wellbeing, cogni‐

tive function, social and cultural features, food acceptance, waste, and cost is assessed.

The OPUS project also contains a number of research projects that will bring additional knowledge to the intervention studies, and a communication part (WP 7) working to increase awareness among the general public of the link between healthy living, food and palatability as part of the work being done in OPUS.

The work described in this thesis is part of the work being done in WP 1, where the goal has been to establish a definition and develop a NND in the context of Danish food production and food culture, with emphasis on palatability, cultural relevance, sustainability and theoretical health benefits. The two intervention studies and other WP’s is not part of the work being done in this thesis and will not be elaborated in this context. However, the diets in the two interventions have been designed based on the work presented in this thesis, and available preliminary results from these studies and similar studies in the literature are discussed later in order to evaluate current evidence for the efficiency of the diets in relation to health, palatability and sustainability.

In the development of a new diet, food safety is an important aspect to consider. Dietary components not currently a part of the Nordic diet, might have potential regarding health and palatability, and could be introduced as part of the NND. For these dietary components precise nutrient composition might be missing from the food compositional databases and a careful examination of the risk of ad‐

verse effects is therefore required. This work is also a part of the work being done in WP 1 and will be reviewed in this thesis.

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4 Development of a New Nordic Diet

This chapter reports on details of the procedures and methods not mentioned in the papers in chapter 5‐8.

The NND is developed on the basis of a comprehensive literature survey where overall paradigms and Nordic foods with the potential to be part of the NND were identified and listed. These where then presented to a large team of experts within the fields of human nutrition, gastronomy, environmental issues, food culture and history, sensory science, and experts with knowledge about children and their food habits and preferences, to get their input. This forum was gathered at an initial OPUS congress held in June 2009 in Copenhagen (see list of participants in appendix 1), and some participants were subsequently selected to form advisory boards for the OPUS working groups (see list of WP 1 advisory boards in appendix 2). The 2009 congress and the subsequent work resulted in a Danish report pub‐

lished in August 2010 (38).

NND is described by a number of overall guidelines resulting in a set of proposed dietary components (Paper I and II). These constitute the presumed carriers of health‐promoting potentials in the NND as well as the concern for environmental issues and the aim of creating a diet with a distinct Nordic iden‐

tity and a gastronomic potential. OPUS has children as the final target group, but the NND was not de‐

veloped specifically for small children, but was targeted at the age‐groups used for older children and adults in NNR and DFDG, i.e. persons aged 10‐75 years. The suggestions for amount of each dietary component consumed in the NND could subsequently be modified to the specific age‐group of interest.

For dietary components already included in DFDG and with substantial evidence for their health pro‐

moting properties, they are naturally included in the NND in at least the same amount as in DFDG; e.g.

fruit, vegetables, potatoes, wholegrain, nuts, fish and shellfish (19,21). The recommended intake of the other dietary components in the NND (e.g. fresh herbs, plants and mushrooms from the wild country‐

side, seaweed, meat and game) is based on the scientific arguments for their health promoting proper‐

ties together with considerations for safety (Paper III), acceptability, availability, and the environmen‐

tal sustainability. The last three of these considerations were evaluated by others in specific OPUS subprojects.

Based on interaction with WP 2 the dietary components were used to develop a range of specific reci‐

pes for the two dietary intervention studies in adults (WP 3) and children (WP 5), and selected recipes have recently been published in two Danish cookbooks (39,40).

Dietary calculations were conducted using the software GIES system (version 1.000 d, National Food Institute, Technical University of Denmark) and the Danish Food Composition Databank (version 7, Søborg; Denmark; www.Foodcomp.dk) to quantify the dietary components and nutrient composition of the NND. The NND was designed to follow the NNR 2004 guidelines with respect to the overall mac‐

ro‐ and micronutrient composition (17). Small adjustments were made when evidence for their health

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promoting properties made this appropriate. For example, the NND aims to increase the intake of wholegrain, as the evidence suggests that a high intake is associated with a reduction in the risk of several diseases (41), and the amount of protein in the NND is at the high end of the recommended range, because recent studies suggest that increased protein intake (20‐25 E%) may have a positive effect on the regulation of body weight, prevent diabetes and have a mild blood pressure‐lowering effect (42‐44). It is important to bear in mind that the NND is not designed as a weight reduction diet, but as an everyday diet developed for normal‐weight people.

OPUS is a Danish project and the two intervention studies within the project has been carried out in Denmark, so the NND in this context is based on the Danish market and food culture, with references to average dietary intake in the Danish population. The overall principles and guidelines can, however, easily be translated and applied to any country in the Nordic or Northern European region.

In the development of the NND the following principles have been crucial: Health, gastronomic poten‐

tial, Nordic identity, and sustainability. These principles are central in the guidelines for the NND (Pa‐

per I) and are elaborated below.

Health

Definition of health in this context

We know that the food we eat affects our health in many ways, and a healthy diet should contribute to the prevention of weight gain, obesity, type 2 diabetes, CVD and cancer. A healthy diet involves con‐

suming appropriate amounts of essential nutrients and water. Nutrients can be obtained from many different foods, so there are numerous diets that may be considered healthy. A healthy diet needs to have a balance of fats, proteins, and carbohydrates, calories to support energy need and micronutri‐

ents to meet the needs for human nutrition without inducing toxicity or excessive weight gain from consuming excessive amounts. WHO has formulated the following recommendations for a healthy diet in their Global Strategy on Diet, Physical Activity and Health (1):

 achieve energy balance and a healthy weight

 limit energy intake from total fats and change fat consumption from saturated fats to unsatu‐

rated fats and towards an elimination of trans‐fatty acids

 increase consumption of fruit and vegetables, legumes, wholegrain and nuts

 limit the intake of free sugars

 limit salt (sodium) consumption from all sources and ensure that salt is iodized

These recommendations are in line with the recommendations from NNR and DFDG (described earli‐

er), and WHO endorses that they are considered when preparing national policies and dietary guide‐

lines, taking the local situation into account (1).

Danish University Colleges Development of a healthy New Nordic Diet Mithril, Charlotte Elisabeth