A systematic review of methods to assess intake of saturated fat (SF) among healthy European adults and children: a DEDIPAC (Determinants of Diet and Physical Activity) study

Background Dietary fat is an essential macronutrient. However, saturated fact has been associated with negative health outcomes including cardiovascular disease. Shifting consumption from saturated fat to unsaturated fats and limiting the level of saturated fat in the diet has been recommended. Currently, there is no standard method to measure saturated fat intake in etiologic studies. Therefore, it is difficult to obtain a reliable picture of saturated fat intake in Europe. To inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods, we aimed to identify the assessment methods and specific instruments which have been used to assess saturated fat intake among children or adults in pan-European studies. Methods Three electronic databases were searched for English language studies of any design which assessed intake of saturated fat. Reference lists were hand-searched. Studies were included if they were conducted in two or more European countries, and involved healthy, free-living children and adults. Results The review identified 20 pan-European studies which assessed saturated fat intake. Food Frequency Questionnaires (n = 8) and diet records (n = 7) were most common, followed by 24-h recalls (n = 5). Methods differed in portion size estimation and the composition data which was used to calculate nutrient intake. Of the instruments used in more than two European countries, five Food Frequency Questionnaires had been specifically tested for validity to assess saturated fat intake; four among adults (Food4me, PURE, IMMIDIET, Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE)) and one among children (used by Piqueras et al.). Conclusions A standardised approach to portion size estimation and a common source of food composition data are required to measure saturated fat intake across Europe effectively. Only five instruments had been used in more than two European countries and specifically tested for validity to assess saturated fat intake. These instruments may be most appropriate to evaluate intake of saturated fat in future pan-European studies. However, only two instruments had been tested for validity in more than one European country. Future work is needed to assess the validity of the identified instruments across European countries. Electronic supplementary material The online version of this article (10.1186/s40795-018-0231-1) contains supplementary material, which is available to authorized users.


Background
Dietary fat is an essential macronutrient, providing a source of energy and facilitating the absorption of fatsoluble dietary components such as vitamins [1]. Saturated fatty acids (SFA) have been associated with the development of non-communicable diseases, including cardiovascular disease (CVD) [2][3][4]. The World Health Organisation (WHO) Global Strategy on Diet and Physical Activity recommends shifting consumption from saturated fat (SF) to unsaturated fats, and limiting the level of SF in the diet [5]. The Food and Agriculture Organisation expert consultation on fat and fatty acids in human nutrition has proposed that SFA be replaced by Monounsaturated Fatty Acids (MUFA) and Polyunsaturated Fatty Acids (PUFA) in the diet to reduce the risk of Coronary Heart Disease [4].
The role of SF in the diet has recently been the subject of debate. Some studies suggest SF increases levels of beneficial high-density lipoprotein (HDL). However, whether this offsets the effect of detrimental low-density lipoprotein (LDL), and consequently the risk of CVD, is unclear [6,7]. To better understand the role of SF in the development of chronic disease there is a need for dietary assessment methods which can measure SF and its contribution to daily energy intake in a reliable and consistent way. However, a number of factors have made cross-country comparisons of macronutrient intake difficult: differences in the methods used to assess dietary intake, different approaches to portion size estimation, and the type of food composition databases (FCD) used to calculate SF intake.
In recent years there has been growing emphasis on the standardisation of food classification systems, including Food Composition Databases (FCD), between European countries. This has been the focus of a number of European projects [8][9][10][11][12][13][14][15], including The Innovative Dietary Assessment Methods in Epidemiological Studies and Public Health (IDAMES) project, which aims to develop new methods to assess dietary intake in Europe [16]. The European Food Safety Authority (EFSA) has recommended the standardized 24-HDR recall method, EPIC-Soft (now known as GloboDiet) [17,18]. However, there are no agreed standards with respect to the assessment of macronutrients, including SF, for monitoring purposes or aetiological studies.
Partly in recognition of the lack of agreed standards and methodologies, the DEDIPAC: "DEterminants of DIet and Physical Activity" project [19], aimed to create a toolbox of dietary assessment methods which may be most appropriate to use in pan-European studies [19,20]. The purpose of the current systematic literature review is to identify the assessment methods and specific instruments which have been used to measure intake of SF in European children or adults in more than one European country.

Data sources and study selection
This review adheres to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The protocol for the review can be accessed from the PROSPERO (CRD42014014175) [21]. A systematic literature search was conducted for pan-European studies which assessed the intake of SF. SF are fatty acids where the fatty acid chain have predominantly single bonds. They can be classified as short, medium, long and very long chain, and are mainly provided in the diet by animal dairy fats, along with some oils, palm oil and coconut oil [4]. Three databases, PubMed, EMBASE and Web of Science, were searched by FR and RM. Search terms included terms for fats (e.g. dietary fat/ s, saturated fat/s, dietary fatty acid/s, saturated fatty acid/s, volatile fatty acid/s, non-essential fatty acid/s, trans fatty acid/s, short chain fatty acid/s, trans fat/s, animal fat/s, lipid/s), along with keywords for dietary and caloric intake, and terms for European countries. A full copy of the EMBASE search strategy is included in Additional file 1: Figure S1. All searches were limited to literatures in English published from 1990 through to 15th March 2017.
Titles and abstract screening of the articles was conducted by FR and RM. In the event of any uncertainty regarding inclusion, the full text of an article was sourced and reviewed. If FR and RM disagreed on article inclusion during full text review then they consulted a third author, JMH. To be included, studies had to be published in a peer-reviewed scientific journal, conducted in two or more European countries, as defined by the Council of Europe [22], and report on the intake of macronutrient SF. Therefore, studies were excluded if they only reported on fat as a food product (e.g. fat-based spreads, fats and oils). SF intake had to be measured at the individual level. Therefore studies which assessed SF intake at the household level or through analysis of biological samples were excluded. Studies had to be conducted among free-living, healthy populations. If study participants were hospital-based or belonged to a disease or societal sub-group they were excluded. The review was not limited by study design; studies with baseline intervention data, and case-control studies where intake was measured in population-based controls, were included (Fig. 1).
Reference lists of all included papers were hand-searched for additional publications. The names of European projects listed in the DEDIPAC Inventory of Relevant European Studies, were also used to search the databases. If necessary, study authors were contacted to request a copy of full paper, or the instrument or questionnaire.

Data extraction and quality assessment
A data extraction form was created and piloted. This form recorded the following information from included studies: design, number and names of European countries involved, sample size (total and number for each country), age range of the included population, the method used and its description (including frequency categories for Food Frequency Questionnaires (FFQs), details of nutrient intake assessment, details of portion estimation), mode of administration, and details on the validation or reproducibility. Double extraction on each article was carried out by FR and RM. If necessary, further information on the methods was obtained from reference list of the originally included articles.
In line with a previous review of methods to assess fruit and vegetable (F&V) intake [23], the aim of the current review was to identify instruments. Therefore the quality of each included article was not appraised as part of the current review. Instead, information from the appropriate validation study was extracted by MvD, SE and NW. For an instrument to be considered suitable to assess intake in a pan-European study it had to meet two criteria: 1. Tested for validity; 2.Used in more than two countries as part of the same study. These two countries had to represent at least one country from at least three of the Southern, Northern, Eastern, Western European regions as defined by the United Nations [24]. Table 1 shows the results of this assessment.

Description of the included studies
In total 10,076 papers were identified. After removing duplicates 7519 remained. Following title and abstract screening and full text review, 82 primary research articles were retained. These articles were organised by the European project to which they belonged. If they did not belong to a project they were grouped as 'Other' (n = 6) (see Fig. 1 for a breakdown). 'Study' refers to the larger project, rather than individual articles based on the same project and methodology. Of the 82 articles retained, 26 provided a detailed description of the project or the method in question. These 26 articles were selected for the current review, which equated to 1-3 articles per project. A further 11 articles were sourced from reference lists [14,[25][26][27][28][29][30][31][32][33][34].  Table 1 Summary of all studies identified to assess saturated fat: design, population studied, and dietary assessment instruments used and details of validation and/or reproducibility. Studies were selected to be included in this review based on the following two criteria: (1) the instrument was tested for validity and (2) Table 1 Summary of all studies identified to assess saturated fat: design, population studied, and dietary assessment instruments used and details of validation and/or reproducibility. Studies were selected to be included in this review based on the following two criteria: (1) the instrument was tested for validity and (2) Table 1 Summary of all studies identified to assess saturated fat: design, population studied, and dietary assessment instruments used and details of validation and/or reproducibility. Studies were selected to be included in this review based on the following two criteria: (1) the instrument was tested for validity and (2)  In total, 37 articles [14, from 20 studies were included in the review. This number included articles from the original search (n = 26), and from reference lists (n = 11). Articles in which the instrument was tested for validity were also recorded (n = 11) [58,[63][64][65][66][67][68][69][70][71][72]. The characteristics of the included studies are described in Table 1. They comprised of large pan-European studies (n = 11) and smaller studies conducted in 2-4 countries (n = 6). Four studies assessed intake of SF in children [60][61][62], or adolescents [59], and 13 assessed intake among adults [35, 40, 41, 46-50, 54-57, 73]. One study instrument was based on a FFQ which had been used as part of a different study and previously tested for validity [62]. Countries in the EPIC study did not use a common FFQ instrument, therefore only the EPIC-Soft instrument is discussed in this review.

Types of methods
According to the two criteria (Table 1) six study instruments were appropriate to assess intake of SF in future pan-European studies. Two, the EPIC 24-HDR instrument EPIC-Soft, and the cross-check dietary history method used by the Seven Countries Study, had been used to measure intake among adult populations. The HELENA-DIAT instrument had been used among adolescents. The IDEFICS FFQ and 24-HDR, and the FFQ used by Piqueras et al. [62] had been used among children. Table 1 shows the instruments which met the two criteria. Some of these instruments were also used to assess intake of other macronutrients, and/or also met the criteria to assess intake of F&V [23] or Sugar Sweetened Beverages (SSBs) [74] as determined from two previous reviews. This is also indicated in Table 1.

Validation
Of the studies which assessed instrument validity and thus fulfilled inclusion criterion 1 (Table 1), only two instruments, EPIC-Soft [63] and the IDEFICS 24-HDR [68], had been tested for validity in more than one country: Belgium, the Czech Republic, France, the Netherlands and Norway in the case of EPIC-Soft [63]; Belgium and Spain in the case of the IDEFICS 24-HDR [68].
In four studies, the instrument reproducibility was also tested. Reproducibility was assessed by correlations [43,49,72], mean/median differences, or intraclass correlation coefficient (ICC) [49] between subsequent assessments of FFQs. References for validation studies are provided in Table 1. Where available, results of the statistical assessments are provided in Table 2.
EPIC used the EPIC Nutrient DataBase (country-specific food composition data standardised across countries) to   [73]. Mulder et al. [51] (Seven Countries Study), determined SF intake by buying food products which represented the average daily intake in a cohort and analysing these products for composition of SF [51]. The remaining studies used local food composition tables (FCT) from participating countries to calculate intake. In some cases, one FCT was used as the main source of composition data. For example, the German Food Code and Nutrient Data Base (Bundeslebensmittelschlussel) was used by the HELENA study and supplemented with information from the Belgian FCT [59,77].

Food frequency questionnaires (FFQs)
Characteristics of the FFQ instruments are summarised in Table 4. Where this information was available, the number of FFQs items ranged from to 43 to 322. Most FFQs recorded habitual consumption over the previous year, with the exception of the IDEFICS FFQ [30,61]. This FFQ assessed intake over a typical week during the previous month. Almost all FFQs were paper-based and self-administered. All were semi-quantitative, and assessed portion size either through specifying a standard portion size on the FFQ for the food item in question [41,49], or asking participants to consult photos [46], or use household measures [78]. The number of pre-coded frequency categories on the FFQs ranged from 3 to 11.

Diet records
Six studies used diet records or diaries (Table 5) to assess SF intake. Portions were estimated using a photo book [33,34,50,57], during the interview (portion description provided by a dietician) [55], using food models [33,50], or by weighing foods [34,48,76]. Most of the identified records were three or seven day records, with one exception, the Zinc Effects on Nutrient/nutrient Interactions and Trends in Health and Aging (ZENITH) study. This study used a four recall day method, over two weekday and two weekend days. All records were self-administered.

Dietary history
A dietary history approach is an interview-based approach used to record usual intake, asking an individual to recall a typical intake patterns, typically over a longer period (e. g. 6 months) [79]. The Seven Countries Study used a cross-check dietary history method conducted by face-toface interview. The dietary history recorded diet intake in the month preceding the interview. This method had been tested for reproducibility, albeit not specifically to assess SF intake [64]. Usual food consumption pattern was recorded (i.e. foods consumed at breakfast, lunch, dinner and between meals) on a daily basis during week and weekend days. A list of all foods was compiled from this record. Interviewers then recorded what was eaten on a daily, weekly, or monthly basis. A checklist with an extensive number of foods was also used to record the frequencies and amount of foods consumed. Portion size was estimated using different approaches: Finland: photos; The Netherlands: portable scale; Italy: artificial models of different foods in Italy), and also weighed [51].
Two 24-HDRs were tested for validity: HELENA-DIAT [80], which was compared with 1-day food records [58] and tested for reproducibility across administrative modes (self-administration and by interview [67]), and IDEFICS Self-Administered Children and Infants Nutrition Assessment (SACINA) which was tested for validity using the doubly labelled water technique [68].

Discussion
All four main assessment methods; FFQs, 24-HDRs, diet records/diaries and diet history methods have been used in pan-European studies to measure intake of SF. Of the 20 studies identified, most assessed intake of SF among adults (n = 16), and few measured intake among adolescents or children (n = 4). While FFQs were most common (n = 8), they differed in terms of the approach used to determine portion size and calculate macronutrient intake. Only one identified study, EPIC, used a standardised database as a source of food composition data. If intake of fat sub-types such as SF and their relationship with disease are to be studied in a standardised way across European countries, it is essential to identify valid instruments. Six study instruments met two criteria (1. the instrument was tested for validity, and; 2. used in more than two European countries) to assess SF among adults in pan-European studies: the EPIC-Soft 24-HDR, HAPIEE, Food4Me, IMMIDIET, and PURE FFQs, and the SENECA 3-day record. However, only four of these, all FFQs (HAPIEE, IMMIDIET, PURE and Food4Me) had been specifically tested for validity to assess SF intake. Two of these (HAPIEE and Food4Me FFQs) were found to have moderate agreement with diet records. The PURE FFQ had low to moderate agreement with repeated 24-HDRs, and the IMMIDIET FFQ had low agreement with repeated 24-HDRs. Only one identified instrument had been used among adolescents, HELENA-DIAT, but this had not been tested for validity to assess SF intake. Finally, the 24-HDR and FFQ used by the IDEFICS study, and the FFQ used by Piqueras et al. [62] had been used to measure SF intake among children. Of the two, only the FFQ used by Piqueras et al. [62] had been tested for validity to assess SF intake. This instrument had good to moderate agreement with repeated 24-HDRs.
All instruments which had been tested for validity to assess SF intake, had done so using food records (4 and 7 day) [42,75] or 24-HDRs [31,49,72] as the reference method. However, using these methods as a reference assumes they are superior in terms of assessing true SF intake. No specific biomarkers for SF exist, therefore, the validity of a 24-HDR to assess true intake cannot be determined. This raises an important question: whether the identified instruments are valid to specifically assess SF intake. Another important consideration is the fact that the level of macronutrient intake may be affected by the source of FCD used for calculations [82]. Ideally pan-European studies would use a common data collection instrument tested for validity, a common approach to portion size estimation, and a standardised source of composition data to calculate intake of SF.
As with previous reviews the results will contribute to the DEDIPAC toolbox of dietary intake assessment methods. The two criteria used in this review, are only an initial approach to identifying suitable instruments. Other factors, including the existing evidence with respect to instrument validity together with instrument feasibility, should be taken into consideration when deciding the appropriateness of an instrument to assess intake of SF in a pan-European population. Only two instruments had been tested for validity in more than one European country. To determine which instruments may be most appropriate, will require further work to test validity across countries. Most identified instruments were also included in two previous reviews on methods to assess intake of F&V [23] and SSBs [74]. Exceptions were the ZENITH 4-day recall method, PURE FFQ, and the FFQs used by Van Oostrom et al., and Piqueras et al. Overall these two reviews identified a greater number, and variety, of instruments. While this review was limited to pan-European studies, this is not to suggest that other instruments used as part of non-European studies, could not be used to assess intake across Europe.
The review has a number of strengths and limitations. A comprehensive search strategy identified all pan-European studies measuring intake of SF among children or adults, and the instruments used by these studies. In addition to searching databases, reference lists were hand-searched and study authors were contacted to identify further instruments. A copy of the instrument was sourced in order to accurately describe each instrument. Although the search was comprehensive, it is possible that all relevant articles were not identified. Furthermore, the search was limited to English-language papers. Where a copy of the original instrument or article could not be sourced, the description may be limited, although the results can still be used as a reference. The quality of the identified instruments was not assessed as part of this review. It is important to emphasize that the current review only provides an initial selection of instruments that may be most appropriate to assess SF across European countries. A decision on appropriateness will depend upon instrument validity, which requires further research. Not all SF may be detrimental to health [83,84]. In light of this, a final limitation of the review may be the focus on total SF intake. Assessing different SFs or subgroups and their relation to health, and reviewing instruments which examine and report on these differences may be an important next step. The majority of the identified instruments evaluated SF as one class. Only one FFQ, used in the IMMIDIET study [31,46], assessed the intake of SF by sub-types. Lastly, it is important to consider the fact that the identified instruments rely on available food composition data for analysis; the assessment of SF may lag behind changes in food production and composition. FFQs may need to be updated in line with such changes e.g. adding new foods, changing numbers on answer options.

Conclusion
This review has identified a range of methods to assess intake of SF, FFQs being the most common method used. Key differences exist between the instruments which are currently available to assess SF intake. In order to standardise and harmonise assessment methods between European countries, and increase the accuracy with which intake of SF is measured, it is essential that (1) an agreed method and approach to portion size estimation is used and (2) this is used in conjunction with a standardised source of composition data. This review has indicated five instruments, all FFQs (Food4me, PURE, IMMIDIET, HAPIEE, and FFQ used by Piqueras et al.) which meet both criteria, and were tested for validity to assess SF intake. These instruments may be most suitable to assess intake of SF among healthy populations across Europe. These methods have been used in pan-European populations which encompass a range of European regions, and should be considered by future studies which focus on evaluating SF intake. However, these instruments have only been tested for validity in one country. Future work is needed to test the validity of these instruments across European countries. Authors' contributions FR planned and conducted the review, drafted and revised the paper. RM planned and conducted the review, and drafted the paper. CK, IJP, AG, PV, LFA, MS and JMH contributed to the planning, drafted and revised the paper. SE, MVD and NWD conducted the review of validation data, drafted and revised the paper. All authors read and approved the final manuscript.
Ethics approval and consent to participate Not applicable