ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY - 2016, Vol

Instruction for authors O.E. Orisakwe,K.O.Okolo,Z.N. Igweze,G.C. Ajaezi, N.A.Udowelle Potential hazardsoftoxicmetals foundintoothpastescommonlyusedNigeria. B. Całyniuk,E.Grochowska-Niedworok, M.Muc-Wierzgoń, The effectiveness ofthelowenergy dietinoverweightand obeseadults. M.H. Borawska R. Markiewicz-Żukowska,J.Moskwa,K.Gromkowska-Kępka, E.Laskowska,J.Soroczyńska, J.Tomczuk, Bakery productsasasourceoftotaldietaryfiberinyoungadults. T. Saleeon,W. Siriwong,H.L.Maldonado-Pérez, M.G.Robson tobacco farmers. Salivary cotininelevelsasabiomarkerforgreentobaccosicknessindryproductionamong Thai traditional M. Łyczewska,J.K.Ludwicki M. Matuszak,Minorczyk, K.Góralczyk, A. Hernik,P. Struciński,M.Liszewska,K.Czaja,W. Korcz, electron capturedetector. polychlorinated biphenylsandorganochlorine pesticidesinhumanbloodserumbygaschromatographywithmicro- Validation oftheanalyticalmethodforsimultaneousdeterminationselectedpolybrominateddiphenylethers, M. Majorczyk, D.Smoląg Effect ofphysicalactivityonIGF-1andIGFBP levelsinthecontextofcivilizationdiseasesprevention. M.M. Dobrzyńska exposure. Phthalates -widespreadoccurrenceandtheeffect onmalegametes.Part1.Generalcharacteristics,sourcesandhuman P. Lenártová,M.Habánová,J.Mrázová,P. Chlebo, Analysis ofvisceral S. Merkiel,W. Chalcarz The needformodifyingenergy intakeinpreschoolchildrenfromPiła,Poland. K. Marcinek, R.W. Wójciak,Z.Krejpcio Assessment ofthenutritionalvaluedailyfoodrations childrenaged1-4years. A. Morawska,I.Górna,Bolesławska,J.Przysławski The nutritionalawarenessoffunctionalfoodamonguniversitystudentsinPoland. A. Kołłajtis-Dołowy, K.Żamojcin The levelofknowledgeonnutritionanditsrelationtohealthamongPolishyoungmen. M. Obara-Gołębiowska Employment discriminationagainstobesewomeninobesityclinic’s patientsperspective.

ROCZNIKI PAŃSTWOWEGO ZAKŁADUHIGIENY Volume 67 Abstracts andfull textsopenaccess:http://wydawnictwa.pzh.gov.pl/roczniki_pzh/roczniki ...... [ANNALS OF THE NATIONAL INSTITUTEOFHYGIENE] ...... fatinpatients ......

...... withchronicobstructivepulmonarydisease( ......

...... ORIGINAL ARTICLES REVIEW ARTICLES

J. Wyka ...... 2016

E. Nowakowska-Zajdel,M.Osowski ......

...... COPD). Number 2 ...... 205 197 189 131 121 105 179 169 163 155 147 137 113 97

ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY - 2016, Vol. 67, No 2, 97-208 INSTITUTE OF HYGIENE OF THE NATIONAL ANNALS ZAKŁADU HIGIENY PAŃSTWOWEGO ROCZNIKI Warsaw, Poland – NATIONAL INSTITUTE OFHYGIENE NATIONAL INSTITUTEOFPUBLICHEALTH EDITOR andPUBLISHER: Number Volume 67 2016 Quarterly ISSN 0035-7715 2 ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY (ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE) ISSN 0035-7715

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ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE

Quarterly 2016 Volume 67 Number 12

EDITOR and PUBLISHER: NATIONAL INSTITUTE OF PUBLIC HEALTH – NATIONAL INSTITUTE OF HYGIENE Warsaw, Poland ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY [ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE]

Volume 67 2016 Number 2

REVIEW ARTICLES

Phthalates - widespread occurrence and the effect on male gametes. Part 1. General characteristics, sources and human exposure. M.M. Dobrzyńska ...... 97

Effect of physical activity on IGF-1 and IGFBP levels in the context of civilization diseases prevention. M. Majorczyk, D. Smoląg ...... 105

ORIGINAL ARTICLES

Validation of the analytical method for the simultaneous determination of selected polybrominated diphenyl ethers, © Copyright by the National Institute of Public Health - National Institute of Hygiene, polychlorinated biphenyls and organochlorine pesticides in human blood serum by gas chromatography with micro- 24 Chocimska Street, 00-791 Warsaw, Poland electron capture detector. www.pzh.gov.pl M. Matuszak, M. Minorczyk, K. Góralczyk, A. Hernik, P. Struciński, M. Liszewska, K. Czaja, W. Korcz, M. Łyczewska, J.K. Ludwicki ...... 113

Salivary cotinine levels as a biomarker for green tobacco sickness in dry tobacco production among Thai traditional tobacco farmers. T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez, M.G. Robson ...... 121

Bakery products as a source of total dietary fiber in young adults. R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka, E. Laskowska, J. Soroczyńska, J. Tomczuk, M.H. Borawska ...... 131

The effectiveness of the low energy diet in overweight and obese adults. B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń, E. Nowakowska-Zajdel, M. Osowski ...... 137

Employment discrimination against obese women in obesity clinic’s patients perspective. M. Obara-Gołębiowska ...... 147

The level of knowledge on nutrition and its relation to health among Polish young men. A. Kołłajtis-Dołowy, K. Żamojcin ...... 155

The nutritional awareness of functional food among university students in Poland. A. Morawska, I. Górna, I. Bolesławska, J. Przysławski ...... 163

Assessment of the nutritional value daily food rations of children aged 1-4 years. K. Marcinek, R.W. Wójciak, Z. Krejpcio ...... 169

The need for modifying energy intake in preschool children from Piła, Poland. S. Merkiel, W. Chalcarz ...... 179

Analysis of visceral fat in patients with chronic obstructive pulmonary disease (COPD). P. Lenártová, M. Habánová, J. Mrázová, P. Chlebo, J. Wyka ...... 189 Printing house: Agencja Reklamowa TOP ul. Toruńska 148, 87-800 Włocławek Potential hazards of toxic metals found in toothpastes commonly used in Nigeria. tel.: + 48 54 423 20 40, fax: + 48 54 423 20 80 O.E. Orisakwe, K.O. Okolo, Z.N. Igweze, G.C. Ajaezi, N.A. Udowelle ...... 197 www.agencjatop.pl Instruction for authors ...... 205

Abstracts and full texts open access: http://wydawnictwa.pzh.gov.pl/roczniki_pzh/roczniki ROCZNIKI PAŃSTWOWEGO ZAKŁADU HIGIENY [ANNALS OF THE NATIONAL INSTITUTE OF HYGIENE]

Volume 67 2016 Number 2

REVIEW ARTICLES

Phthalates - widespread occurrence and the effect on male gametes. Part 1. General characteristics, sources and human exposure. M.M. Dobrzyńska ...... 97

Effect of physical activity on IGF-1 and IGFBP levels in the context of civilization diseases prevention. M. Majorczyk, D. Smoląg ...... 105

ORIGINAL ARTICLES

Bakery products as a source of total dietary fiber in young adults. R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka, E. Laskowska, J. Soroczyńska, J. Tomczuk, M.H. Borawska ...... 131

The effectiveness of the low energy diet in overweight and obese adults. B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń, E. Nowakowska-Zajdel, M. Osowski ...... 137

Employment discrimination against obese women in obesity clinic’s patients perspective. M. Obara-Gołębiowska ...... 147

The level of knowledge on nutrition and its relation to health among Polish young men. A. Kołłajtis-Dołowy, K. Żamojcin ...... 155

The nutritional awareness of functional food among university students in Poland. A. Morawska, I. Górna, I. Bolesławska, J. Przysławski ...... 163

Assessment of the nutritional value daily food rations of children aged 1-4 years. K. Marcinek, R.W. Wójciak, Z. Krejpcio ...... 169

The need for modifying energy intake in preschool children from Piła, Poland. S. Merkiel, W. Chalcarz ...... 179

Abstracts and full texts open access: http://wydawnictwa.pzh.gov.pl/roczniki_pzh/roczniki Rocz Panstw Zakl Hig 2016;67(2):97-103 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

REVIEW ARTICLE

PHTHALATES - WIDESPREAD OCCURRENCE AND THE EFFECT ON MALE GAMETES. PART 1. GENERAL CHARACTERISTICS, SOURCES AND HUMAN EXPOSURE

Małgorzata M. Dobrzyńska*

National Institute of Public Health – National Institute of Hygiene, Department of Radiation Hygiene and Radiobiology, Warsaw, Poland

ABSTRACT Phthalates are widely present in human environment. Widespead exposure to those agents, which are compounds of numerous daily use products, is unavoidable. In the current paper following phthalates benzylbutyl phthalate (BBP), di- n-butyl phthalate (DBP), di(2-ethylhexyl)phthalate (DEHP), diethyl phthalate (DEP), di-isononyl phthalate (DINP) are described. Phthalates mainly enter to the composition of plastic goods, like boxes and containers for storage of foods, toys, medical devices, and also cosmetics, personal care products, as well as paints, vanishes, printing inks. This paper describes the occurence of individual phthalates in the environment (water, air) and in different products. During production, transportation, manufacturing of goods and improper disposal, phthalates released into soil, water and air. For example indoor air included 13 mg/m3 phthalates, where 72 % of all constitutes DEP (2.29 mg/m3), BBP (3.97 mg/m3) and DEHP (2.43 mg/m3). Exposure to phthalates take place mainly by ingestion or inhalation air or through the skin. Presence of phthalates were observed in numerous food products and is connected with migration of those compounds from food storage containers to preserved food. They could mirgate to salivia during sucking and chewing of toys and this way increased exposure to of children. The results of studies regarding to concentration of phthalates in human tissues and excretions are also described. The level of phthalates were measured in numerous of human biological samples. For example, DEHP, DEP and DBP were detected at levels of 5.71 mg/L in blood serum, of 0.30 mg/L in semen and of 0.72 mg/kg in fat samples.

Key words: phthalates, occurence and sources of exposure, concentration in human tissues and excretions

STRESZCZENIE Ftalany są szeroko rozpowszechnione w środowisku człowieka. Powszechne narażenie na te związki, które wchodzą w skład wielu produktów codziennego użytku jest nieuniknione. W niniejszej pracy opisano ftalany butylobenzylu (BBP), dibutylu (DBP) i dietyloheksylu (DEHP), dietlylu (DEP) oraz diizononylu (DINP). Ftalany przede wszytkim wchodzą w skład wyrobów plastikowych, takich jak pojemników do przechowywania żywności, zabawek, wyrobów medycznych oraz kosmetyków środków higieny osobistej, a także farb, lakierów, tuszów drukarskich. W niniejszej pracy opisano występowanie poszczególnych ftalanów w w środowisku (np. w wodzie, powierzu) oraz w różnych produktach. Podczas produkcji, transportu, wyrobu produktów oraz niewłaściwej utylizacji, ftalany przenikają do gleby, wody i powietrza. Na przykład, w powietrzu w pomieszczeniach stwierdzono 13 mg/m3 ftalanów, z których 72% of stanowiły DEP (2,29 mg/m3), BBP (3,97 mg/m3) i DEHP (2,43 mg/m3). Narażenie na ftalany nastepuje głównie drogą pokarmową, inhalacyjną oraz poprzez skórę. Obecność ftalanów stwierdzono w wielu produktach żywnościowych, co jest związane z migracją tych związków z opakowań do przechowywanej w nich żywności. Mogą migrować do śliny podczas ssania i żucia zabawek i w ten sposób powodują zwiększone narażenie niemowląt i małych dzieci. Omówiono także wyniki badań dotyczących stężenia ftalanów w tkankach i wydalinach ludzkich. Stężenie ftalanow mierzone było w różnych thankach ludzkich. Przykładowo, obecność DEHP, DEP i DBP stwierdzono w surowicy krwi (5,71 mg/l), w nasieniu (0,30 mg/l) oraz w tłuszczu (0,72 mg/kg).

Słowa kluczowe: ftalany, występowanie, źródła narażenia, stężenia w tkankach i wydalinach ludzkich

*Correspondence to: Małgorzata Dobrzyńska, National Institute of Public Health – National Institute of Hygiene, Department of Radiation Hygiene and Radiobiology, 24 Chocimska Street, 00-791 Warsaw, Poland, Tel. +48 22 5421253, Fax+48 22 5421309, email: [email protected]

REVIEW ARTICLE

PHTHALATES - WIDESPREAD OCCURRENCE AND THE EFFECT ON MALE GAMETES. PART 1. GENERAL CHARACTERISTICS, SOURCES AND HUMAN EXPOSURE

Małgorzata M. Dobrzyńska*

National Institute of Public Health – National Institute of Hygiene, Department of Radiation Hygiene and Radiobiology, Warsaw, Poland

Key words: phthalates, occurence and sources of exposure, concentration in human tissues and excretions

Słowa kluczowe: ftalany, występowanie, źródła narażenia, stężenia w tkankach i wydalinach ludzkich

INTRODUCTION DEHP is the most often used plasticizer (approximately Diisononyl phthalate (CAS Nos 28553-12-0 and One of the most impartant sourece of exposure to 50% of total used phthalates) in polyvinyl chloride 68515-68-0) is named also isononyl alcohol phthalate, DEHP is drinking water. It has been detected there at Humans and animals are continously exposed to (PVC), polyethylene and polypropylene products. Palatinol DN, Palatinol N, 1,2-benzenedicarboxylic different levels depending on the country, for example wide range of natural and synthetic estrogens. The Plastics may contain from 1-40% DEHP by weight. acid diisononyl ester, bis(7-methyloctyl) phthalate, in Poland and Germany at 0.05-0.06 µg/l, in Greece most important seems to be xenoestrogens, called also It is a component of many consumer products such di(C8-C10) branched alkyl phthalate, Vestinol 9, at 0.93 µg/l, in US at 0.95 µg/l, in China at 3.47 µg/l endocrine disruptors, endocrine disrupting compounds, as artificial leather, waterproof clothing, footwear, Vestinol NN, Vinylcizer 90, or Witamol 150. DINP is [12, 64]. The daily dose of DEHP taken by human hormone disruptors, xenobiotics or estrogen mimicking upholstery, floor tiles, various types of furnishing, typically a mixture of chemical compounds consisting general population with food is estimated as about chemicals. The name “xenoestrogen” comes from Greek industrial tubing, wires and cables, tablecloths, shower of various isononyl esters of phthalic acid. It is clearly 25 µg/kg bw/day [43]. Concentration of DEHP in language. ‘Xeno’ means foreign, so xenoestrogens curtains, wraps and boxes for food, children’s toys, viscous liquid, insoluble in water. DINP is mainly used food varied depeding on products, for instance in are compounds that act like estrogens from a foreign and a variety of medical plastic devices like blood as additives in plastics to make them more flexible, fishes from 129.5 to 253.9 mg/kg of dry mass [29]. source. They possess heterogenous chemical structure. storage bags, catheters and haemodialysis instruments. and also in varous products like electrical wire and In European countries, DEHP among others was Endocrine disruptors are chemicals which interact with Among others DEHP is also used in a hydraulic and cables, coated fabrics, automotive parts, building and detected in milk at average 12 mg/L, and in cheease at hormonal system, mimic estrogens and impact hormone dielectric fluids, liquid detergents, decorative inks, construction (waterproofing), vinyl flooring, footwear, average 2000 mg/L [51]. On this bases, the dose taken balance in the body, and may also have antiandrogenic industrial lubricating oils, paints, glues [4, 15, 17, 46]. sealings, lamination film and in PVC-containing by ifants with mothers and cow milk was estimated as ability. Due to structural similarity to estrogens, they may Dibutyl phthalate (CAS No 84-74-2) is called school supplies (such as scented erasers and pencil 1-10 µg/kg daily [30]. In children between 0.5 to easily bind to hormone receptors and block the action of also di-n-butyl phthalate, butyl phthalate, n-butyl case). This phthalate can be blended into a paste 11 years old daily DEHP intake was estimatated as natural hormones. They may also affect the synthesis, phthalate, 1,2-benzenedicarboxylic acid dibutyl ester, (plastisol), for coating (tarpaulins, synthetic leather 14-19 µg/kg/day [52]. The exposure coming from metabolism, binding or cellular responses of natural o-benzenedicarboxylic acid dibutyl ester, Palatinol and wall covering) and rotomoulding (toys, play and cosmetisc, personal care products and children toys estrogens [50]. C, Elaol, dibutyl-1,2-benzene-dicarboxylate. DBP is exercise balls, hoppers) applications. Moreover, DINP was estimated as from 8.2 to 25.8 µg/kg/day [33]. Xenoestrogens including some pharmaceutics colourless or light yellow liquid with weak similar to is used in non-polymer applications such as adhesives, DBP was detected in surface waters of Europe (i.e.contraceptive), metals (i.e. aluminum, arsenite, ether smell and expressive bitter savor. It is soluble paints, surfactants and printing inks for T-shirts. It can and United States at concentration from 0.01 to barium, cadmium, chromium, lead, mercury), in various organic solvents like alcohol, ether and be found in plasticine, in several categories of toys 622.9 µg/dm3 [62]. On the basis of measuration in parabens, used as preservatives in cosmetic and benzene. DBP is commonly used plasticizer and as an (plastic books, balls, dolls and cartoon characters) several factories produced DBP in Europe, it was pharmaceutical products, detergents and plasticizers additive to adhesive and printing ink, as a solvent for and in baby products (changing mats/cushions) which detected at majority of work place at the level below (i.e. bisphenol A, phthalates). paints, for impregnation of tissues and as antifoamer. could be placed in the mouth. DINP has been found 0.5 mg/m3, although somewhere this level was 10-fold The general population is exposed to phthalates, DBP is a component of plastic goods, containers for in other articles that may come into contact with higher. Concentration of DBP during manufacturing of because they are ubiquistos environmental contaminant food preservation, plastic pipes, glues, perfumes, nail children (clothes, mittens, coverage of pacifiers, PVC- goods containing this phthalate was from <0.008 mg/m3 [25, 60]. Humans are exposed to phthalates directly or polishes and washers, shadows, hair sprays [11]. containing soap packaging and shower mats) [14]. to 0.75 mg/m3 [49]. DBP was found in home dust at indirectly, by multiple routes, depending on the kind of Diethyl phthalate (CAS No 84-66-2) known also the level from 36 to 50 mg/kg [28, 42]. It was detected phthalate. One of the most important way of exposure as diethyl ester of phthalic acid and ethyl phthalate is SOURCES AND LEVELS in 19 of 21 nail polishes and in 11 of 42 perfumes at is ingestion (via phthalate-contaminated food, water a colorless liquid at room temperature and is only slightly OF HUMAN EXPOSURE concentration from 444.567 to 1671.139 µg/ml [37]. and other liquids and in case of children through denser than water. DEP has a faint, disagreeable odor, Occupational exposure to DBP, which take place mouthing of toys and teethers) or also dermal exposure when burned, produces toxic gases [5]. DEP like other As was stated earlier, phthalates are widely present mainly by inhalation and sometimes by dermal way, (via cosmetics and other personal care products). phthalates is commonly used to make plastics more in human environment. Indoor air included 12 mg/m3 was estimated as approximatelly 143 µg/kg bw/day, Exposure can also result via inhalation; because they flexible. Products in which it is found include toothbrushes, of phthalates, where 72% of all constitutes DEP whereas the exposure of general population mainly by volatilize from phthalate-containing products, and automobile parts, tools, toys, and food packaging. DEP (2.29 mg/m3), BBP (3.97 mg/m3) and DEHP ingestion as 2-10 µg/kg bw/day [44]. directly via blood from blood storage bags, catheters can be released fairly easily from these products. It is also (2.43 mg/m3) [47]. The median concentration of sum of The main way of occupational exposure to BBP and haemodialysis instruments [18]. The total daily used as solvent, fixative or alcohol denaturatant in many phthalates in house dust was measured as 362 mg/kg, is inhalation. The concentration of BBP in the air phthalate exposure in US was estimated as 0.27 mg personal care products and cosmetics, like fragrances, including DBP at the level of 14 mg/kg and DEHP at during manufacture of phthalates was estimated as daily for ambient, 0.25 mg daily from food, 0.002 µg skin lotions, nail polishes and removers, eye shadows, the level of 4 mg/kg [1]. 1 mg/m3, whereas during manufacture of PVC as daily through water and 0.4 µg daily by air [56]. hair sprays [5, 36]. DEP may be used also for solvent for The main routes of exposure to phthalates are 2 mg/m3. This is the equivalent of staff exposure to This paper describes sources of selected phthalates in insecticides and mosquito repellents, as well as detergent consumptions of contaminated food and drinking of doses of 143 µg/kg bw/day and 286 µg/kg bw/day, the environment and their concentration in products and bases and aerosol sprays. It is used in aspirin coatings contaminated water, inhalation, which is highly toxic, respectively [49]. Exposure of general population human tissues. The following phthalates were chosen to and in different medical devices inluding dialysis tubing and dermal exposure. Phthalates are released into is connected with presence of BBP in daily use this review di(2-ethylhexyl)phthalate (DEHP), dibutyl [3, 22, 58]. Moreover, DEP has been used a componet of the environment during production, transportation, products and take place mainly through drinking phthalate (DBP); butylbenzyl phthalate (BBP), diethyl food and pharmaceutical packaging [5, 34]. manufacturing and improper disposal. They are also water, food and home dust. Nagorka et al., [42] phthalate (DEP), di-isononyl phthalate (DINP). Benzylbutylphthalate (CAS No 85-68-7) also released from products into soil, water and air. showed approximately 48 mg of BBP per kg of home named n-butyl benzyl phthalate or benzyl butyl Four phthalates or their metabolites concentrations dust. Daily exposure to BBP of adult was estimated GENERAL CHARACTERISTIC phthalate, Palatinol BB, Unimoll BB, Sicol 160 or were measured in personal air samples of pregnant as 2 µg/kg body mass, whereas of children 3-fold AND OCCURRENCE OF SELECTED Santicizer 160 is a colorless liquid with weak smell. women in New York City (US) and in Kraków (Poland). higher [32]. PHTHALATES It is used mainly as plasticizer during manufacturig The concentarions of them in air samples were as follows DEP has been found in ground water at 0.0125 ppm, of goods containing PVC. BBP may be a component DEP 0.26-7.12 µg/m3, DBP 0.11-14.76 µg/m3, DEHP in soil at 0.039 ppm, in drinking water from 0.00001 Di(2-ethylhexyl)phthalate (CAS No 117-81-7) of vinyl floor tiles, traffic cones, conveyor belts, 0.05-1.08 µg/m3 and BBP 0- 0.63 µg/m3 [2]. to 0.0046 ppm, in indoor air 0.00018-0.00022 ppm, known also as bis(2-ethylhexyl) phthalate, diethylhexyl roof covers, upholsterer’s padding, artificial leather, Concentration of DEHP in residences was detected in outdoor air 0.00004-0.00006 ppm [13]. Other phthalate, di-sec octylphthalate or octylphthalate, is an industrial solvents, adhesives, plastic wraps for food, at level from below than 0.002 µg/l to 5 ng/m3 [20], study reported the concentration of DEP in indoor 3 oil liguid of low volalility used in chemical industry. toys, cosmetics, personal care products [25]. whereas at work place approximately of 60 ng/m3 [35]. air from 1.60 to 2.03 µg/m , in outdoor air from 98 M.M. Dobrzyńska No 2 No 2 Phthalates - widespread occurrence and the effect on male gametes. 99

INTRODUCTION DEHP is the most often used plasticizer (approximately Diisononyl phthalate (CAS Nos 28553-12-0 and One of the most impartant sourece of exposure to 50% of total used phthalates) in polyvinyl chloride 68515-68-0) is named also isononyl alcohol phthalate, DEHP is drinking water. It has been detected there at Humans and animals are continously exposed to (PVC), polyethylene and polypropylene products. Palatinol DN, Palatinol N, 1,2-benzenedicarboxylic different levels depending on the country, for example wide range of natural and synthetic estrogens. The Plastics may contain from 1-40% DEHP by weight. acid diisononyl ester, bis(7-methyloctyl) phthalate, in Poland and Germany at 0.05-0.06 µg/l, in Greece most important seems to be xenoestrogens, called also It is a component of many consumer products such di(C8-C10) branched alkyl phthalate, Vestinol 9, at 0.93 µg/l, in US at 0.95 µg/l, in China at 3.47 µg/l endocrine disruptors, endocrine disrupting compounds, as artificial leather, waterproof clothing, footwear, Vestinol NN, Vinylcizer 90, or Witamol 150. DINP is [12, 64]. The daily dose of DEHP taken by human hormone disruptors, xenobiotics or estrogen mimicking upholstery, floor tiles, various types of furnishing, typically a mixture of chemical compounds consisting general population with food is estimated as about chemicals. The name “xenoestrogen” comes from Greek industrial tubing, wires and cables, tablecloths, shower of various isononyl esters of phthalic acid. It is clearly 25 µg/kg bw/day [43]. Concentration of DEHP in language. ‘Xeno’ means foreign, so xenoestrogens curtains, wraps and boxes for food, children’s toys, viscous liquid, insoluble in water. DINP is mainly used food varied depeding on products, for instance in are compounds that act like estrogens from a foreign and a variety of medical plastic devices like blood as additives in plastics to make them more flexible, fishes from 129.5 to 253.9 mg/kg of dry mass [29]. source. They possess heterogenous chemical structure. storage bags, catheters and haemodialysis instruments. and also in varous products like electrical wire and In European countries, DEHP among others was Endocrine disruptors are chemicals which interact with Among others DEHP is also used in a hydraulic and cables, coated fabrics, automotive parts, building and detected in milk at average 12 mg/L, and in cheease at hormonal system, mimic estrogens and impact hormone dielectric fluids, liquid detergents, decorative inks, construction (waterproofing), vinyl flooring, footwear, average 2000 mg/L [51]. On this bases, the dose taken balance in the body, and may also have antiandrogenic industrial lubricating oils, paints, glues [4, 15, 17, 46]. sealings, lamination film and in PVC-containing by ifants with mothers and cow milk was estimated as ability. Due to structural similarity to estrogens, they may Dibutyl phthalate (CAS No 84-74-2) is called school supplies (such as scented erasers and pencil 1-10 µg/kg daily [30]. In children between 0.5 to easily bind to hormone receptors and block the action of also di-n-butyl phthalate, butyl phthalate, n-butyl case). This phthalate can be blended into a paste 11 years old daily DEHP intake was estimatated as natural hormones. They may also affect the synthesis, phthalate, 1,2-benzenedicarboxylic acid dibutyl ester, (plastisol), for coating (tarpaulins, synthetic leather 14-19 µg/kg/day [52]. The exposure coming from metabolism, binding or cellular responses of natural o-benzenedicarboxylic acid dibutyl ester, Palatinol and wall covering) and rotomoulding (toys, play and cosmetisc, personal care products and children toys estrogens [50]. C, Elaol, dibutyl-1,2-benzene-dicarboxylate. DBP is exercise balls, hoppers) applications. Moreover, DINP was estimated as from 8.2 to 25.8 µg/kg/day [33]. Xenoestrogens including some pharmaceutics colourless or light yellow liquid with weak similar to is used in non-polymer applications such as adhesives, DBP was detected in surface waters of Europe (i.e.contraceptive), metals (i.e. aluminum, arsenite, ether smell and expressive bitter savor. It is soluble paints, surfactants and printing inks for T-shirts. It can and United States at concentration from 0.01 to barium, cadmium, chromium, lead, mercury), in various organic solvents like alcohol, ether and be found in plasticine, in several categories of toys 622.9 µg/dm3 [62]. On the basis of measuration in parabens, used as preservatives in cosmetic and benzene. DBP is commonly used plasticizer and as an (plastic books, balls, dolls and cartoon characters) several factories produced DBP in Europe, it was pharmaceutical products, detergents and plasticizers additive to adhesive and printing ink, as a solvent for and in baby products (changing mats/cushions) which detected at majority of work place at the level below (i.e. bisphenol A, phthalates). paints, for impregnation of tissues and as antifoamer. could be placed in the mouth. DINP has been found 0.5 mg/m3, although somewhere this level was 10-fold The general population is exposed to phthalates, DBP is a component of plastic goods, containers for in other articles that may come into contact with higher. Concentration of DBP during manufacturing of because they are ubiquistos environmental contaminant food preservation, plastic pipes, glues, perfumes, nail children (clothes, mittens, coverage of pacifiers, PVC- goods containing this phthalate was from <0.008 mg/m3 [25, 60]. Humans are exposed to phthalates directly or polishes and washers, shadows, hair sprays [11]. containing soap packaging and shower mats) [14]. to 0.75 mg/m3 [49]. DBP was found in home dust at indirectly, by multiple routes, depending on the kind of Diethyl phthalate (CAS No 84-66-2) known also the level from 36 to 50 mg/kg [28, 42]. It was detected phthalate. One of the most important way of exposure as diethyl ester of phthalic acid and ethyl phthalate is SOURCES AND LEVELS in 19 of 21 nail polishes and in 11 of 42 perfumes at is ingestion (via phthalate-contaminated food, water a colorless liquid at room temperature and is only slightly OF HUMAN EXPOSURE concentration from 444.567 to 1671.139 µg/ml [37]. and other liquids and in case of children through denser than water. DEP has a faint, disagreeable odor, Occupational exposure to DBP, which take place mouthing of toys and teethers) or also dermal exposure when burned, produces toxic gases [5]. DEP like other As was stated earlier, phthalates are widely present mainly by inhalation and sometimes by dermal way, (via cosmetics and other personal care products). phthalates is commonly used to make plastics more in human environment. Indoor air included 12 mg/m3 was estimated as approximatelly 143 µg/kg bw/day, Exposure can also result via inhalation; because they flexible. Products in which it is found include toothbrushes, of phthalates, where 72% of all constitutes DEP whereas the exposure of general population mainly by volatilize from phthalate-containing products, and automobile parts, tools, toys, and food packaging. DEP (2.29 mg/m3), BBP (3.97 mg/m3) and DEHP ingestion as 2-10 µg/kg bw/day [44]. directly via blood from blood storage bags, catheters can be released fairly easily from these products. It is also (2.43 mg/m3) [47]. The median concentration of sum of The main way of occupational exposure to BBP and haemodialysis instruments [18]. The total daily used as solvent, fixative or alcohol denaturatant in many phthalates in house dust was measured as 362 mg/kg, is inhalation. The concentration of BBP in the air phthalate exposure in US was estimated as 0.27 mg personal care products and cosmetics, like fragrances, including DBP at the level of 14 mg/kg and DEHP at during manufacture of phthalates was estimated as daily for ambient, 0.25 mg daily from food, 0.002 µg skin lotions, nail polishes and removers, eye shadows, the level of 4 mg/kg [1]. 1 mg/m3, whereas during manufacture of PVC as daily through water and 0.4 µg daily by air [56]. hair sprays [5, 36]. DEP may be used also for solvent for The main routes of exposure to phthalates are 2 mg/m3. This is the equivalent of staff exposure to This paper describes sources of selected phthalates in insecticides and mosquito repellents, as well as detergent consumptions of contaminated food and drinking of doses of 143 µg/kg bw/day and 286 µg/kg bw/day, the environment and their concentration in products and bases and aerosol sprays. It is used in aspirin coatings contaminated water, inhalation, which is highly toxic, respectively [49]. Exposure of general population human tissues. The following phthalates were chosen to and in different medical devices inluding dialysis tubing and dermal exposure. Phthalates are released into is connected with presence of BBP in daily use this review di(2-ethylhexyl)phthalate (DEHP), dibutyl [3, 22, 58]. Moreover, DEP has been used a componet of the environment during production, transportation, products and take place mainly through drinking phthalate (DBP); butylbenzyl phthalate (BBP), diethyl food and pharmaceutical packaging [5, 34]. manufacturing and improper disposal. They are also water, food and home dust. Nagorka et al., [42] phthalate (DEP), di-isononyl phthalate (DINP). Benzylbutylphthalate (CAS No 85-68-7) also released from products into soil, water and air. showed approximately 48 mg of BBP per kg of home named n-butyl benzyl phthalate or benzyl butyl Four phthalates or their metabolites concentrations dust. Daily exposure to BBP of adult was estimated GENERAL CHARACTERISTIC phthalate, Palatinol BB, Unimoll BB, Sicol 160 or were measured in personal air samples of pregnant as 2 µg/kg body mass, whereas of children 3-fold AND OCCURRENCE OF SELECTED Santicizer 160 is a colorless liquid with weak smell. women in New York City (US) and in Kraków (Poland). higher [32]. PHTHALATES It is used mainly as plasticizer during manufacturig The concentarions of them in air samples were as follows DEP has been found in ground water at 0.0125 ppm, of goods containing PVC. BBP may be a component DEP 0.26-7.12 µg/m3, DBP 0.11-14.76 µg/m3, DEHP in soil at 0.039 ppm, in drinking water from 0.00001 Di(2-ethylhexyl)phthalate (CAS No 117-81-7) of vinyl floor tiles, traffic cones, conveyor belts, 0.05-1.08 µg/m3 and BBP 0- 0.63 µg/m3 [2]. to 0.0046 ppm, in indoor air 0.00018-0.00022 ppm, known also as bis(2-ethylhexyl) phthalate, diethylhexyl roof covers, upholsterer’s padding, artificial leather, Concentration of DEHP in residences was detected in outdoor air 0.00004-0.00006 ppm [13]. Other phthalate, di-sec octylphthalate or octylphthalate, is an industrial solvents, adhesives, plastic wraps for food, at level from below than 0.002 µg/l to 5 ng/m3 [20], study reported the concentration of DEP in indoor 3 oil liguid of low volalility used in chemical industry. toys, cosmetics, personal care products [25]. whereas at work place approximately of 60 ng/m3 [35]. air from 1.60 to 2.03 µg/m , in outdoor air from 100 M.M. Dobrzyńska No 2 No 2 Phthalates - widespread occurrence and the effect on male gametes. 101

0.4 to 0.52 µg/m3 [53]. Human exposure to DEP can way increasing exposure. Nowadays, the presence of approximatelly of 8.84 mg/L DEHP and 7.67mg/L CONCLUSIONS result from eating food contaminated from packing phthalates, like DEHP, DINP, DBP and BBP, in toys is of DBP in the blood of mothers after delivery. materials and contaminated seafood, or drinking prohibited by European Union directive. Unfortunatelly, Simultaneously they detected 5.20 mg/L DEHP and Taking into consideration numerous sources, contaminated water, or breading contaminated air or toys produced in Asia still contained phthalates. 5.71 mg/L DBP in umbilical blood [38]. In urine diversity and application of of phthalates it seems to as result of medical treatment [13]. DEP from plastic samples of healty Danish children and adolescents the be important to inform widely of society about the packaging may gets into food and has been found PHTHALATES CONCENTRATIONS median concentration of several phthalate metabolites hazard carrying by them. Particularly important is in packaged food at the level of 2-5 ppm, The daily IN HUMAN TISSUES were detected as follows 29 ng/ml for DEP, 17 ng/ml escape of heating up of food and drinks in cans and in human intake of this phthalate has been estimated for DBP, 111 ng/ml for DEHP, and 31 ng/ml for plastic containers. It is also important to pay attention to be 4 mg based on the food intake [31]. DEP The level of phthalates were measured in DINP. On the basis of above results, the median of on presence of phthalates in toys, and personal care was detected in pies (average 1.8 µg/g), in crakers numerous human biological samples. Three phthalates estimated daily intake was 4.29 µg/kg bw/24 h for DBP, and daily use aricles assigned for infants and small (5.3 µg/g), and in chockolate bars (5.3 µg/g) [45]. The DEHP, DEP and DBP were detected among others 4.04 µg/kg bw/24 h for DEHP, 1.70 µg/kg bw/24 h children. anuual exposure from drinking contaminated water in biological samples of people residing in Shanghai for DINP, 1.09 µg/kg bw/24 h for DEP and has been estimated to be 0.0058 mg/year/person [13]. area with median levels of 5.71 mg/L in blood serum, 0.62 µg/kg bw/24 h for BBP [19]. Conflict of interest. Because of DEP was present mainly in fragrance 0.30 mg/L in semen speciments and 0.72 mg/kg in fat In breast milk of women in Bavaria were found The author declares no conflict of interest. products, dermal exposure seems to be the most samples [63]. the following median concentration of phthalates important. It was found in 35 of 36 perfume products Exposure to phthalates is usually determined 3.9 ng/g for DEHP, 0.8 ng/g for DBP [21]. In other REFERENCES sold in Europe with the highest concentration of by measuring metabolite levels in the urine. The study the mean concentration of DINP metabolites 2.23% [24]. The median value of DEP in fragrance urinary level of several phthalate metabolites in study in breast milk was measured less than 0.25 µg/l, 1. Abb M., Heinrich T., Sorkau E., Lorenz W.: Phthalates products was 1679 µg/g [36]. Based on the level different human populations have been measured. The and in cord blood samples < 0.25 – 4.05 µg/l. The in house dust. Environ Int 2009;35(6):965-970. of DEP in cosmetic and personal care products, concentration of phthalate metabolites in the urine of levels of DEHP metabolites were detected from <0.25 2. Adibi J.J., Perera F.P., Jedrychowski W., Camann children’s exposure to this phthalate was estimated as pregnant women in US were as follows; 26.7-5.52 x to 46.53 µg/l and from 0.25 to 32.20 µg/l, respectively, D.E., Barr D., Jacek R., Whyatt R.M.: Prenatal exposures to phthalates among women in New York 42 µg/kg bw daily for babies, as 20 µg/kg bw daily for 103 µg/g creatine for DEP, 21.3-105 µg/g creatine for whereas metabolites of BBP from <0.25 to 39.70 and City and Krakow, Poland. Environ Health Perspect toddlers, and as 18 µg/kg bw daily for female adults DBP, 5.6-120 µg/g creatine for BBP and 1.8-449 µg/g from <0.25 to 39.70 µg/l, respectively [39]. [36]. Moreover, people receiving medical treatment The concentrations of phthalates in the blood of 2003;111:1719–1722. creatine for DEHP [2]. The levels of phthalate 3. Api A.M.: Toxicological profile of diethyl phthalatea that involve the use of PVC tubing may be exposed to human were measured in several countries. In 2004 metabolites in the urine in men of reproductive age was vehicle for fragrance and cosmetic ingredients. Food DEP of its leaching from tubing [13]. as follows 5.6-53.5 µg/l for DEHP, 4.9-15.2 µg/l for World Wilde Fund for Nature Poland measured Chem Toxicol 2001;39(2)97-108. The concentration of DINP in home dust was BBP, 26.6-278 µg/l for DEP, 16.3-38.1 µg/l for DBP the level of several phthalates in the blood of 15 4. ATSDR. Toxicological profile for di-(2-ethylhexyl) estimated as 184 mg/kg [42]. The average DINP [26]. The highest levels of metabolites of following voluntaries. The concentration of DEHP varied from phthalate (DEHP). Agency for Toxic Substances and concentration level in 24 kinds of food was 0.24 mg/kg. phthalates were detected in the urine of adult American 49 to 293 ng/kg of blood, whereas of DBP from bottom Disease Registry, United States Public Health Service, [41]. DINP was detected in baby snaks at the level of population DEP (16 200 ng/ml, 6790 µg/g creatinine), limit of notation to 103 ng/kg of blood. DEP, DINP Atlanta GA 2002. 1.83 µg/g and it is equivalent of 0.77 µg/kg bw [57]. DBP (4670 µg/g, 2760 µg/g creatinine), BBP (1020 and BBP were not found [55]. In the blood serum of 5. ATSDR. Toxicological profile for diethyl phthalate. The average dietary intake of this phthalate was ng/ml, 540 µg/g creatinine [8]. DEP metabolites Hong-Kong inhabitants from 3.51 to 28.45 ng DEHP/ Agency for Toxic Substances and Disease Registry, estimated as 4.39 µg/kg/day in general population, were detected in the urine of 6 year old children at ml, from 0.82 to 1.97 ng BBP/ml, from 0.77 to 12.50 United States Public Health Service, Atlanta, GA. US, 1995. 8.91 µg/kg in children aged 2 to 6 years, 6.53 µg/kg the concentration of 171 µg/l and in persons over ng DBP/ml and from 1.02 to 5.91 ng DINP/ml were 6. Axelsson J., Rylander L., Rignell-Hydbom A., Jőnsson in children aged 7 to 12 years [41]. DINP intake in 6 years at 1160 µg/l [9]. In the urine of pregnant women detected [59]. Elevated DEHP residue concentration German students ranged from 0.02 to 20.2 µg/kg bw/day has been found in the blood and tissues of patients B.A.G., Lindh C.H., Giwercman A.: Phthalate exposure from Taiwan 0.09-859 µg/l, metabolites of DEHP, and reproductive parameters in young men from the [61]. The estimated DINP exposure in European after numerous transfusions [17, 40, 54]. Above group <0.25-55 µg/l metabolites of BBP, 1.02-269 µg/l of DBP general Swedish population. Environ Int 2015;85:8554- Union through the use of concumer products in metabolites, and 0.25-36.5 µg/l of DINP metabolites of people may receive considerably higher doses of 8560. infants is 249.9 µg/kg bw/day, whereas in adults were detected. In the urine of their 2 years old children DEHP compared to general population. Amount of 7. Babich M.A., Chen S.B., Greene M.A., Kiss C.T., 10.8 µg/kg bw/day [16]. Then, in Canada DINP from 1.25 to 8.81 µg/l of DEHP, from 1.02 to 269 µg/l DEHP entering dialyzed patient ranged ranged from Porter W.K., Smith T.P., Wind M.L., Zemula W.W.: Risk exposure of ifants was estimated to range from of DBP, approximately 3.86 µg/l of BBP and <0.25 9 to 150 mg in a 5-hr hemodialysis session [23] or assessment of oral exposure to diisononyl phthalate 5 µg/kg bw/day to 45.8 µg/kg bw/day [27]. The – 398.84 µg/l of DINP metabolites were detected. In from 23.8 to 360 mg in a 4-hr dialysis period [48]. from children’s products. Regul Toxicol Phramacol exposure of 12-123 months old children to DINP was the urine of their children aged 5 years from 1.04 to Patients subjected dialyses may be exposed to dose 2004;40(2):151-167. estimated from 1.3 to 3.2 µg/kg daily [7]. 1390 µg/l of DEHP, from 4.16 to 165 µg/l of DBP, of 12 g of DEHP per year [17]. In case of pregnant 8. Blount B.C., Silva M.J., Caudill S.P., Needham L.L., The average and high daily intakes for infants approximately 3.66 µg/l of BBP and 0.6 - 1188 µg/l females, where the exposure to DEHP coming from Pirkle J.L., Sampson E.J., Lucier G.W., Jackson R.J., Brock J.W.: Levels of seven urinary phthalate were estimated on the basis of phthalate concentration DINP metabolites were found [39]. The concentration dialysis treatment or blood transfusions, the health metabolites in a human reference population. Environ in breast milk. They are as follow 0.6 µg/kg bw and of phthalate metabolites in the urine of young consequences might be present in their children [46]. 2.1 µg/kg bw for DEHP, 0.1 µg/kg bw and 0.5 µg/kg bw Neonatales may be heavily exposed to DEHP and its Health Perspect 2000;108(10):979-982. (17.5-20.5 years old) Swedish men were as follows 9. CDC. Centers for Disease Control and Prevention. for DBP, 3.2 µg/kg bw and 6.4 µg/kg bw for DINP, metabolites receiving blood products by usage of PVC 2-6900 µg/ml for DEP, 1-690 µg/ml for DBP, National report on human exposure to environmental respectively [21]. 0.5-260 µg/ml for BBP, < level of detection – 1900 µg/ml comtaining medical devices. For example to DEHP chemicals. Atlanta, GA, 2001. The important potential health effects of pthalates is for DEHP, < level of detection – 980 µg/ml [6]. exposure per exchange transfusion may be up to 3.3 10. Chen J.A., Liu H., Shu W.: Analysis of di-n-butyl connected with children exposure from toys and other In the study, of women after delivery the mean mg/kg [54]. phthalate and other organic pollutanta in Chongqing sources [46]. Infantas and young children could be under concentrations of DBP were measured as follow in the women undergoing parturition. Environ Pollut higher phthalate exposure. As phthalates plasticizers peripheral blood 84.75 µg/ml, in umbilical cord blood 2008;156(3):849-853. are not chemically bound to PVC, they could migrate 52.23 µg/ml, in milk 57.78 µg/ml and in the urine to salivia during sucking and cheving of toy and this 24.93 µg/ml [10]. Chineese study showed concentration 100 M.M. Dobrzyńska No 2 No 2 Phthalates - widespread occurrence and the effect on male gametes. 101

0.4 to 0.52 µg/m3 [53]. Human exposure to DEP can way increasing exposure. Nowadays, the presence of approximatelly of 8.84 mg/L DEHP and 7.67mg/L CONCLUSIONS result from eating food contaminated from packing phthalates, like DEHP, DINP, DBP and BBP, in toys is of DBP in the blood of mothers after delivery. materials and contaminated seafood, or drinking prohibited by European Union directive. Unfortunatelly, Simultaneously they detected 5.20 mg/L DEHP and Taking into consideration numerous sources, contaminated water, or breading contaminated air or toys produced in Asia still contained phthalates. 5.71 mg/L DBP in umbilical blood [38]. In urine diversity and application of of phthalates it seems to as result of medical treatment [13]. DEP from plastic samples of healty Danish children and adolescents the be important to inform widely of society about the packaging may gets into food and has been found PHTHALATES CONCENTRATIONS median concentration of several phthalate metabolites hazard carrying by them. Particularly important is in packaged food at the level of 2-5 ppm, The daily IN HUMAN TISSUES were detected as follows 29 ng/ml for DEP, 17 ng/ml escape of heating up of food and drinks in cans and in human intake of this phthalate has been estimated for DBP, 111 ng/ml for DEHP, and 31 ng/ml for plastic containers. It is also important to pay attention to be 4 mg based on the food intake [31]. DEP The level of phthalates were measured in DINP. On the basis of above results, the median of on presence of phthalates in toys, and personal care was detected in pies (average 1.8 µg/g), in crakers numerous human biological samples. Three phthalates estimated daily intake was 4.29 µg/kg bw/24 h for DBP, and daily use aricles assigned for infants and small (5.3 µg/g), and in chockolate bars (5.3 µg/g) [45]. The DEHP, DEP and DBP were detected among others 4.04 µg/kg bw/24 h for DEHP, 1.70 µg/kg bw/24 h children. anuual exposure from drinking contaminated water in biological samples of people residing in Shanghai for DINP, 1.09 µg/kg bw/24 h for DEP and has been estimated to be 0.0058 mg/year/person [13]. area with median levels of 5.71 mg/L in blood serum, 0.62 µg/kg bw/24 h for BBP [19]. Conflict of interest. Because of DEP was present mainly in fragrance 0.30 mg/L in semen speciments and 0.72 mg/kg in fat In breast milk of women in Bavaria were found The author declares no conflict of interest. products, dermal exposure seems to be the most samples [63]. the following median concentration of phthalates important. It was found in 35 of 36 perfume products Exposure to phthalates is usually determined 3.9 ng/g for DEHP, 0.8 ng/g for DBP [21]. In other REFERENCES sold in Europe with the highest concentration of by measuring metabolite levels in the urine. The study the mean concentration of DINP metabolites 2.23% [24]. The median value of DEP in fragrance urinary level of several phthalate metabolites in study in breast milk was measured less than 0.25 µg/l, 1. Abb M., Heinrich T., Sorkau E., Lorenz W.: Phthalates products was 1679 µg/g [36]. Based on the level different human populations have been measured. The and in cord blood samples < 0.25 – 4.05 µg/l. The in house dust. Environ Int 2009;35(6):965-970. of DEP in cosmetic and personal care products, concentration of phthalate metabolites in the urine of levels of DEHP metabolites were detected from <0.25 2. Adibi J.J., Perera F.P., Jedrychowski W., Camann children’s exposure to this phthalate was estimated as pregnant women in US were as follows; 26.7-5.52 x to 46.53 µg/l and from 0.25 to 32.20 µg/l, respectively, D.E., Barr D., Jacek R., Whyatt R.M.: Prenatal exposures to phthalates among women in New York 42 µg/kg bw daily for babies, as 20 µg/kg bw daily for 103 µg/g creatine for DEP, 21.3-105 µg/g creatine for whereas metabolites of BBP from <0.25 to 39.70 and City and Krakow, Poland. Environ Health Perspect toddlers, and as 18 µg/kg bw daily for female adults DBP, 5.6-120 µg/g creatine for BBP and 1.8-449 µg/g from <0.25 to 39.70 µg/l, respectively [39]. [36]. Moreover, people receiving medical treatment The concentrations of phthalates in the blood of 2003;111:1719–1722. creatine for DEHP [2]. The levels of phthalate 3. Api A.M.: Toxicological profile of diethyl phthalatea that involve the use of PVC tubing may be exposed to human were measured in several countries. In 2004 metabolites in the urine in men of reproductive age was vehicle for fragrance and cosmetic ingredients. Food DEP of its leaching from tubing [13]. as follows 5.6-53.5 µg/l for DEHP, 4.9-15.2 µg/l for World Wilde Fund for Nature Poland measured Chem Toxicol 2001;39(2)97-108. The concentration of DINP in home dust was BBP, 26.6-278 µg/l for DEP, 16.3-38.1 µg/l for DBP the level of several phthalates in the blood of 15 4. ATSDR. Toxicological profile for di-(2-ethylhexyl) estimated as 184 mg/kg [42]. The average DINP [26]. The highest levels of metabolites of following voluntaries. The concentration of DEHP varied from phthalate (DEHP). Agency for Toxic Substances and concentration level in 24 kinds of food was 0.24 mg/kg. phthalates were detected in the urine of adult American 49 to 293 ng/kg of blood, whereas of DBP from bottom Disease Registry, United States Public Health Service, [41]. DINP was detected in baby snaks at the level of population DEP (16 200 ng/ml, 6790 µg/g creatinine), limit of notation to 103 ng/kg of blood. DEP, DINP Atlanta GA 2002. 1.83 µg/g and it is equivalent of 0.77 µg/kg bw [57]. DBP (4670 µg/g, 2760 µg/g creatinine), BBP (1020 and BBP were not found [55]. In the blood serum of 5. ATSDR. Toxicological profile for diethyl phthalate. The average dietary intake of this phthalate was ng/ml, 540 µg/g creatinine [8]. DEP metabolites Hong-Kong inhabitants from 3.51 to 28.45 ng DEHP/ Agency for Toxic Substances and Disease Registry, estimated as 4.39 µg/kg/day in general population, were detected in the urine of 6 year old children at ml, from 0.82 to 1.97 ng BBP/ml, from 0.77 to 12.50 United States Public Health Service, Atlanta, GA. US, 1995. 8.91 µg/kg in children aged 2 to 6 years, 6.53 µg/kg the concentration of 171 µg/l and in persons over ng DBP/ml and from 1.02 to 5.91 ng DINP/ml were 6. Axelsson J., Rylander L., Rignell-Hydbom A., Jőnsson in children aged 7 to 12 years [41]. DINP intake in 6 years at 1160 µg/l [9]. In the urine of pregnant women detected [59]. Elevated DEHP residue concentration German students ranged from 0.02 to 20.2 µg/kg bw/day has been found in the blood and tissues of patients B.A.G., Lindh C.H., Giwercman A.: Phthalate exposure from Taiwan 0.09-859 µg/l, metabolites of DEHP, and reproductive parameters in young men from the [61]. The estimated DINP exposure in European after numerous transfusions [17, 40, 54]. Above group <0.25-55 µg/l metabolites of BBP, 1.02-269 µg/l of DBP general Swedish population. Environ Int 2015;85:8554- Union through the use of concumer products in metabolites, and 0.25-36.5 µg/l of DINP metabolites of people may receive considerably higher doses of 8560. infants is 249.9 µg/kg bw/day, whereas in adults were detected. In the urine of their 2 years old children DEHP compared to general population. Amount of 7. Babich M.A., Chen S.B., Greene M.A., Kiss C.T., 10.8 µg/kg bw/day [16]. Then, in Canada DINP from 1.25 to 8.81 µg/l of DEHP, from 1.02 to 269 µg/l DEHP entering dialyzed patient ranged ranged from Porter W.K., Smith T.P., Wind M.L., Zemula W.W.: Risk exposure of ifants was estimated to range from of DBP, approximately 3.86 µg/l of BBP and <0.25 9 to 150 mg in a 5-hr hemodialysis session [23] or assessment of oral exposure to diisononyl phthalate 5 µg/kg bw/day to 45.8 µg/kg bw/day [27]. The – 398.84 µg/l of DINP metabolites were detected. In from 23.8 to 360 mg in a 4-hr dialysis period [48]. from children’s products. Regul Toxicol Phramacol exposure of 12-123 months old children to DINP was the urine of their children aged 5 years from 1.04 to Patients subjected dialyses may be exposed to dose 2004;40(2):151-167. estimated from 1.3 to 3.2 µg/kg daily [7]. 1390 µg/l of DEHP, from 4.16 to 165 µg/l of DBP, of 12 g of DEHP per year [17]. In case of pregnant 8. Blount B.C., Silva M.J., Caudill S.P., Needham L.L., The average and high daily intakes for infants approximately 3.66 µg/l of BBP and 0.6 - 1188 µg/l females, where the exposure to DEHP coming from Pirkle J.L., Sampson E.J., Lucier G.W., Jackson R.J., Brock J.W.: Levels of seven urinary phthalate were estimated on the basis of phthalate concentration DINP metabolites were found [39]. The concentration dialysis treatment or blood transfusions, the health metabolites in a human reference population. Environ in breast milk. They are as follow 0.6 µg/kg bw and of phthalate metabolites in the urine of young consequences might be present in their children [46]. 2.1 µg/kg bw for DEHP, 0.1 µg/kg bw and 0.5 µg/kg bw Neonatales may be heavily exposed to DEHP and its Health Perspect 2000;108(10):979-982. (17.5-20.5 years old) Swedish men were as follows 9. CDC. Centers for Disease Control and Prevention. for DBP, 3.2 µg/kg bw and 6.4 µg/kg bw for DINP, metabolites receiving blood products by usage of PVC 2-6900 µg/ml for DEP, 1-690 µg/ml for DBP, National report on human exposure to environmental respectively [21]. 0.5-260 µg/ml for BBP, < level of detection – 1900 µg/ml comtaining medical devices. For example to DEHP chemicals. Atlanta, GA, 2001. The important potential health effects of pthalates is for DEHP, < level of detection – 980 µg/ml [6]. exposure per exchange transfusion may be up to 3.3 10. Chen J.A., Liu H., Shu W.: Analysis of di-n-butyl connected with children exposure from toys and other In the study, of women after delivery the mean mg/kg [54]. phthalate and other organic pollutanta in Chongqing sources [46]. Infantas and young children could be under concentrations of DBP were measured as follow in the women undergoing parturition. Environ Pollut higher phthalate exposure. As phthalates plasticizers peripheral blood 84.75 µg/ml, in umbilical cord blood 2008;156(3):849-853. are not chemically bound to PVC, they could migrate 52.23 µg/ml, in milk 57.78 µg/ml and in the urine to salivia during sucking and cheving of toy and this 24.93 µg/ml [10]. Chineese study showed concentration 102 M.M. Dobrzyńska No 2 No 2 Phthalates - widespread occurrence and the effect on male gametes. 103

11. CIRC. Cosmetic Ingradient Review Committee. Final 26. Hauser R., Meeke J.D., Park S., Silva M.J., Calafat 40. Manojkumar V., Deepadevi K.V., Arun P., Nair K.G., plasticizers. Pediatrics 2005;111:1467-74. report on the safety assessment of dibutyl phthalate, A.M.: Temporal variability of urinary phthalate Lakshmi L.R., Kurup P.A.: Changes in the composition 53. Shields H.C., Weschler C.J.: Analysis of ambient dimethyl phthalate and diethyl phthalate. J Am Coll metabolite levels in men of reproductive age. Environ of erythrocyte membrane during storage of blood in di- concentrationsof organic vapors with a passive sampler. Toxicol 1985;4267-303. Health Perspect 2004;112:1734-1740. (2-ethyl hexyl) phthalate [DEHP] plasticized poly vinyl J Air Pollut Control Associat 1987;37(9):1039-1045. 12. De Moura S.M., Carrara D.M., Morita, Gimenez-Boscov 27. Health Canada, Risk assessment on diisononyl chloride (PVC) blood storage bags. Indian J Med Res 54. Sjőberg P., Lindquist N.G., Montin G., Ploen L.: Effects M.E.: Biodegradation of di(2-ethylhexyl) phthalate in phthalate in vinyl children’s product. Consumer 1999;109:157-163. of repeated intravenous infusions of the plasticizer a typical tropical soil. J. Hazard. Mater 2011;197:40-48. products safety Bureau, Ottawa, ON, Canada, 1998. 41. Mao W., Liu S., Zhang L., Song Y., Zhou P., Yong L., Sui di-(2-ethylhexyl) phthalate in young male rats. Arch 13. Diethyl phthalate. Concise International Chemical 28. Heudorf U., Mersch-Sudermann V., Angerer J.: H.: Dietary intake and risk assessment of diisononyl Toxicol 1985;58:78-83. Assessment Document 52. World Health Organization PhthalatesToxicology and exposure. Int J Hyg Environ phthalate (DINP) in Chinese population. Wei Sheng 55. Struciński P., Goralczyk K., Ludwicki J.K., Czaja K., Geneva, 2003. Health. 2007;210(5):623-634. Yan Jiu 2015;44(5):822-826. Hernik A., Korcz W.: Poziomy wybranych insektycydów, 14. Diisononyl phthalate (DINP). FactSheet National 29. Huang P-.C., Tien C-.J., Sun Y.-M., Hsieh C.-Y., 42. Nagorka R., Conrad A., Scheller C., Süssenbach B., polichlorowanych bifenyli, ftalanów i perfluorowanych Industrial Chemicals Notification and Assessment Lee C.-C.: Occurrence of phthalates in sediment Moriske H. J.: Weichmacher und Flammschutzmittel związków alifatycznych we krwi – badanie WWF Scheme (http://www.nicnas.gov.au). and biotarelationship to aquatic factors and the im Hausstaub – Teil 1Phthalate. Gefahrstoffe- Polska. [Levels of selected organochlorine insecticides, 15. Environmental Protection Agency. Technical Factsheet biota sediment accumulation factor. Chemosphere Reinhaltung der Luft, 2010;70(3):70-76. polychlorinated biphenyls, phthalates and perfluorinated ondi(2-ethyl)phthalate (DEHP). Office of Ground 2008;73:539-544. 43. Nakamiya K., Hashimoto S., Ito H., Edmonds J.S., aliphatic substances in blood – Polish WWF study]. Water and Drinking Water,Washington DC, 1998. 30. Kamrin M.A.: Phthalate risks, phthalate regulation and Yasuhara A., Morita M.: Microbial treatment of bis(2- Rocz Panstw Zakl Hig 2006;57(2):99-112 (in Polish) 16. European Chemicals Bureau, Risk Assessment Report public healthA review. J Toxicol Environ Health Part B ethylhexylo phthalate in polyvinyl chloride with [PMID17044303; http://www.ncbi.nlm.nih.gov/ on 1,2 Benzedicarboxylic acid, di-C8-11 bracnched 2009;12:157-174. isolated bacteria. J Biosci Bioeng 2005;99:115-119. pubmed/17044303]. alkyl esters, C9-rich, and di-isononyl phthalate 31. Kamrin M.A., Mayor G.H.: Diethyl phthalate — 44. NTP-CERHR. Monograph on the potential human 56. Tickner J., Hunt P., Rossi M., Haiama N., Lappe M.: (DINP). Institute for Health and Consumer Protection, a perspective. J Clin Pharmacol 1991;31(5):484-489. reproductive abd developmental effects of di-n-butyl The use of di-2-ethylhexyl phthalate in PVC medical European Union, 2003. 32. Kavlock R., Boekelheide K., Chapin R., Cunningham phthalate (DBP). NIH Publ. No 03-4486, 2003. devicesexposure, toxicity, and alternatives. The report 17. Faouzi A.., Dine T., Gressier B., Kambia K., Luyckx M., Faustman E., Foster P., Golub M., Henderson R., 45. Page B.D., Lacroix GM.: The occurrence of phthalate of Lowell Center for Sustainable Production University M., Pagniez D., Brunet C., Cazin M., Belabed A., Irwin Hinberg I., Little R., Seed J., Shea K., Tabacova ester and di-2-ethylhexyl adipate plasticizers in of Massachusetts Lowell, 1999. Cazin J.C.: Exposure of hemodialysis patients to di-2- S., Tyl R., Williams P., Zacharewski T.: NTP Center for Canadian packaging and food sampled in 1985–1989a 57. Tsumura Y., Ischimitsu S., Kaihara A., Yoshi K., ethylhexyl phthalate. Int J Pharm 1999;180(1):113-121. Evaluation of Risks to Human Reproductionphthalates survey. Food Addit Contam 1995;12(1):129-151. Tonogai Y.: Phthalates, adipates, citrarate and some of 18. FDA. U.S. Food and Drug Administration. Center for expert panel report on the reproductive and 46. Parks L.G., Ostby J.S., Lambright C.R., Abbott B.D., the other plasticizers detected in Japanese retail foodsa Food Safety and Applied Nutrition. Food and Drug developmental toxicity of di-n-butyl phthalate. Reprod Klinefelter G.R., Barlow N.J. Gray E.: The plasticizer survey. J Health Sci 2002;48(6):493-502. Administration Total Diet Study; summary of residues Toxicol. 2002;16:489-527. diethylhexyl phthalate induced malformations be 58. Wahl H.G., Hoffmann A., Häring H.U., Liebich H.M.: found ordered by pesticide market baskets 91-3-99- 33. Kavlock R., Barr D., Boekelheide K.,Breslin W., Breysse decreasing fetal testosterone synthesis during sexual Identification of plasticizers in medical products by 1. Office of Plant and Dairy Foods and Beverages. P., Chapin R. Gaido K., Hodgson E., Marcus M., Shea differentiation in the male rat. Toxicol Sci 2000;58:339- a combined direct thermodesorption-cooled injection Rockville, MD, 2001. K., Williams P.: NTP-CERHR expert panel updateon 349. system and gas chromatography–mass spectrometry. J 19. Frederiksen H., Aksglaede L., Soerensen K., the reproductive and developmental toxicity on di-(2- 47. Pie X.Q., Song M., Guo M., Mo F.F., Shen X.Y.: Chromatogr 1999;847:1–7. Skakkebaek N.E., Juul A., Andersson A.M.: Urinary ethylhexyl) phthalate. Reprod Toxicol 2006;22:291-399. Concentration and risk assessment of phthalates 59. Wan H.T., Leung P.Y., Zhao Y.G., Wei X., Wong excretion of phthalate metabolites in 129 healthy 34. Kelley K.E., Hernández-Díaz S., Chaplin E.L., Hauser present in indoor air from newly decorated apartments. M.H., Wong C.K.C.: Blood plasma concentrations Danish children and adolescents:estimation of daily R., Mitchell A.A.: Identification of phthalates in Atmos. Environ 2013;68:17-23 of endocrine disrupting chemicals in Hong Kong phthalate intake. Environ Res 2011;111(5):656-663. medications and dietary supplement formulations in 48. Pollack G.M., Buchanan J.F., Slaughter R.L., populations. J Hazard Mat 2013;261:763-69. 20. Fromme H., Lahrz T., Piloty M., Gebhart H., Oddoy the United States and Canada. Environ Health Perspect. Kohli R.K., Shen DD.: Circulating concentrations 60. Wittassek M., Angerer J.: Phthalates metabolism and A, Rüden H.: Occurrence of phthalates and musk 2012;120(3):379-84. of di(2-ethylhexyl) phthalate and its de-esterified exposure. Int J Androl 2008;3:1131-1138. fragrances in idoor air and dust from apartments 35. Kim Y-H., Lee J., Moon S.-H.: Degradation of phthalic-acid products following plasticizer exposure 61. Wittassek M., Wiesmüller G.A., Koch H.M., Eckard and kindergartens in Berlin (Germany). Indoor Air an endocrine disrupting chemical, DEHP [di-(2- in patientsreceiving hemodialysis.Toxicol Appl R., Dobler R., Müller J., Angerer J., Schlüter C.: 2004;14:188-195. ethylhexyl)phthalate] by Fusarium oxysporium f. sp. Pharmacol 1985;79:257-267. Internal phthalate exposure over the last two decades 21. Fromme H., Gruber L., Seckin E., Raab U., Zimmermann pisi cutinase. Appl Microbiol Biotechnol 2003;63:75- 49. RAR. Risk Assessment Report (2004) Benzyl butyl – a retrospective human biomonitoring study. Int J Hyg S., Kiranoglu M., Schlummer M., Schweiger U., Smolic 80. phthalate, Draft March. http://ecb.jrc.it/ Environ Health 2007;210:319-333. S., Vőkei W., HBMnet: Phthalates and their metabolites 36. Koniecki D., Wang R., Moody R.P., Zhu J.: Phthalate 50. Roy J.R., Chakraborty S., Chakraborty T.R.: Estrogen- 62. Wypych G.: Handbook of plasticizers. ChemTech in breast milk – results from the Bavarian monitoring in cosmetic amd personal care productsConcentrations like endocrine disrupting chemicals affecting puberty Publishing, Ontario, Canada, 2004. of breast milk (BAMBI). Environ Int 2011;37(4):715- and possible dermal exposure. Environ Res in humans – a review. Med Sci Monit 2009;15 63. Zhang Y.H., Chen B.H., Zheng L.X., Wu X.Y.: Study 722. 2011;111:329-336. (6):RA137-145. on the level of phthalate in human biological samples. 22. Ghorpade N., Mehta V., Khare M.: Toxicity study of 37. Koo H.J., Lee B.M.: Estimated exposure to phthalates 51. Sharman M., Read W.A., Castle L., Gilbert J.: Levels Zhonghua Yu Fang Yi Xe Za Zhi 2003;37(6):429-34. diethyl phthalate on freshwater fish Cirrhina mrigala. in cosmetics and risk assessment. J Toxicol Environ of di(2-ethylhexyl)phthalate and total phthalate esters 64. Zolfaghari M., Drogui P., Seyhi B., Brar S.K., Bueina Ecotoxicol Environ Safety 2002;53(2):255-258. Health Part A. 2004;67:1901-1914. in milk, cream, butter and cheese. Food Addit Contam G., Dube R.: Occurrence fate and effects of di(2- 23. Gibson T.P., Briggs W.A., Boone B.J.: Delivery 38. Lin L., Zheng L.X., Gu Y.P., Wang J.Y., Zhang Y.H., 1994;11:375-85. ethylhexyl)phthalate in wastewater treatment plantsA of di-2-ethylhexyl phthalate to patients during Song W.M.: Levels of environmental endocrine 52. Shea K.M. and Committee on Environmental Health: review. Environ Pollut 2014;194:281-292. hemodialysis. J Lab Clin Med 1976;87(3):519-524. disruptors in umbilical cord blood and maternal blood Pediatric exposure and potential toxicity of phthalate 24. Greenpeace. Perfume - An investigation of chemicals of low-birth-weight infants. Zhonghua Yu Fang Ti Xue Received: 16.02.2016 in 36 eaux de toilette and eaux de parfum. Greenpeace Za Zhi. 2008;42(3):177-180. Accepted: 04.05.2016 International. 2005. Available at http://www. 39. Lin S., Ku H.-S., Su P.-H., Chen J.-W., Huang P.- greenpeace.org/international/en/publications/reports/ C., Angerer J., Wang S.-L.: Phthalate exposure in perfume-an-investigation-of/ pregnant women and their children in central Taiwan. 25. Hauser R., Calafat A.M.: Phthalates and human health. Chemosphere 2011;82:947-955. Occupat Environ Med 2005;62:806-818. 102 M.M. Dobrzyńska No 2 No 2 Phthalates - widespread occurrence and the effect on male gametes. 103

11. CIRC. Cosmetic Ingradient Review Committee. Final 26. Hauser R., Meeke J.D., Park S., Silva M.J., Calafat 40. Manojkumar V., Deepadevi K.V., Arun P., Nair K.G., plasticizers. Pediatrics 2005;111:1467-74. report on the safety assessment of dibutyl phthalate, A.M.: Temporal variability of urinary phthalate Lakshmi L.R., Kurup P.A.: Changes in the composition 53. Shields H.C., Weschler C.J.: Analysis of ambient dimethyl phthalate and diethyl phthalate. J Am Coll metabolite levels in men of reproductive age. Environ of erythrocyte membrane during storage of blood in di- concentrationsof organic vapors with a passive sampler. Toxicol 1985;4267-303. Health Perspect 2004;112:1734-1740. (2-ethyl hexyl) phthalate [DEHP] plasticized poly vinyl J Air Pollut Control Associat 1987;37(9):1039-1045. 12. De Moura S.M., Carrara D.M., Morita, Gimenez-Boscov 27. Health Canada, Risk assessment on diisononyl chloride (PVC) blood storage bags. Indian J Med Res 54. Sjőberg P., Lindquist N.G., Montin G., Ploen L.: Effects M.E.: Biodegradation of di(2-ethylhexyl) phthalate in phthalate in vinyl children’s product. Consumer 1999;109:157-163. of repeated intravenous infusions of the plasticizer a typical tropical soil. J. Hazard. Mater 2011;197:40-48. products safety Bureau, Ottawa, ON, Canada, 1998. 41. Mao W., Liu S., Zhang L., Song Y., Zhou P., Yong L., Sui di-(2-ethylhexyl) phthalate in young male rats. Arch 13. Diethyl phthalate. Concise International Chemical 28. Heudorf U., Mersch-Sudermann V., Angerer J.: H.: Dietary intake and risk assessment of diisononyl Toxicol 1985;58:78-83. Assessment Document 52. World Health Organization PhthalatesToxicology and exposure. Int J Hyg Environ phthalate (DINP) in Chinese population. Wei Sheng 55. Struciński P., Goralczyk K., Ludwicki J.K., Czaja K., Geneva, 2003. Health. 2007;210(5):623-634. Yan Jiu 2015;44(5):822-826. Hernik A., Korcz W.: Poziomy wybranych insektycydów, 14. Diisononyl phthalate (DINP). FactSheet National 29. Huang P-.C., Tien C-.J., Sun Y.-M., Hsieh C.-Y., 42. Nagorka R., Conrad A., Scheller C., Süssenbach B., polichlorowanych bifenyli, ftalanów i perfluorowanych Industrial Chemicals Notification and Assessment Lee C.-C.: Occurrence of phthalates in sediment Moriske H. J.: Weichmacher und Flammschutzmittel związków alifatycznych we krwi – badanie WWF Scheme (http://www.nicnas.gov.au). and biotarelationship to aquatic factors and the im Hausstaub – Teil 1Phthalate. Gefahrstoffe- Polska. [Levels of selected organochlorine insecticides, 15. Environmental Protection Agency. Technical Factsheet biota sediment accumulation factor. Chemosphere Reinhaltung der Luft, 2010;70(3):70-76. polychlorinated biphenyls, phthalates and perfluorinated ondi(2-ethyl)phthalate (DEHP). Office of Ground 2008;73:539-544. 43. Nakamiya K., Hashimoto S., Ito H., Edmonds J.S., aliphatic substances in blood – Polish WWF study]. Water and Drinking Water,Washington DC, 1998. 30. Kamrin M.A.: Phthalate risks, phthalate regulation and Yasuhara A., Morita M.: Microbial treatment of bis(2- Rocz Panstw Zakl Hig 2006;57(2):99-112 (in Polish) 16. European Chemicals Bureau, Risk Assessment Report public healthA review. J Toxicol Environ Health Part B ethylhexylo phthalate in polyvinyl chloride with [PMID17044303; http://www.ncbi.nlm.nih.gov/ on 1,2 Benzedicarboxylic acid, di-C8-11 bracnched 2009;12:157-174. isolated bacteria. J Biosci Bioeng 2005;99:115-119. pubmed/17044303]. alkyl esters, C9-rich, and di-isononyl phthalate 31. Kamrin M.A., Mayor G.H.: Diethyl phthalate — 44. NTP-CERHR. Monograph on the potential human 56. Tickner J., Hunt P., Rossi M., Haiama N., Lappe M.: (DINP). Institute for Health and Consumer Protection, a perspective. J Clin Pharmacol 1991;31(5):484-489. reproductive abd developmental effects of di-n-butyl The use of di-2-ethylhexyl phthalate in PVC medical European Union, 2003. 32. Kavlock R., Boekelheide K., Chapin R., Cunningham phthalate (DBP). NIH Publ. No 03-4486, 2003. devicesexposure, toxicity, and alternatives. The report 17. Faouzi A.., Dine T., Gressier B., Kambia K., Luyckx M., Faustman E., Foster P., Golub M., Henderson R., 45. Page B.D., Lacroix GM.: The occurrence of phthalate of Lowell Center for Sustainable Production University M., Pagniez D., Brunet C., Cazin M., Belabed A., Irwin Hinberg I., Little R., Seed J., Shea K., Tabacova ester and di-2-ethylhexyl adipate plasticizers in of Massachusetts Lowell, 1999. Cazin J.C.: Exposure of hemodialysis patients to di-2- S., Tyl R., Williams P., Zacharewski T.: NTP Center for Canadian packaging and food sampled in 1985–1989a 57. Tsumura Y., Ischimitsu S., Kaihara A., Yoshi K., ethylhexyl phthalate. Int J Pharm 1999;180(1):113-121. Evaluation of Risks to Human Reproductionphthalates survey. Food Addit Contam 1995;12(1):129-151. Tonogai Y.: Phthalates, adipates, citrarate and some of 18. FDA. U.S. Food and Drug Administration. Center for expert panel report on the reproductive and 46. Parks L.G., Ostby J.S., Lambright C.R., Abbott B.D., the other plasticizers detected in Japanese retail foodsa Food Safety and Applied Nutrition. Food and Drug developmental toxicity of di-n-butyl phthalate. Reprod Klinefelter G.R., Barlow N.J. Gray E.: The plasticizer survey. J Health Sci 2002;48(6):493-502. Administration Total Diet Study; summary of residues Toxicol. 2002;16:489-527. diethylhexyl phthalate induced malformations be 58. Wahl H.G., Hoffmann A., Häring H.U., Liebich H.M.: found ordered by pesticide market baskets 91-3-99- 33. Kavlock R., Barr D., Boekelheide K.,Breslin W., Breysse decreasing fetal testosterone synthesis during sexual Identification of plasticizers in medical products by 1. Office of Plant and Dairy Foods and Beverages. P., Chapin R. Gaido K., Hodgson E., Marcus M., Shea differentiation in the male rat. Toxicol Sci 2000;58:339- a combined direct thermodesorption-cooled injection Rockville, MD, 2001. K., Williams P.: NTP-CERHR expert panel updateon 349. system and gas chromatography–mass spectrometry. J 19. Frederiksen H., Aksglaede L., Soerensen K., the reproductive and developmental toxicity on di-(2- 47. Pie X.Q., Song M., Guo M., Mo F.F., Shen X.Y.: Chromatogr 1999;847:1–7. Skakkebaek N.E., Juul A., Andersson A.M.: Urinary ethylhexyl) phthalate. Reprod Toxicol 2006;22:291-399. Concentration and risk assessment of phthalates 59. Wan H.T., Leung P.Y., Zhao Y.G., Wei X., Wong excretion of phthalate metabolites in 129 healthy 34. Kelley K.E., Hernández-Díaz S., Chaplin E.L., Hauser present in indoor air from newly decorated apartments. M.H., Wong C.K.C.: Blood plasma concentrations Danish children and adolescents:estimation of daily R., Mitchell A.A.: Identification of phthalates in Atmos. Environ 2013;68:17-23 of endocrine disrupting chemicals in Hong Kong phthalate intake. Environ Res 2011;111(5):656-663. medications and dietary supplement formulations in 48. Pollack G.M., Buchanan J.F., Slaughter R.L., populations. J Hazard Mat 2013;261:763-69. 20. Fromme H., Lahrz T., Piloty M., Gebhart H., Oddoy the United States and Canada. Environ Health Perspect. Kohli R.K., Shen DD.: Circulating concentrations 60. Wittassek M., Angerer J.: Phthalates metabolism and A, Rüden H.: Occurrence of phthalates and musk 2012;120(3):379-84. of di(2-ethylhexyl) phthalate and its de-esterified exposure. Int J Androl 2008;3:1131-1138. fragrances in idoor air and dust from apartments 35. Kim Y-H., Lee J., Moon S.-H.: Degradation of phthalic-acid products following plasticizer exposure 61. Wittassek M., Wiesmüller G.A., Koch H.M., Eckard and kindergartens in Berlin (Germany). Indoor Air an endocrine disrupting chemical, DEHP [di-(2- in patientsreceiving hemodialysis.Toxicol Appl R., Dobler R., Müller J., Angerer J., Schlüter C.: 2004;14:188-195. ethylhexyl)phthalate] by Fusarium oxysporium f. sp. Pharmacol 1985;79:257-267. Internal phthalate exposure over the last two decades 21. Fromme H., Gruber L., Seckin E., Raab U., Zimmermann pisi cutinase. Appl Microbiol Biotechnol 2003;63:75- 49. RAR. Risk Assessment Report (2004) Benzyl butyl – a retrospective human biomonitoring study. Int J Hyg S., Kiranoglu M., Schlummer M., Schweiger U., Smolic 80. phthalate, Draft March. http://ecb.jrc.it/ Environ Health 2007;210:319-333. S., Vőkei W., HBMnet: Phthalates and their metabolites 36. Koniecki D., Wang R., Moody R.P., Zhu J.: Phthalate 50. Roy J.R., Chakraborty S., Chakraborty T.R.: Estrogen- 62. Wypych G.: Handbook of plasticizers. ChemTech in breast milk – results from the Bavarian monitoring in cosmetic amd personal care productsConcentrations like endocrine disrupting chemicals affecting puberty Publishing, Ontario, Canada, 2004. of breast milk (BAMBI). Environ Int 2011;37(4):715- and possible dermal exposure. Environ Res in humans – a review. Med Sci Monit 2009;15 63. Zhang Y.H., Chen B.H., Zheng L.X., Wu X.Y.: Study 722. 2011;111:329-336. (6):RA137-145. on the level of phthalate in human biological samples. 22. Ghorpade N., Mehta V., Khare M.: Toxicity study of 37. Koo H.J., Lee B.M.: Estimated exposure to phthalates 51. Sharman M., Read W.A., Castle L., Gilbert J.: Levels Zhonghua Yu Fang Yi Xe Za Zhi 2003;37(6):429-34. diethyl phthalate on freshwater fish Cirrhina mrigala. in cosmetics and risk assessment. J Toxicol Environ of di(2-ethylhexyl)phthalate and total phthalate esters 64. Zolfaghari M., Drogui P., Seyhi B., Brar S.K., Bueina Ecotoxicol Environ Safety 2002;53(2):255-258. 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REVIEW ARTICLE

EFFECT OF PHYSICAL ACTIVITY ON IGF-1 AND IGFBP LEVELS IN THE CONTEXT OF CIVILIZATION DISEASES PREVENTION

Marta Majorczyk1*, Danuta Smoląg2

1Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Cracow, Poland 2 Faculty of Medicine, Jagiellonian University Collegium Medicum, Cracow, Poland

ABSTRACT Background. Insulin-like growth factor 1 (IGF-1) is known as somatomedin C. This polypeptide hormone is functionally and structurally similar to insulin. IGF-1 effects on tissue by the IGF-1R and the insulin-like growth factor-binding protein also known as IGFBP. Abnormal IGF-1 and IGFBP signaling are positively correlated with a high risk of selected civilization diseases development. Physical inactivity is a one of the main causes of majority of chronic diseases and it is associated with eg. IGF-1 and IGFBPs level. Objective. The aim of the study was to explanation the effect of physical activity on IGF-1 and its binding protein – IGFB- Ps concentration in the context of selected civilization diseases prevention. The review of clinical trial. Material and Methods. The review of articles had published in databases: MEDLINE, EMBASE, Scopus and Web of Science until December 2015. The selected prospective studies about the effect of exercise on IGF-1 level and its binding protein IGFBP in the context of selected civilization diseases prevention were collected. Results. The majority of the included studies indicate that mechanical loading is a key mechanism linking IGF-1/IGFBPs concentration and selected chronic diseases development. The duration and intensity of physical activity have a significant impact on IGF-1 and IGFBP serum. The highest concentration of IGF-1 in serum was after eccentric training. “Overtraining” increases unfavorable and unbound IGF-1 levels and contributes to the increased incidence of hormone-cancer and osteoarthritis. Conclusions. Irregularity of the GH/IGF-1 axis may affect on the development of rheumatic diseases, cardiovascular diseases (regulate cardiac growth and metabolism) and metabolic syndrome.

Key words: insulin-like growth factor 1, physical activity, rheumatic diseases, cardiovascular diseases

STRESZCZENIE Wprowadzenie. Insulinopodobny czynnik wzrostu 1 (IGF-1, insulin-like growth factor 1), zwany inaczej somatomedyną C. IGF-1 to hormon polipeptydowy, który funkcjonalnie i strukturalnie jest podobny do insuliny. IGF-1 oddziałuje na tkanki za pomocą receptora IGF-1R i białek wiążących IGFBP. Nieprawidłowości w produkcji IGF-1 i IGFBP są związane z wysokim ryzykiem rozwoju wielu chorób cywilizacyjnych. Brak aktywności fizycznej i związany z tym nieprawidłowy poziom krążącego IGF-1 przyczyniają się do rozwoju wielu przewlekłych chorób. Cel. Celem badania była próba wyjaśnienia wpływu zmian stężenia IGF-1 i jego białka wiążącego IGFBP pod wpływem aktywności fizycznej na profilaktykę chorób cywilizacyjnych na podstawie analizy badań klinicznych. Materiał i metody. Dokonano przeglądu artykułów opublikowanych do grudnia 2015 i zamieszczonych w bazach: MED- LINE, EMBASE, Scopus i Web of Science. Zebrano najnowsze badania prospektywne dotyczące znaczenia wysiłku fizycznego dla utrzymania prawidłowego poziomu IGF-1 i jego białka wiążącego IGFBP w kontekście profilaktyki wybranych chorób cywilizacyjnych. Wyniki. Większość analizowanych badań wskazuje, że aktywność fizyczna regulując stężenie IGF-1 i IGFBPs wpływa na rozwój wybranych chorób cywilizacyjnych. Długość trwania i intensywność wysiłku fizycznego ma istotne znaczenie dla stężenia IGF-1 i IGFBPs. Największy wzrost IGF-1 obserwuje się w wyniku escentrycznej pracy mięśni. Stan „prze- trenowania” powoduje wzrost niekorzystnego, niezwiązanego IGF-1 w surowicy. Wzrost poziomu IGF-1 niezwiązanego przyczynia się do zwiększonej zachorowalności na nowotwory hormonozależne i chorobę zwyrodnieniową stawów. Wnioski. Nieprawidłowości osi GH/IGF-1 mogą wpływać na rozwój chorób reumatycznych, chorób układu krążenia i zespołu metabolicznego.

Słowa kluczowe: IGF-1, aktywność fizyczna, choroby reumatyczne, schorzenia sercowo-naczyniowe

*Correspoonding author: Marta Majorczyk, Zakład Fizjologii Medycznej, Wydział Nauk o Zdrowiu, Uniwersytet Jagielloński Collegium Medicum, ul. Michałowskiego 12, 31-126 Kraków, phone: +48 513048656; e-mail: [email protected]

REVIEW ARTICLE

EFFECT OF PHYSICAL ACTIVITY ON IGF-1 AND IGFBP LEVELS IN THE CONTEXT OF CIVILIZATION DISEASES PREVENTION

Marta Majorczyk1*, Danuta Smoląg2

1Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Cracow, Poland 2 Faculty of Medicine, Jagiellonian University Collegium Medicum, Cracow, Poland

Key words: insulin-like growth factor 1, physical activity, rheumatic diseases, cardiovascular diseases

Słowa kluczowe: IGF-1, aktywność fizyczna, choroby reumatyczne, schorzenia sercowo-naczyniowe

© Copyright by the National Institute of Public Health - National Institute of Hygiene 106 M. Majorczyk, D. Smoląg No 2 No 2 Effect of physical activity on IGF-1 and IGFBP levels in the context of civilization diseases prevention 107

INTRODUCTION MATERIALS AND METHODS IGF-1 level after moderate-intensity aerobic exercise or mechanism of physical activity against several sites strength training [43]. Several of clinical studies have of cancer [71]. Genes related to the IGF pathway Civilization diseases are an chronic diseases. Search strategy. The review of published articles shown increased [35], decreased [14], or unchanged expression is modified by overweight and a lack of 70% of all deaths in the U.S. are the patients with in databases: MEDLINE, EMBASE, Scopus and Web levels of IGF-I after endurance or resistance training physical activity that increases colorectal cancer risk chronic diseases. These diseases are associated with of Science and contained. The recent prospective [17]. Another study showed that resistance exercises [30]. Women who engage in regular physical activity many limitations of daily living among approximately studies about the effect of exercise on IGF-1 level changes concentrations of IGFBPs that influence on have a reduced risk for both colon and breast cancers 25 million people in U.S. [10]. and its binding protein IGFBP in the context of biological activity of IGF-1 [37]. It is interesting that if compared with inactive women. The hypothesis is Insulin-like growth factor 1 (IGF-1, insulin- prevention of civilization diseases were collected. IGF-1 level is higher after marathon run, than after one that reduction of circulating free IGF-1 and increasing like growth factor 1) is known as somatomedin While searching the database, the following key words day the IGFBP-1 level had returned to baseline [34]. IGFBP-3 level decrease breast and colon cancer risk C. IGF-1 belongs to polypeptide hormones, which are were used: insulin-like growth factor 1, physical IGF-1 stimulates the proliferation and differentiation [6]. The combination of a low fat diet and physical functionally and structurally similar to the insulin. IGF-1 activity, osteoarthritis, rheumatoid arthritis, metabolic of stem cells which are located at the periphery of activity reduces IGF serum concentration and increase is metabolic mediates of growth hormone (GH). Growth syndrome, insulin tolerance, cardiovascular diseases. muscle fibers and called satellite cells [22]. IGFBP-1 level. It effects cancer cell growth reduction hormone is produced by the anterior pituitary gland, is Publications until December 2015 were included. Japanese study evaluating the effect of a low- and induces apoptosis pathway in LNCaP prostate essential for growth in the postnatal period. Growth Only English and Polish articles or foreign language intensity exercise program on circulating levels cancer cells. Cancer prevention is highly dependent hormone affects the tissue by the IGF1. IGF-1 stimulates articles with English abstract were included. of IGF-I, IGFBP-1, and IGFBP-3, in previously on the intensity and type of training. High intensity all growth processes. Researches show that IGF-1 can Articles selection. All prospective studies and sedentary males. After aerobic training, insulin exercise stimulate to acute increase in circulating be synthesized in vivo and in vitro in some tissues, but cross-sectional studies of the effects of physical activity sensitivity improved by 20%, decreased the circulating IGF-1 concentration and it contributes to the cancer the main IGF-1 synthesizing organ is the liver. IGF-1 is on IGF-1 and IGFBP levels in context of prevention of levels of IGF-I by 9% (p<0,01) and IGFBP-1 levels growth. Low or moderate intensity cause IGF-I level secreted from hepatocytes into the serum, where it binds the selected civilization diseases were selected from increased by 16% (p<0,05) while IGFBP-3 levels reduction [36]. Researchers have proposed several to insulin-like growth factor binding protein –IGFBP. the search results and included in this review. Case were not changed. The study involved 14 healthy men biological mechanisms to explain the relationship Six types of IGFBPs is known. In human, IGF-binding reports were excluded. Only some of meta-analyses (22.6+/-0.5 years) participated in cycle ergometer between physical activity and breast cancer protein-1 (IGFBP-1) is the basis. IGFBPs play an and systematic reviews were included. In conclusion, training at lactate threshold intensity for 60 min/ development. Physical activity may prevent tumor integral role in involving storage of IGF-1 by extending the 73 publications was included in this review. The day, 5 days/week for 6 weeks. Higher pre-training development by lowering hormone levels, particularly the period of its disintegration and protect tissues from publications identified include 69 published as full IGF-1 level was associated with greater decline in in premenopausal women; low level of insulin and undesirable effects of IGF-1. These proteins modulate the articles and 4 abstracts. IGF-1 after training. [51]. insulin-like growth factor I (IGF-1), improve the cellular response to IGF [1, 14, 16]. IGFBP-3 regulates immune response and weight maintenance to avoid growth independently of IGF-1 [2, 14, 16]. IGFBP-3 RESULTS IGF-1 and cancer development a high body mass index (BMI) [28]. acting (independently of IGF-1) can bind specifically to the proteins or membrane receptors. In the central region IGF-1 levels and several types of exercises IGF-1 is a central regulator of somatic, anabolic IGF-1, physical exercises and rheumatic diseases of molecule IGFBP-3 is a fragment capable of binding to (growth) processes, metabolism, and cellular the membrane receptor in breast cancer cells [3, 14]. IGF-1 is not only related to growth hormone. proliferation, differentiation and survival [60]. On Several studies show that IGF-1 has a key role IGF-1 plays a key role in exercises associated Growth hormone (GH) stimulates IGF in skeletal the one hand, some studies indicate that IGF-1 has in the maintenance of a cartilage metabolism. IGF-1 muscle growth and development. IGF-I response muscle, promoting satellite cell activation, proliferation important role in neoplasia regulation [21, 63]. In stimulates the synthesis and decreases the degradation is related to the intensity and duration of exercise. and differentiation [18]. It results increased levels of study with mice (n=156), the low IGF1 concentration of proteoglycans in cartilage in laboratory tests [68]. After short-term (20 min) ergometer exercise reported IGF-1 during exercise [15]. Reduced physical activity inhibits the growth of colon cancer and reduce Dynamic exercise normalize IGF-1 level among increased IGF-I but after 3 h endurance exercise, IGF- may influence on decreasing IGF-1. Myostatin and cancer spreading [72]. On the other hand, IGF-1 was patients with rheumatoid arthritis (RA). It has 1 level was decreased and no change after interval insulin like growth factor-I plays a key role in regulation identified in very early phase of tumor development a positive impact on their health by lowering indicators training. In the same study, IGFBP-3 seems to increase of muscle homeostasis. The study comparing the types but they did not confirm that IGF-1 was reason of this of disease activity and pain [44, 68]. Abnormalities in during exercise [47]. This suggests that more prolonged of training among Sprague-Dawley rats indicates that cancer [40]. It suggests that IGF-1 level in the blood IGF-1 level are associated with dwarfism in children, exercise causes decreasing in total IGF-1 level. In the higher concentration of IGF-1 in serum was after of people may be an early important indicator that can muscle disorders, lipids and bone mineral density in study involving children has been shown that exercise eccentric training (Ecc) and isometric training (Iso) confirm a tumor is developing in the body. The studies adults (BMD). Optimal training speeds up the growth stimulates anabolic components like GH-IGF-1 axis. than after concentric (Con) training (p < 0.05) [19, that compared the levels of tumor markers and the process, improves the structure of trabecular bone and On the other side, exercise increases catabolic pro- 42]. Studies among people confirmed that total serum level of IGF in serum, demonstrated the relationship bone chemical composition (increased mineral salts) inflammatory cytokines such as interleukin-6 (IL-6), IGF-1 concentrations increase with endurance and between the risk of colorectal cancer and levels of [41]. In the study of the relation between serum IGF- IL-1 and tumor necrosis factor-α (TNF-α) what could strength exercise [13, 48]. The level of IGF should be IGF-I and IGFBP-3 in serum [27, 56, 63]. Increased 1 and BMD, 16-wk strength training program was be associated with rheumatic diseases development. considered as locally (in tissue) and peripherally (in circulating concentrations of insulin-like growth used in the group 61+/-1 yr and showed that strength This balance between anabolic and catabolic serum). In the case of a local increase (ex. muscle), factor 1 (IGF-1) are associated with increased risks for training can increase femoral neck BMD and this components depends on individual predisposition IGF-1 constantly increase after exercise, regardless of colorectal, prostate, and premenopausal breast cancers affect does not appear to be accompanied by changes to the training load and to tolerate it. Hypokinesia the length and intensity of exercise. However results [57, 63]. Higher concentrations of IGF binding protein in anabolic hormones or markers of bone formation or excessive exercise too much burden the body and for peripheral IGF-1 have been more differential 3 (IGFBP-3) are associated with increased risk of and resorption. There are no significant changes in GH cause adverse hormonal changes that affect the body (increases, decreases and no changes) [49, 50, 61]. premenopausal breast cancer [57]. There is many and IGF-1 [54, 58]. systems [45]. Moreover, IGFBP-3 level changes in serum following scientific evidence indicates that apart from IGF and In the Snow et al. study, they examine the levels The aim of this study was to review the literature exercise also are differential [62]. Some studies have IGFBPs levels, a diet and sedentary lifestyle contributes of IGF-1 and BMD in gymnasts and runners adults. about correlation between IGF-1 and IGFBPs level, shown that circulating levels of IGFBP-1 and IGFBP-3 to an increased risk of hormone-cancers development, Excessive training load causes an increase in IGF-1 physical activity and selected civilization diseases are also modulated by several types of exercise including colon, prostate, breast, and endometrial and IGFBP-3 level. Lean and bone mass at the hip and development. [18, 40]. Another study demonstrates no effects in cancers [67, 70]. IGF-I participates in the protective spine were higher in gymnasts and runners compared 108 M. Majorczyk, D. Smoląg No 2 No 2 Effect of physical activity on IGF-1 and IGFBP levels in the context of civilization diseases prevention 109 to control group [64]. Optimal physical activity in the insulin resistance. These cytokines have an inflammatory CONCLUSIONS L., Zelek L.: Role of physical activity and sport in school age is a strategic action that leads to increase effect on hepatocytes. IGF-1 production in liver is oncology: scientific commission of the National bone mass and prevent the osteopenia and osteoporosis disrupted and the level is reduced [33]. IGF-1 has The majority of the included studies indicate that Federation Sport and Cancer CAMI. Crit Rev Oncol development in adulthood. This physical activity anti-inflammatory effects and decreases expression of mechanical loading is a key mechanism linking IGF- Hematol. 2015;94(1):74-86. must be optimal and not leads to overloading of the proinflammatory cytokines [66]. Type 2 diabetes mellitus 1/IGFBPs concentration and selected chronic diseases 7. Buckwalter J.A., Lane N.E.: Athletics and osteoarthritis. Am. J. Sports Med. 1997;25(6): 873-881. musculoskeletal system [41]. GH-IGF-1 system works (T2DM) is associated with metabolic disorders and development. The duration and intensity of physical 8. Burchardt P., Żurawski J., Nowak W.: Istotnie wyższe locally at the epiphyseal plate and it is essential for chronic inflammation. Exercises have anti-inflammatory activity have a significant impact on IGF-1 and IGFBP poziomy insulinopodobnego czynnika wzrostu 1 normal growth. Over-activity among children brings effects by IGF-1 level and may decrease proinflammatory serum. The highest concentration of IGF-1 in serum u pacjentów z zaawansowaną miażdżycą naczyń them too fast ossification of the epiphysis which cytokines inT2DM [32]. In cross-sectional study was after eccentric training. Physical activity increase wieńcowych. Nowiny Lekarskie 2010;79(4):273–278. inhibits growth, reduces mobility and causes premature consisted of 186 Caucasian nondiabetic subjects reported IGF-1, IGFBPs levels and has a protective influence 9. Cassilhas R.C., Antunes H.K., Tufik S., de Mello M.T.: and osteoarthritis. Over-physical activity is associated inverse relationship between plasma IGF-1 and IL-6 and on IHD and MI development. IGF-1 is one of the Mood, anxiety, and serum IGF-1 in elderly men given with numerous injuries. The most prevalence of risk of having MetS. Higher IL-6 and lower IGF-1 levels leading growth factors implicated in bone remodeling 24 weeks of high resistance exercise. Percept Mot Skills epiphyseal growth plate injuries is to children ages 10 correlate with increased risk of MetS development and and moderate strength training influence positively 2010;110(1):265-276. to 16 years [24, 26]. Over-physical activity is not also related diseases: visceral obesity and insulin resistance on increases bone density. “Overtraining” increases 10. Centers for Disease Control and Prevention Chronic beneficial for middle aged and older people. Sports [65]. The another cross-sectional study with random unfavorable and unbound IGF-1 levels and leads Disease Prevention and Health Promotion. 2011. with repetitive high level of impact and torsional subsample (n=922) of the Cardiovascular Health Study to hormone-cancer development and osteoarthritis. Available at: http://www.cdc.gov/chronicdisease/index. loading cause cartilage degeneration and osteoarthritis (CHS) had a similar results [55]. Irregularity of the GH / IGF-1 axis may affect on the htm 11. Chao-Hung L., Tsung-Jung H., Wei-Wen K, Day but moderate habitual exercises inhibits osteoarthritis IGF1 has important survival roles in myocardial development of rheumatic diseases, cardiovascular C.H., Pai P.Y., Chung L.C., Liao P.H., Lin F.H., Wu development [7]. The study of 174 healthy, inactive, cells to promote it survival. IGF-1 survival pathway diseases (regulate cardiac growth and metabolism) E.T., Huang C.Y.: Exercise training enhanced SIRT1 pubertal children aged 11–15 years explained that in the young rat’s heart can be increased through and metabolic syndrome. Physical inactivity is a one longevity signaling replaces the IGF1 survival pathway hormonal variations and IGF1 are associated with exercise training [11]. IGF-1 also influence on cardiac of the reason of civilization diseases. Moderate, to attenuate aging-induced rat heart apoptosis. 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IGF-1 production in liver is oncology: scientific commission of the National bone mass and prevent the osteopenia and osteoporosis disrupted and the level is reduced [33]. IGF-1 has The majority of the included studies indicate that Federation Sport and Cancer CAMI. Crit Rev Oncol development in adulthood. This physical activity anti-inflammatory effects and decreases expression of mechanical loading is a key mechanism linking IGF- Hematol. 2015;94(1):74-86. must be optimal and not leads to overloading of the proinflammatory cytokines [66]. Type 2 diabetes mellitus 1/IGFBPs concentration and selected chronic diseases 7. Buckwalter J.A., Lane N.E.: Athletics and osteoarthritis. Am. J. Sports Med. 1997;25(6): 873-881. musculoskeletal system [41]. GH-IGF-1 system works (T2DM) is associated with metabolic disorders and development. The duration and intensity of physical 8. Burchardt P., Żurawski J., Nowak W.: Istotnie wyższe locally at the epiphyseal plate and it is essential for chronic inflammation. Exercises have anti-inflammatory activity have a significant impact on IGF-1 and IGFBP poziomy insulinopodobnego czynnika wzrostu 1 normal growth. Over-activity among children brings effects by IGF-1 level and may decrease proinflammatory serum. The highest concentration of IGF-1 in serum u pacjentów z zaawansowaną miażdżycą naczyń them too fast ossification of the epiphysis which cytokines inT2DM [32]. In cross-sectional study was after eccentric training. Physical activity increase wieńcowych. Nowiny Lekarskie 2010;79(4):273–278. inhibits growth, reduces mobility and causes premature consisted of 186 Caucasian nondiabetic subjects reported IGF-1, IGFBPs levels and has a protective influence 9. Cassilhas R.C., Antunes H.K., Tufik S., de Mello M.T.: and osteoarthritis. Over-physical activity is associated inverse relationship between plasma IGF-1 and IL-6 and on IHD and MI development. IGF-1 is one of the Mood, anxiety, and serum IGF-1 in elderly men given with numerous injuries. The most prevalence of risk of having MetS. Higher IL-6 and lower IGF-1 levels leading growth factors implicated in bone remodeling 24 weeks of high resistance exercise. Percept Mot Skills epiphyseal growth plate injuries is to children ages 10 correlate with increased risk of MetS development and and moderate strength training influence positively 2010;110(1):265-276. to 16 years [24, 26]. Over-physical activity is not also related diseases: visceral obesity and insulin resistance on increases bone density. “Overtraining” increases 10. Centers for Disease Control and Prevention Chronic beneficial for middle aged and older people. Sports [65]. The another cross-sectional study with random unfavorable and unbound IGF-1 levels and leads Disease Prevention and Health Promotion. 2011. with repetitive high level of impact and torsional subsample (n=922) of the Cardiovascular Health Study to hormone-cancer development and osteoarthritis. Available at: http://www.cdc.gov/chronicdisease/index. loading cause cartilage degeneration and osteoarthritis (CHS) had a similar results [55]. Irregularity of the GH / IGF-1 axis may affect on the htm 11. Chao-Hung L., Tsung-Jung H., Wei-Wen K, Day but moderate habitual exercises inhibits osteoarthritis IGF1 has important survival roles in myocardial development of rheumatic diseases, cardiovascular C.H., Pai P.Y., Chung L.C., Liao P.H., Lin F.H., Wu development [7]. The study of 174 healthy, inactive, cells to promote it survival. 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Cancer Received: 18.09.2015 Biology and Medicine 2004;229(3):240–246. Minimally invasive sampling of transdermal body Epidemiol Biomarkers Prev 2002;11:1597– 1604. Accepted: 17.03.2016 110 M. Majorczyk, D. Smoląg No 2 No 2 Effect of physical activity on IGF-1 and IGFBP levels in the context of civilization diseases prevention 111

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ORIGINAL ARTICLE

VALIDATION OF THE ANALYTICAL METHOD FOR THE SIMULTANE- OUS DETERMINATION OF SELECTED POLYBROMINATED DIPHENYL ETHERS, POLYCHLORINATED BIPHENYLS AND ORGANOCHLORINE PESTICIDES IN HUMAN BLOOD SERUM BY GAS CHROMATOGRAPHY WITH MICRO-ELECTRON CAPTURE DETECTOR

Małgorzata Matuszak, Maria Minorczyk*, Katarzyna Góralczyk, Agnieszka Hernik, Paweł Struciński, Monika Liszewska, Katarzyna Czaja, Wojciech Korcz, Monika Łyczewska, Jan K. Ludwicki

National Institute of Public Health – National Institute of Hygiene Department of Toxicology and Risk Assessment, Warsaw, Poland

ABSTRACT Background. Polybrominated diphenyl ethers (PBDEs) as other persistent organic pollutants like polychlorinated biphenyls (PCBs) and organochlorine pesticides (OCPs) pose a significant hazard to human health, mainly due to interference with the endocrine system and carcinogenetic effects. Humans are exposed to these substances mainly through a food of animal origin. These pollutants are globally detected in human matrices which requires to dispose reliable and simple analytical method that would enable further studies to assess the exposure of specific human populations to these compounds. Objective. The purpose of this study was to modify and validate of the analytical procedure for the simultaneous determination of selected PBDEs, PCBs and OCPs in human blood serum samples. Material and Methods. The analytical measurement was performed by GC-µECD following preparation of serum samples (denaturation, multiple extraction, lipid removal). Identity of the compounds was confirmed by GC-MS. Results. The method was characterised by the appropriate linearity, good repeatability (CV below 20%). The recoveries ranged from 52.9 to 125.0% depending on compound and level of fortification. The limit of quantification was set at 0.03 ng -1mL of serum. Conclusions. The modified analytical method proved to be suitable for the simultaneous determination of selected PBDEs, PCBs and OCPs in human blood serum by GC-µECD with good precision.

Key words: validation method, chromatography, human serum, PCBs, PBDEs, OCPs

STRESZCZENIE Wprowadzenie. Obecność w środowisku polibromowanych difenyloetrów (PBDE), podobnie jak innych trwałych zanie- czyszczeń organicznych, do których zaliczane są polichlorowane bifenyle (PCB) i pestycydy chloroorganiczne stanowi istotne zagrożenie dla zdrowia ludzi. Substancje te mają m.in. zdolność do zaburzania równowagi układu hormonalnego i wywoływania efektów nowotworowych. Głównym źródłem narażenia ludzi na te substancje jest żywność, głównie po- chodzenia zwierzęcego. Związki te wykrywane są w wielu matrycach biologicznych, co stwarza potrzebę dysponowania wiarygodną i prostą metodą analityczną, która umożliwiłaby ocenę narażenia różnych populacji na te związki. Cel badań. Celem pracy była modyfikacja i walidacja metody analitycznej przydatnej do jednoczesnego oznaczania stężeń wybranych kongenerów PBDE i PCB, a także pestycydów chloroorganicznych w surowicy krwi u ludzi. Materiał i metody. Oznaczanie stężeń wybranych związków prowadzono za pomocą GC-µECD po uprzednim przygo- towaniu próbki surowicy (denaturacja, kilkukrotna ekstrakcja, usunięcie tłuszczu). Potwierdzanie tożsamości związków wykonywano z zastosowaniem GC-MS. Wyniki. Metoda charakteryzuje się odpowiednią liniowością, dobrą powtarzalnością (CV poniżej 20%). Uzyskane warto- ści odzysków mieściły się w zakresie od 52,9 do 125% w zależności od badanej substancji i poziomu fortyfikacji. Granica oznaczalności dla wszystkich badanych związków wynosi 0,03 ng mL-1 surowicy. Wnioski. Zaprezentowana metoda analityczna została uznana za odpowiednią do jednoczesnego oznaczania wybranych kongenerów PBDE, PCB oraz pestycydów chloroorganicznych w surowicy krwi metodą GC-μECD.

Słowa kluczowe: walidacja metody, chromatografia, surowica ludzka, PCB, PBDE, pestycydy chloroorganiczne

*Corresponding author: Maria Minorczyk, Department of Toxicology and Risk Assessment, National Institute of Public Health – National Institute of Hygiene, Chocimska 24, 00-791 Warsaw, Poland, phone: +48 22 5421 370, fax: +48 22 8497441, e-mail: [email protected]

ORIGINAL ARTICLE

Małgorzata Matuszak, Maria Minorczyk*, Katarzyna Góralczyk, Agnieszka Hernik, Paweł Struciński, Monika Liszewska, Katarzyna Czaja, Wojciech Korcz, Monika Łyczewska, Jan K. Ludwicki

National Institute of Public Health – National Institute of Hygiene Department of Toxicology and Risk Assessment, Warsaw, Poland

Key words: validation method, chromatography, human serum, PCBs, PBDEs, OCPs

Słowa kluczowe: walidacja metody, chromatografia, surowica ludzka, PCB, PBDE, pestycydy chloroorganiczne

© Copyright by the National Institute of Public Health - National Institute of Hygiene 114 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 No 2 Method for determination of PBDEs, PCBs, OCPs in blood by GC-µECD. 115

INTRODUCTION the levels of these compound in humans show ether), BDE-153 (2,2’,4,4’,5,5’-hexabromodiphenyl decreasing tendency during the last decades [21]. ether), BDE-154 (2,2′,4,4′,5,6′-hexa-bromodiphenyl Humans are constantly exposed to the large However due to widespread use in the past, PCBs are ether), BDE-183 (2,2′,3,4,4′,5′,6-hepta-bromodiphenyl number of ubiquitous chemicals. Persistent organic still routinely detected in human tissues, breast milk, ether), five PCB congeners: CB-77 (3,3’,4,4’-tetra- pollutants (POPs) are chemical substances, that have blood, in wildlife and environmental samples [14]. chlorobiphenyl), CB-138 (2,2’,3,4,4’,5’-hexachlorobi- been identified as environmental contaminants with Organochlorine pesticides (OCPs) are another phenyl), CB-153 (2,2’,4,4’,5,5’-hexachlorobiphenyl), global distribution. Because of their lipophilicity environmental pollutants with potential toxic effects CB-170 (2,2’,3,3’,4,4’,5-heptachlorobiphenyl), CB-180 and persistent in environment POPs bioaccumulate on humans and wildlife. OCPs, such as DDT and its (2,2’,3,4,4’,5,5’-heptachlorobiphenyl) and the follow- in fat tissue and biomagnify in food chains [22, 35]. metabolites DDE and DDD, have been classified ing organochlorine pesticides: HCB (hexachloroben- Exposure to POPs may be associated with a wide as possible human carcinogens (Group 2A) [30]. zene), β-HCH (beta-hexachlorocyclohexane), γ-HCH variety of human health disorders. Many of them have Humans are exposed to these chemicals, like others (gamma-hexachlorocyclohexane), p,p’-DDE (dichlo- been classified as endocrine disruptors (EDs) due to chalogenated POPs, through food chain, especially rodiphenyldichloroethylene), p,p’-DDT (dichlorodiphe- their interference with normal hormone function [33, products which contain fat. Some of OCPs such as HCB, nyltrichloroethane), and p,p’-DDD (dichlorodiphenyldi- 36, 37]. POPs include, among others: polychlorinated hexachlorocyclohexane (HCH) and DDT were among chloroethane). biphenyls (PCBs), hexa-, hepta- and octa- brominated oldest, and most environmentally destructive pesticides diphenyl ethers, hexachlorobenzene (HCB), isomer used in the past [7, 19]. Most of these compounds have Chemicals β-hexachlorocyclohexane (β-HCH) and DDT, been prohibited for use due to their toxic effects [20], The following reagents and solvents were used: including its metabolites – DDD and DDE, etc. but due to its low price and good efficacy, some OCPs, n-hexane for organic trace analysis (Merck), tert-butyl PBDEs belong to brominated flame retardants such as DDT, are still used in malaria endemic countries. methyl ether (MTBE) obtained from Merck, 2-propanol (FRs), which since 1970s have been added to A wide range of analytical methods has been (POCH), KCl (Merck), concentrated sulfuric acid (Merck) variety of commonly used products, to reduce the developed for determination of POPs in human and 6M hydrochloric acid (Merck). The following certified development of fire [5, 13, 39]. Theoretically there specimens [1, 31]. Due to similarities in physicochemical standards were used: BDE-28, BDE-47, BDE-99, BDE- are 209 possible PBDEs, so called congeners, some properties of these chemicals (e.g. hydrophobicity, 100, BDE-153, BDE-154, BDE-183 dissolved in n-nonane Figure 1. Diagram for preparation of blood serum sample of them are present in variety of consumer products, lipophilicity, relatively good thermal stability), some purchased from the Cambridge Isotope Laboratories; PCBs such as electronics (TV-sets, computers), household steps in various ‘traditional’ analytical methods are (CB-77, CB-153, CB-138, CB-180, CB-170) purchased Chromatographic conditions appliances [12], foam padding used for mattresses, almost identical [23, 34]. Generally, analytical methods from the Ultra Scientific;p,p’ -DDD, p,p’-DDT, p,p’-DDE, The gas chromatography (GC) analysis was furniture and carpet production, paints and plastics include sample preparation: extraction (for example β-HCH and γ-HCH obtained from the Institute of Organic performed using an Agilent Technologies 6890N [26]. PBDE concentrations have decreased in Europe liquid-liquid extraction or solid-phase extraction) and Industrial Chemistry; hexachlorobenzene purchased from GC, equipped with an Agilent Technologies 7683B during the last decades [4, 28] but they are still clean-up of extracts which are followed by analysis with Dr. Ehrenstorfer GmbH. autosampler, a micro-electron capture detector (µECD) being globally detected in food, household dust and suitable detector. For identification and quantification and a PTV split-splitless injector operating in the human matrices [8, 14]. Humans are mainly exposed most researchers used GC-MS with electron capture Standard solutions splitless mode. We used a HP-5 Phenyl Methyl Siloxane to these pollutants through food intake, especially negative ionization (ECNI) and electron ionization (EI) All of certified standards were diluted in n-hexane. (30 m x 250 µm x 0.25 µm) column with helium as food of animal origin [6]. Toxicological studies on or GC-ECD. The latter technique offers great sensitivity From the individual standard solutions the stock a carrier gas at a constant flow rate of 3.7 mL min-1, and animal models suggest that the exposure to PBDEs is and selectivity, however confirmatory techniques are solutions and working solution were prepared which nitrogen as a make-up gas at a flow rate of 60 mL min-1. associated with endocrine disruption, increased risk of required. For determination of PBDEs and PCBs LC- contained all of the analysed compounds. The injector temperature ramp programme in ‘solvent reproductive risk disorders, immunotoxic effects and MS technique can be used and it is the best analytical vent’ mode was: 40ºC (0.2 min) – 700ºC min-1 – 220ºC behavioral problems [3, 9]. tool when sample volume is small [2, 32]. However for Sample preparation (1 min) – 700ºC min-1 – 260ºC (2 min). The GC oven Similar adverse effects on human endocrine routine analysis is needed fast, simple and inexpensive A modified version of the sample preparation temperature ramp programme mode was: 70ºC (1.7 systems have also polychlorinated biphenyls (PCBs) method for determination of this compounds in blood method described by Hovander et al. [16] was applied. min.) – 30ºC min-1 – 210ºC (0 min.) – 5ºC min-1 – 300ºC and their metabolites, even at low levels [10, 18], samples. The modification included omitting of the first step of (5 min). The temperature of detector was set at 250ºC. some PCBs have recently been classified by the The objective of this study was to optimize and clean-up with methanol:chloroform and chloroform, as The 5 µL of the sample was injected. Identification of IARC as carcinogenic to humans (Group 1) [18, 27]. validate a simple, quick and efficient method for the not influencing the recovery. The 2 or 3 mL of serum the compounds was based on their retention times. Most of 209 potentially possible PCB congeners, are determination of selected POPs in human blood serum samples were denatured with 6M HCl (1 mL) and The confirmation of the compounds identity was chemically stable and might be transferred into the samples with adequate precision and sensitivity. 2-propanole (3 or 4 mL). Then samples were extracted conducted by gas chromatography coupled with the mass food chains. PCBs have been used extensively since with n-hexane:MTBE (3 or 4 mL) and centrifuged at spectrometric detector (ion-trap Varian 4000) equipped 1930 in a variety of application, e.g. dielectric and MATERIAL AND METHODS room temperature at 3200 g for 5 min. The extraction was with a different column (DB-5MS). The working coolant fluids [38]. Since early 1970s use of these repeated two more times. Additionally, sample was stirred conditions of GC-MS used for confirmation of identity of compounds in the USA has been prohibited. European Material and centrifuged after each extraction with hexane:MTBE. PCBs and PBDEs were as follows: injector temperature countries in which PCBs had been produced are the Pooled human blood serum collected as waste after Then the organic phase was collected. The collected – 250ºC; carrier gas – helium; injected sample volume UK, Germany, Italy, France, Spain and Slovakia. The the diagnostic studies was the study material. The serum organic phases were evaporate to dryness. In the dry – 2 µL; ion trap temperature – 200ºC. The temperature use of PCBs as a raw material or chemical intermediate was stored in the temperature of -24ºC up to analysis. residue content of the fat was determined gravimetrically. ramp programme mode was: 70ºC (1 min); 30ºC min-1 – has been banned in the EU since 1985 (85/467/EEC, This material was used to validate a method of determi- The dry residue was dissolved in n-hexane (4 mL) and 170º C, 8ºC min-1 – 300ºC (15 min). Identification of the 6th amendment to Directive 76/769/EEC). The most nation of seven PBDE congeners: BDE-28 (2,4,4’-tri- extracted with concentrated sulphuric acid (2 mL) and compounds was based on their retention times and selected important regulations – Council Directive 96/59/EC bromodiphenyl ether), BDE-47 (2,2’,4,4’-tetrabromodi- centrifuged for 5 min. The hexane phase was transferred characteristics ions. and HELCOM Recommendation 6/1 have been fully phenyl ether), BDE-99 (2,2’,4,4’,5-pentabromodiphenyl to a new test tube and extracted once more. The combined The retention times of all compounds analysed by implemented only by the EU-Countries. Consequently, ether), BDE-100 (2,2’,4,4’,6-pentabromodiphenyl extracts were concentrated and analysed by GC-µECD. GC-µECD and GC/MS systems and their characteristic Whole procedure is presented on Figure 1. ions are shown in Table 1. 114 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 No 2 Method for determination of PBDEs, PCBs, OCPs in blood by GC-µECD. 115

INTRODUCTION the levels of these compound in humans show ether), BDE-153 (2,2’,4,4’,5,5’-hexabromodiphenyl decreasing tendency during the last decades [21]. ether), BDE-154 (2,2′,4,4′,5,6′-hexa-bromodiphenyl Humans are constantly exposed to the large However due to widespread use in the past, PCBs are ether), BDE-183 (2,2′,3,4,4′,5′,6-hepta-bromodiphenyl number of ubiquitous chemicals. Persistent organic still routinely detected in human tissues, breast milk, ether), five PCB congeners: CB-77 (3,3’,4,4’-tetra- pollutants (POPs) are chemical substances, that have blood, in wildlife and environmental samples [14]. chlorobiphenyl), CB-138 (2,2’,3,4,4’,5’-hexachlorobi- been identified as environmental contaminants with Organochlorine pesticides (OCPs) are another phenyl), CB-153 (2,2’,4,4’,5,5’-hexachlorobiphenyl), global distribution. Because of their lipophilicity environmental pollutants with potential toxic effects CB-170 (2,2’,3,3’,4,4’,5-heptachlorobiphenyl), CB-180 and persistent in environment POPs bioaccumulate on humans and wildlife. OCPs, such as DDT and its (2,2’,3,4,4’,5,5’-heptachlorobiphenyl) and the follow- in fat tissue and biomagnify in food chains [22, 35]. metabolites DDE and DDD, have been classified ing organochlorine pesticides: HCB (hexachloroben- Exposure to POPs may be associated with a wide as possible human carcinogens (Group 2A) [30]. zene), β-HCH (beta-hexachlorocyclohexane), γ-HCH variety of human health disorders. Many of them have Humans are exposed to these chemicals, like others (gamma-hexachlorocyclohexane), p,p’-DDE (dichlo- been classified as endocrine disruptors (EDs) due to chalogenated POPs, through food chain, especially rodiphenyldichloroethylene), p,p’-DDT (dichlorodiphe- their interference with normal hormone function [33, products which contain fat. Some of OCPs such as HCB, nyltrichloroethane), and p,p’-DDD (dichlorodiphenyldi- 36, 37]. POPs include, among others: polychlorinated hexachlorocyclohexane (HCH) and DDT were among chloroethane). biphenyls (PCBs), hexa-, hepta- and octa- brominated oldest, and most environmentally destructive pesticides diphenyl ethers, hexachlorobenzene (HCB), isomer used in the past [7, 19]. Most of these compounds have Chemicals β-hexachlorocyclohexane (β-HCH) and DDT, been prohibited for use due to their toxic effects [20], The following reagents and solvents were used: including its metabolites – DDD and DDE, etc. but due to its low price and good efficacy, some OCPs, n-hexane for organic trace analysis (Merck), tert-butyl PBDEs belong to brominated flame retardants such as DDT, are still used in malaria endemic countries. methyl ether (MTBE) obtained from Merck, 2-propanol (FRs), which since 1970s have been added to A wide range of analytical methods has been (POCH), KCl (Merck), concentrated sulfuric acid (Merck) variety of commonly used products, to reduce the developed for determination of POPs in human and 6M hydrochloric acid (Merck). The following certified development of fire [5, 13, 39]. Theoretically there specimens [1, 31]. Due to similarities in physicochemical standards were used: BDE-28, BDE-47, BDE-99, BDE- are 209 possible PBDEs, so called congeners, some properties of these chemicals (e.g. hydrophobicity, 100, BDE-153, BDE-154, BDE-183 dissolved in n-nonane Figure 1. Diagram for preparation of blood serum sample of them are present in variety of consumer products, lipophilicity, relatively good thermal stability), some purchased from the Cambridge Isotope Laboratories; PCBs such as electronics (TV-sets, computers), household steps in various ‘traditional’ analytical methods are (CB-77, CB-153, CB-138, CB-180, CB-170) purchased Chromatographic conditions appliances [12], foam padding used for mattresses, almost identical [23, 34]. Generally, analytical methods from the Ultra Scientific;p,p’ -DDD, p,p’-DDT, p,p’-DDE, The gas chromatography (GC) analysis was furniture and carpet production, paints and plastics include sample preparation: extraction (for example β-HCH and γ-HCH obtained from the Institute of Organic performed using an Agilent Technologies 6890N [26]. PBDE concentrations have decreased in Europe liquid-liquid extraction or solid-phase extraction) and Industrial Chemistry; hexachlorobenzene purchased from GC, equipped with an Agilent Technologies 7683B during the last decades [4, 28] but they are still clean-up of extracts which are followed by analysis with Dr. Ehrenstorfer GmbH. autosampler, a micro-electron capture detector (µECD) being globally detected in food, household dust and suitable detector. For identification and quantification and a PTV split-splitless injector operating in the human matrices [8, 14]. Humans are mainly exposed most researchers used GC-MS with electron capture Standard solutions splitless mode. We used a HP-5 Phenyl Methyl Siloxane to these pollutants through food intake, especially negative ionization (ECNI) and electron ionization (EI) All of certified standards were diluted in n-hexane. (30 m x 250 µm x 0.25 µm) column with helium as food of animal origin [6]. Toxicological studies on or GC-ECD. The latter technique offers great sensitivity From the individual standard solutions the stock a carrier gas at a constant flow rate of 3.7 mL min-1, and animal models suggest that the exposure to PBDEs is and selectivity, however confirmatory techniques are solutions and working solution were prepared which nitrogen as a make-up gas at a flow rate of 60 mL min-1. associated with endocrine disruption, increased risk of required. For determination of PBDEs and PCBs LC- contained all of the analysed compounds. The injector temperature ramp programme in ‘solvent reproductive risk disorders, immunotoxic effects and MS technique can be used and it is the best analytical vent’ mode was: 40ºC (0.2 min) – 700ºC min-1 – 220ºC behavioral problems [3, 9]. tool when sample volume is small [2, 32]. However for Sample preparation (1 min) – 700ºC min-1 – 260ºC (2 min). The GC oven Similar adverse effects on human endocrine routine analysis is needed fast, simple and inexpensive A modified version of the sample preparation temperature ramp programme mode was: 70ºC (1.7 systems have also polychlorinated biphenyls (PCBs) method for determination of this compounds in blood method described by Hovander et al. [16] was applied. min.) – 30ºC min-1 – 210ºC (0 min.) – 5ºC min-1 – 300ºC and their metabolites, even at low levels [10, 18], samples. The modification included omitting of the first step of (5 min). The temperature of detector was set at 250ºC. some PCBs have recently been classified by the The objective of this study was to optimize and clean-up with methanol:chloroform and chloroform, as The 5 µL of the sample was injected. Identification of IARC as carcinogenic to humans (Group 1) [18, 27]. validate a simple, quick and efficient method for the not influencing the recovery. The 2 or 3 mL of serum the compounds was based on their retention times. Most of 209 potentially possible PCB congeners, are determination of selected POPs in human blood serum samples were denatured with 6M HCl (1 mL) and The confirmation of the compounds identity was chemically stable and might be transferred into the samples with adequate precision and sensitivity. 2-propanole (3 or 4 mL). Then samples were extracted conducted by gas chromatography coupled with the mass food chains. PCBs have been used extensively since with n-hexane:MTBE (3 or 4 mL) and centrifuged at spectrometric detector (ion-trap Varian 4000) equipped 1930 in a variety of application, e.g. dielectric and MATERIAL AND METHODS room temperature at 3200 g for 5 min. The extraction was with a different column (DB-5MS). The working coolant fluids [38]. Since early 1970s use of these repeated two more times. Additionally, sample was stirred conditions of GC-MS used for confirmation of identity of compounds in the USA has been prohibited. European Material and centrifuged after each extraction with hexane:MTBE. PCBs and PBDEs were as follows: injector temperature countries in which PCBs had been produced are the Pooled human blood serum collected as waste after Then the organic phase was collected. The collected – 250ºC; carrier gas – helium; injected sample volume UK, Germany, Italy, France, Spain and Slovakia. The the diagnostic studies was the study material. The serum organic phases were evaporate to dryness. In the dry – 2 µL; ion trap temperature – 200ºC. The temperature use of PCBs as a raw material or chemical intermediate was stored in the temperature of -24ºC up to analysis. residue content of the fat was determined gravimetrically. ramp programme mode was: 70ºC (1 min); 30ºC min-1 – has been banned in the EU since 1985 (85/467/EEC, This material was used to validate a method of determi- The dry residue was dissolved in n-hexane (4 mL) and 170º C, 8ºC min-1 – 300ºC (15 min). Identification of the 6th amendment to Directive 76/769/EEC). The most nation of seven PBDE congeners: BDE-28 (2,4,4’-tri- extracted with concentrated sulphuric acid (2 mL) and compounds was based on their retention times and selected important regulations – Council Directive 96/59/EC bromodiphenyl ether), BDE-47 (2,2’,4,4’-tetrabromodi- centrifuged for 5 min. The hexane phase was transferred characteristics ions. and HELCOM Recommendation 6/1 have been fully phenyl ether), BDE-99 (2,2’,4,4’,5-pentabromodiphenyl to a new test tube and extracted once more. The combined The retention times of all compounds analysed by implemented only by the EU-Countries. Consequently, ether), BDE-100 (2,2’,4,4’,6-pentabromodiphenyl extracts were concentrated and analysed by GC-µECD. GC-µECD and GC/MS systems and their characteristic Whole procedure is presented on Figure 1. ions are shown in Table 1. 116 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 No 2 Method for determination of PBDEs, PCBs, OCPs in blood by GC-µECD. 117

Table 1. The retention times of the individual compounds analysed using GC-µECD and corresponding retention times with Table 2. Calibrations points for particular compounds [ng mL-1] selected characteristic ions examined using a gas chromatograph coupled with mass spectrometric detector (GC/MS) Compound 1 2 3 4 5 6 7 8 9 10 GC-µECD GC/MS p,p’-DDT 0.095 0.24 0.98 1.97 3.94 12.31 27.36 54.72 79.80 114.0 Compound retention time (min) retention time (min) characteristic jon (m/z) p,p’-DDE 0.095 0.24 0.98 1.97 3.94 12.31 24.62 49.25 71.82 102.6 HCB 8.02 16.40 284 p,p’-DDD 0.093 0.23 0.97 1.95 3.89 12.17 24.34 48.67 70.98 101.4 β-HCH 8.20 17.00 181 β-HCH 0.100 0.25 1.04 2.09 4.18 13.06 - - - - γ-HCH 8.29 18.50 181 γ-HCH 0.102 0.25 1.06 2.12 4.25 13.27 - - - - p,p’-DDE 11.32 35.23 246 HCB 0.092 0.23 0.96 1.92 3.83 11.98 - - - - p,p’-DDD 12.16 35.73 235 CB-77 0.096 0.24 1.00 1.99 3.98 12.45 - - - - p,p’-DDT 12.99 38.93 235 CB-138 0.094 0.23 0.97 1.95 3.90 12.18 - - - - CB-77 11.50 14.06 292 CB-153 0.095 0.24 0.99 1.98 3.96 12.36 - - - - CB-153 12.47 15.02 484 CB-170 0.092 0.23 0.96 1.92 3.85 12.02 - - - - CB-138 13.11 15.65 360 CB-180 0.093 0.23 0.97 1.94 3.89 12.14 - - - - CB-180 14.79 17.76 394 BDE-28 0.094 0.24 0.98 1.96 3.92 12.24 - - - - CB-170 15.59 17.75 396 BDE-47 0.094 0.24 0.98 1.96 3.92 12.24 - - - - BDE-28 12.05 14.60 246 BDE-99 0.094 0.24 0.98 1.96 3.92 12.24 - - - - BDE-47 14.88 17.32 486 BDE-100 0.094 0.24 0.98 1.96 3.92 12.24 - - - - BDE-100 17.39 19.03 406 BDE-153 0.094 0.24 0.98 1.96 3.92 12.24 - - - - BDE-99 18.12 19.78 564 BDE-154 0.093 0.23 0.97 1.94 3.89 12.14 - - - - BDE-154 20.32 21.09 484 BDE-183 0.092 0.23 0.96 1.92 3.84 12.00 - - - - BDE-153 21.40 22.24 360 BDE-183 24.73 25.35 722

based on the standard deviation (SDrepeat.) of series of Accuracy measurements made by the same analyst, in a short The accuracy of the method has been reported period of time. The results are shown in Tables 4 and 5. as mean recoveries and was investigated by standard Coefficients of variation (CV) were below 20% in any addition experiment. The samples were fortified by case. The method was characterized by good precision adding a known quantity of analytes. Recoveries were according to the modifiedHorwitz equation [15]. determined at two levels of fortification: 0.13 ng and 5 ng per mL of serum for all compounds except p,p’- Limit of quantification DDD, p,p’-DDT, p,p’-DDE and , 5 ng and 125 ng per The limit of quantification (LOQ) has been assumed mL of serum for p,p’-DDD, p,p’-DDT, p,p’-DDE. The as the lowest calibration point and was approximately Dixon test [17, 25] was using for the elimination of the 0.03 ng mL-1 of serum. Figure 3. GC-µECD chromatogram obtained for analysis of the fortified blood serum sample of 18 compounds approx. 10 ng mL-1 116 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 No 2 Method for determination of PBDEs, PCBs, OCPs in blood by GC-µECD. 117

Validation procedure outliers. Mean recoveries of fortification level at 0.13 ng The following validation parameters such as mL-1 ranged from 57.5 (BDE-28) to 102% (CB-77), as linearity, accuracy (expressed as recovery for two shown in Table 3. Similar tendencies can be observed in levels of fortification), precision (repeatability), limit case of low recovery for BDE-28 and BDE-47, observed of quantification, and also measurement uncertainty by other researchers, for example Hovander et al. [16] were assessed. The present study was carried out and Loconto et al. [29], that lower substituted PBDE according to validation criteria [11, 35]. congeners showed lower recovery. In the case of the PCBs similar relationship was observed by Keller et al. for PCB RESULTS AND DISCUSSION that recoveries decreased with increasing chlorination of PCBs (except of CB-170 and CB-180) [24]. Linearity GC-µECD chromatograms of the mixture containing The calibration curves consisted of six points for all tested compounds and fortified blood serum sample all study compounds, except p,p’-DDD, p,p’-DDT, extract are shown in Figure 2 and Figure 3. Figure 2. GC-µECD chromatogram of the standard mixture containing all determined compounds in approx. 12 ng mL-1 p,p’-DDE. Due to wide range of environmental levels Eight samples were fortified at level of 50 ng mL-1. of these compounds, ten-points calibration curves were The mean recoveries ranged from 52.9 (BDE-183) to applied. Each of concentrations was injected three times. 125% (p,p’-DDE), as shown in Table 4. The concentrations of the respective standard solutions used to prepare calibrations curves are shown in Table Repeatability 2. The correlation coefficients met validation criteria. The repeatability of the method was calculated based on the standard deviation (SDrepeat.) of series of Accuracy measurements made by the same analyst, in a short The accuracy of the method has been reported period of time. The results are shown in Tables 4 and 5. as mean recoveries and was investigated by standard Coefficients of variation (CV) were below 20% in any addition experiment. The samples were fortified by case. The method was characterized by good precision adding a known quantity of analytes. Recoveries were according to the modifiedHorwitz equation [15]. determined at two levels of fortification: 0.13 ng and 5 ng per mL of serum for all compounds except p,p’- Limit of quantification DDD, p,p’-DDT, p,p’-DDE and , 5 ng and 125 ng per The limit of quantification (LOQ) has been assumed mL of serum for p,p’-DDD, p,p’-DDT, p,p’-DDE. The as the lowest calibration point and was approximately Dixon test [17, 25] was using for the elimination of the 0.03 ng mL-1 of serum. Figure 3. GC-µECD chromatogram obtained for analysis of the fortified blood serum sample of 18 compounds approx. 10 ng mL-1 118 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 No 2 Method for determination of PBDEs, PCBs, OCPs in blood by GC-µECD. 119

Table 3. Summary of validation parameters; fortification Table 5. Summary of validation parameters; fortification – 2. Covaci A., Voorspoels S., de Boer J.: Determination 15. Horwitz W., Albert R.: The Horwitz ratio (HorRat): – 0.13 ng mL-1 in serum 125 ng mL-1 in serum of brominated flame retardants, with emphasis a useful index of method performance with respect to Mean Mean on polybrominated diphenyl ethers (PBDEs) in precision. J AOAC Int 2006;89(4):1095-1109. SD CV U SD CV U Compound recovery n -1 Compound recovery n environmental and human samples – a review. Environ 16. Hovander L., Athanasiadou M., Asplund L., Jensen S., [ng mL ] [%] [%] [ng mL-1] [%] [%] [%] [ %] Int 2003;29:735-756. Klasson Wehler E.: Extraction and Cleanup Methods HCB 82.5 9 0.05 16.5 31 p,p’-DDE 87.1 16 4.9 5.6 20 3. Darnerud P.O.: Brominated flame retardants as possible for Analysis of Phenolic and Neutral Organohalogens β-HCH 78.6 9 0.02 5.2 12 endocrine disrupters. Int J Androl 2008;31:152-160. in Plasma. J Anal Toxicol. 2000;24:696-703. p,p’-DDD 95.1 16 3.5 3.7 12 γ-HCH 61.9 7 0.05 20.8 50 4. Darnerud P.O., Lignell S., Aune M., Isaksson M., 17. Hyk W., Stojek Z.: Analiza statystyczna w laboratorium p,p’-DDT 94.9 16 6.2 6.6 20 CB-77 102.3 9 0.11 26.1 41 Cantillana T., Redeby J., Glynn A.: Time trends of analitycznym. Wydział Chemii Uniwersytetu polybrominated diphenylether (PBDE) congeners in Warszawskiego, Wydanie trzecie, Warszawa 2010. CB-138 83.8 9 0.04 13.0 24 Measurement uncertainty serum of Swedish mothers and comparisions to breast 18. International Agency for Research on Cancer. CB-153 83.2 9 0.02 5.6 20 The relative expanded uncertainty was calculated milk data. Environ Research 2015;138:352-360. Polychlorinated biphenyls and polybrominated

CB-170 79.5 9 0.04 8.5 18 according to the equation: U = k x uc (k=2) in the 95% 5. de Wit C.A.: An overview of brominated flame retardants biphenyls. IARC Monographs on the evaluation of CB-180 74.9 9 0.03 13.2 27 confidence interval, assuming squared probability in the environment. Chemosphere 2002;46:583-624. carcinogenic risks to humans 2015, vol. 107. 6. EHP: Environmental Health Criteria 162, Brominated 19. Jacob J.: A Review of the accumulation and distribution BDE-28 57.5 7 0.01 4.4 12 of results distribution, where uc - combined standard Diphenyl Ethers. IPCS, WHO, Geneva, 1994. of persistent organic pollutants in the environment. BDE-47 60.7 9 0.02 9.4 23 uncertainty of series of repeated measurement. The combined standard uncertainty (u ) was calculated 7. El-Shahawi M.S., Hamza A., Bashammakh A.S., Int J Bioscience, Biochemistry and Bioinformatics BDE-99 87.7 9 0.05 14.0 26 c according to the formula on the concentration of the Al-Saggaf W.T.: An overview on the accumulation, 2013;3(6):657-661. distribution, transformations, toxicity and analytical 20. Jacob J., Cherian J.: Review of environmental and BDE-100 94.3 9 0.04 11.2 16 test compound, taking into account recovery. For each BDE-153 67.2 9 0.03 12.3 27 methods for the monitoring of persistent organic human exposure to persistent organic pollutants. Asian parameter of the formula standard uncertainty (u) was pollutants. Talanta 2010;80:1587-1597. Social Science 2013;9(11):107-120. BDE-154 91.2 9 0.02 6.6 11 calculated according to the appropriate distribution 8. Frederiksen M., Vorkamp K., Thomsen M., Knudsen 21. Jaraczewska K., Lulek J., Covaci A., Voorspoels BDE-183 62.9 9 0.02 8.7 22 (square or triangular) [11]. The estimated uncertainty L.E.: Human internal and external exposure to PBDEs – S., Kaluba-Skotarczak A., Drews K., Schepens values for tested compounds for different levels of review of levels and sources. Int J Hyg Environ Health, P.: Distribution of polychlorinated biphenyls, fortification are presented in Tables 3, 4 and 5, were in 2009;212:109-134. organochlorine pesticides and polybrominated diphenyl Table 4. Summary of validation parameters; fortification – the ranged from 6% to 50%. 9. Gill U., Chu I., Ryan J.J., Feeley M.: Polybrominated ethers in human umbilical cord serum, maternal serum 5 ng mL-1 in serum diphenyl ethers: human tissue levels and toxicology. and milk from Wielkopolska region. Sci Total Environ Mean Rev Environ Contam Toxicol 2004;183:55-97. 2006;372(1):20-31. SD CV U CONCLUSIONS Compound recovery n 10. Góralczyk K., Hernik A., Czaja K., Struciński P., 22. Jones K.C., de Voogt P.: Persistent organic pollutants [ng mL-1] [%] [%] [%] The result of validation of presented analytical Korcz W., Snopczyński T., Ludwicki J.K.: Związki (POPs): state of the science. Environ Pollution HCB 76.2 8 1.3 16.8 35 method prove its usefulness for biomonitoring halogenoorganiczne – stare i nowe zagrożenia dla ludzi 1999;100:209-221. [Organohalogen compounds – old and new hazards for 23. Kalachova K., Pulkrabova J., Drabova L., Cajka β-HCH 88.1 8 0.6 6.1 18 purposes. The omission of the blood serum clean-up people]. Rocz Panstw Zakl Hig 2010;61(2):109-117 (in T., Kocourek V., Hajslova J.: Simplified and rapid γ-HCH 77.7 8 1.2 14.5 29 step had no adverse effect on the recovery values. On Polish) [PMID: 20839456; http://www.ncbi.nlm.nih. determination of polychlorinated biphenyls, p,p’-DDE 125.0 8 1.7 13.3 17 the basis of the determined validation parameters it can gov/pubmed/20839456]. polybrominated diphenyl ethers, and polycyclic p,p’-DDD 96.5 8 0.5 4.7 8 be concluded that the method is characterized by good 11. Góralczyk K., Hernik A., Struciński P., Czaja K., aromatic hydrocarbons in fish and shrimps integrated repeatability and can be successfully applied for the p,p’-DDT 78.3 8 0.4 5.3 11 Ludwicki J.K.: Walidacja metod i niepewność wyników into a single method. Anal Chimica Acta 2011;707:84- simultaneous determination of eighteen organohalogen w badaniach pozostałości pestycydów w żywności 91. CB-77 83.5 8 0.3 3.8 7 compounds (i.e. PBDEs, PCBs, OCPs) in blood serum [Validation methods and ambiguous results in the 24. Keller J.M., Swarthout R.F., Carlson B.K.R, Yordy J., CB-138 80.3 8 0.5 6.5 13 samples, allowing to estimate the human exposure analysis of pesticide residues in food]. Rocz Panstw Zakl Guichard A, Schantz M.M., Kucklick J.R.: Comparison CB-153 80.0 8 0.2 2.4 4 to these substances. Presented analytical method is Hig 2003;54(1):39-48 (in Polish) [PMID: 12870296; of five extraction methods for measuring PCBs, PBDEs, CB-170 84.8 8 0.2 2.9 6 relatively quick and simple. http://www.ncbi.nlm.nih.gov/pubmed/12870296]. organochlorine pesticides, and lipid content in serum. 12. Góralczyk K., Struciński P., Hernik A., Czaja K., Anal Bioanal Chem 2009;393:747–760. CB-180 85.5 8 0.3 3.5 7 Acknowledgements Korcz W., Minorczyk M., Ludwicki J.K.: Kurz źródłem 25. Konieczka P. Namieśnik J.: Ocena i kontrola jakości BDE-28 92.5 8 0.4 4.0 7 narażenia człowieka na polibromowane difenyloetery wyników pomiarów analitycznych. Wydawnictwo This study was supported by the National Institute of BDE-47 85.3 8 0.3 3.3 7 (PBDE) [Indoor dust as a pathway of human exposure to Naukowo-Techniczne, Warszawa, 2007. Public Health-National Institute of Hygiene (NIPH- BDE-99 91.1 8 0.3 2.8 6 polybrominated diphenyl ethers (PBDEs)]. Rocz Panstw 26. Król S., Zabiegała B., Namieśnik J.: PBDEs in NIH) in the frame of public health protection activities Zakl Hig 2012;63(1):1-8 (in Polish) [PMID: 22642063; environmental samples: Sampling and analysis. Talanta BDE-100 84.1 8 0.3 3.5 7 project (No 13/ZŚ/2015 and 7/ZŚMŁ/2015) http://www.ncbi.nlm.nih.gov/pubmed/22642063]. 2012;93:1-17. BDE-153 88.6 8 0.4 4.0 8 13. Hernik A., Góralczyk K., Czaja K., Struciński P., Korcz 27. Lauby-Secretan B., Loomis D., Grosse Y., El Ghissassi BDE-154 96.4 8 0.4 3.9 6 Conflict of interest W., Minorczyk M., Ludwicki J.K.: Polybrominated F., Bouvard V., Benbrahim-Tallaa L., Guha N., Baan R., BDE-183 52.9 8 0.3 6.1 18 The authors declare no conflict of interest. diphenyl ethers and polychlorinated biphenyls in Mattock H., Straif K . : Carcinogenicity of polychlorinated cord blood from women in Poland. Chemosphere biphenyls and polybrominated biphenyls. The Lancet 2013;93:526-531. Oncology 2013,14(4),287-288. For recovery testing at level of 125 ng mL-1 the REFERENCES 14. Hernik A., Góralczyk K., Struciński P., Czaja K., 28. Law R.J., Covaci A., Harrad S., Herzke D., Abdallah M. total number of samples fortified was 16. The mean 1. Covaci A., Voorspoels S.: Optimization of the Kucharska A., Korcz W., Snopczyński T., Ludwicki A.-E., Fernie K., Toms L.-M.L., Takigami H.: Levels and recoveries for p,p’-DDE, p,p’-DDD, p,p’-DDT, were determination of polybrominated diphenyl ethers in J.K.: Polybrominated diphenyl ethers, polychlorinated trends of PBDEs and HBCDs in the global environment: respectively 87.1, 95.1 and 94.9% (Table 5). human serum using solid-phase extraction and gas biphenyls and organochlorine pesticides in human Status at the end of 2012. Environ Int 2014;65:47-158. chromatography-electron capture negative ionization milk as markers of environmental exposure to these 29. Loconto P.R., Isenga D., O’Keefe M., Knottnerus M.: mass spectrometry. J Chromatogr B 2005;827:216-233. compounds. Ann Agric Environ Med 2011;18:113-118. Isolation and Recovery of selected polybrominated diphenyl ethers from human serum and sheep serum: 120 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):121-130 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ coupling reversed-phase solid-phase disk extraction polybrominated diphenyl ethers in small volumes of and liquid–liquid extraction techniques with a capillary human serum. J Chromatogr A, 2007;1152:124-129. gas chromatographic electron capture negative ion 35. SANTE/11945/2015. Guidance document on analytical ORIGINAL ARTICLE mass spectrometric determinative technique. JCS quality control and method validation procedures for 2008;46:54-60. pesticide residue analysis in food and feed. 1 December SALIVARY COTININE LEVELS AS A BIOMARKER FOR GREEN 30. Loomis D., Guyton K., Grosse Y., El Ghissasi F., 2015. Bouvard V., Benbrahim-Tallaa L., Guha N., Mattock 36. State of the science of endocrine disrupting chemicals TOBACCO SICKNESS IN DRY TOBACCO PRODUCTION AMONG THAI H., Straif K.: Carcinogenicity of lindane, DDT, and – 2012; WHO. TRADITIONAL TOBACCO FARMERS 2,4-dichlorophenoxyacetic acid. The Lancet Oncology 37. Vallack H.W., Bakker D.J., Brandt I., Broström-Lundén 2015;16(8),891-892. E., Brouwer A., Bull K.R., Gough C., Guardans R., Thanusin Saleeon1, Wattasit Siriwong1,2*, Héctor Luis Maldonado-Pérez3, 31. Pirard C., Pauw E. D., Focant J.-F.: New strategy for Holoubek I., Jansson B., Koch R., Kuylenstierna J., 2,3 comprehensive analysis of polybrominated diphenyl ethers, Lecloux A., Mackay D., McCutcheon P., Mocarelli Mark Gregory Robson polychlorinated dibenzo-p-dioxins, polychlorinated P., Taalman R.D.F.: Controlling persistent organic dibenzofurans and polychlorinated biphenyls by gas pollutants – what next? Environ Toxicol Pharmacol 1 College of Public Health Science, Chulalongkorn University, Bangkok, Thailand chromatography coupled with mass spectrometry. 1998;6:143-175. 2 Thai Fogarty ITREOH Center, Chulalongkorn University, Bangkok, Thailand J Chromatogr A 2003;998:169-181. 38. World Health Organization. Polychlorinated biphenyls 3School of Environmental and Biological Sciences, Rutgers University, New Jersey, USA 32. Quinete N., Schettgen T., Betram J., Kraus T.: Analytical and terphenyls, IPCS, Environmental Health Criteria approaches for the determination of PCB metabolites in 140, Geneva, Switzerland, 1992. blood: a review. Anal Bioanal Chem 2014;406:6151-6164. 39. World Health Organization. Flame retardants, ABSTRACT 33. Rahman Kabir E., Sharfin Rahman M., Rahman I.: IPCS, Environmental Health Criteria 192, Geneva, Background. Dry Thai traditional tobacco (Nicotiana Tabacum L.) production involves a unique process: (a) picking A review on endocrine disruptors and their possible Switzerland, 1997. tobacco leaves, (b) curing tobacco leaves, (c) removing stems of tobacco leaves, cutting leaves and putting on a bamboo impacts on human health. Environ Toxicol Pharmacol rack, (d) drying in the sun, reversing a rack, spraying a tobacco extract to adjust the tobacco’s color, storing dried tobacco 2015;40:241-258. Received: 28.01.2016 and packaging. These processes may lead to adverse health effects caused by dermal absorption of nicotine such as Green 34. Ramos J.J., Gómara B., Fernández M.A., González Accepted: 15.04.2016 Tobacco Sickness (GTS). M.J.: A simple and fast method for the simultaneous Objectives. The aim of this study was to determine the correlation between GTS resulting from dry Thai traditional tobacco determination of polychlorinated biphenyls and production and salivary cotinine levels among Thai traditional tobacco farmers in Nan Province, Thailand. Materials and Methods. A prospective cohort study was conducted with 20 tobacco farmers and 20 non-tobacco farmers in Praputtabath Sub-District and Phatow Sub-District. The participants were randomly selected and interviewed using in person questionnaires with bi-weekly follow-up for 14 weeks. During each contact, the cotinine concentration was measured by NicAlertTM Saliva strip tests (NCTS). Descriptive statistics and Spearman’s correlation (Spearman’s rho) was used to examine the relationship between the variables at both 0.01 and 0.05 significant probability levels. Results. This study indicated that GTS from dry tobacco production has the potential to be considered a common occupational disease. This study demonstrated the usefulness of salivary cotinine level measurements by NCTS. The levels were well correlated with farmers who were employed in the dry Thai tobacco production industry. Salivary cotinine levels were also significantly correlated with the prevalence of GTS in the group of tobacco farmers at any given time within a crop season. However, the production process of dry Thai traditional tobacco is different from that evaluated in our previous studies where GTS and salivary cotinine level were correlated in workers working in humid conditions. Conclusions. The long-term effects of such exposure should be investigated and health education programs with health risk exposure studies to increase awareness amongst farmers is recommended.

Key words: salivary cotinine levels, green tobacco sickness, dry Thai traditional tobacco

INTRODUCTION chills, fluctuations in blood pressure and heart rate, drenching sweats and increased salivation [9, 18, 19]. Tobacco farming is associated with the hazard GTS is a type of acute nicotine poisoning caused by for the so called green tobacco sickness (GTS). The dermal absorption of nicotine from mature tobacco disease is caused by nicotine which penetrates through plants. The combined symptoms of acute nicotine the skin of the hands of the workers who cultivate and poisoning are vomiting, nausea, headaches and harvest tobacco [19]. GTS is an occupational illness dizziness [1, 3]. The Nan Province is one of the most reported in tobacco workers worldwide [6, 11, 14, popular areas for Thai traditional tobacco cultivation 28]. The GTS morbidity affects nearly one quarter of in the North of Thailand. Thai traditional tobacco tobacco workers. Typical symptoms include: nausea, (Nicotiana Tabacum L.) is known as a non-Virginia vomiting, headache, abdominal cramps, breathing type tobacco. Mature leaves are thicker and contain difficulty, abnormal body temperature, pallor, diarrhea, 3-4 times more nicotine as compared to Virginia

*Corresponding author: Wattasit Siriwong, College of Public Health Science, Chulalongkorn University, Soi Chulalongkorn 62 Phyathai Rd., Bangkok 10330 , Thailand, Phone: +66 2 218 8184; Fax : +66 2 255 6046, e-mail: [email protected]

© Copyright by the National Institute of Public Health - National Institute of Hygiene 120 M. Matuszak, M. Minorczyk, K. Góralczyk et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):121-130 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ coupling reversed-phase solid-phase disk extraction polybrominated diphenyl ethers in small volumes of and liquid–liquid extraction techniques with a capillary human serum. J Chromatogr A, 2007;1152:124-129. gas chromatographic electron capture negative ion 35. SANTE/11945/2015. Guidance document on analytical ORIGINAL ARTICLE mass spectrometric determinative technique. JCS quality control and method validation procedures for 2008;46:54-60. pesticide residue analysis in food and feed. 1 December SALIVARY COTININE LEVELS AS A BIOMARKER FOR GREEN 30. Loomis D., Guyton K., Grosse Y., El Ghissasi F., 2015. Bouvard V., Benbrahim-Tallaa L., Guha N., Mattock 36. State of the science of endocrine disrupting chemicals TOBACCO SICKNESS IN DRY TOBACCO PRODUCTION AMONG THAI H., Straif K.: Carcinogenicity of lindane, DDT, and – 2012; WHO. TRADITIONAL TOBACCO FARMERS 2,4-dichlorophenoxyacetic acid. The Lancet Oncology 37. Vallack H.W., Bakker D.J., Brandt I., Broström-Lundén 2015;16(8),891-892. E., Brouwer A., Bull K.R., Gough C., Guardans R., Thanusin Saleeon1, Wattasit Siriwong1,2*, Héctor Luis Maldonado-Pérez3, 31. Pirard C., Pauw E. D., Focant J.-F.: New strategy for Holoubek I., Jansson B., Koch R., Kuylenstierna J., 2,3 comprehensive analysis of polybrominated diphenyl ethers, Lecloux A., Mackay D., McCutcheon P., Mocarelli Mark Gregory Robson polychlorinated dibenzo-p-dioxins, polychlorinated P., Taalman R.D.F.: Controlling persistent organic dibenzofurans and polychlorinated biphenyls by gas pollutants – what next? Environ Toxicol Pharmacol 1 College of Public Health Science, Chulalongkorn University, Bangkok, Thailand chromatography coupled with mass spectrometry. 1998;6:143-175. 2 Thai Fogarty ITREOH Center, Chulalongkorn University, Bangkok, Thailand J Chromatogr A 2003;998:169-181. 38. World Health Organization. Polychlorinated biphenyls 3School of Environmental and Biological Sciences, Rutgers University, New Jersey, USA 32. Quinete N., Schettgen T., Betram J., Kraus T.: Analytical and terphenyls, IPCS, Environmental Health Criteria approaches for the determination of PCB metabolites in 140, Geneva, Switzerland, 1992. blood: a review. Anal Bioanal Chem 2014;406:6151-6164. 39. World Health Organization. Flame retardants, ABSTRACT 33. Rahman Kabir E., Sharfin Rahman M., Rahman I.: IPCS, Environmental Health Criteria 192, Geneva, Background. Dry Thai traditional tobacco (Nicotiana Tabacum L.) production involves a unique process: (a) picking A review on endocrine disruptors and their possible Switzerland, 1997. tobacco leaves, (b) curing tobacco leaves, (c) removing stems of tobacco leaves, cutting leaves and putting on a bamboo impacts on human health. Environ Toxicol Pharmacol rack, (d) drying in the sun, reversing a rack, spraying a tobacco extract to adjust the tobacco’s color, storing dried tobacco 2015;40:241-258. Received: 28.01.2016 and packaging. These processes may lead to adverse health effects caused by dermal absorption of nicotine such as Green 34. Ramos J.J., Gómara B., Fernández M.A., González Accepted: 15.04.2016 Tobacco Sickness (GTS). M.J.: A simple and fast method for the simultaneous Objectives. The aim of this study was to determine the correlation between GTS resulting from dry Thai traditional tobacco determination of polychlorinated biphenyls and production and salivary cotinine levels among Thai traditional tobacco farmers in Nan Province, Thailand. Materials and Methods. A prospective cohort study was conducted with 20 tobacco farmers and 20 non-tobacco farmers in Praputtabath Sub-District and Phatow Sub-District. The participants were randomly selected and interviewed using in person questionnaires with bi-weekly follow-up for 14 weeks. During each contact, the cotinine concentration was measured by NicAlertTM Saliva strip tests (NCTS). Descriptive statistics and Spearman’s correlation (Spearman’s rho) was used to examine the relationship between the variables at both 0.01 and 0.05 significant probability levels. Results. This study indicated that GTS from dry tobacco production has the potential to be considered a common occupational disease. This study demonstrated the usefulness of salivary cotinine level measurements by NCTS. The levels were well correlated with farmers who were employed in the dry Thai tobacco production industry. Salivary cotinine levels were also significantly correlated with the prevalence of GTS in the group of tobacco farmers at any given time within a crop season. However, the production process of dry Thai traditional tobacco is different from that evaluated in our previous studies where GTS and salivary cotinine level were correlated in workers working in humid conditions. Conclusions. The long-term effects of such exposure should be investigated and health education programs with health risk exposure studies to increase awareness amongst farmers is recommended.

Key words: salivary cotinine levels, green tobacco sickness, dry Thai traditional tobacco

© Copyright by the National Institute of Public Health - National Institute of Hygiene 122 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 123 type [14] and average 10% of all tobacco products from this study can be helpful to expand surveillance the purpose of determining whether an individual has worked in dried tobacco production. Salivary samples and cultivation areas in Thailand. Furthermore, dried and prevention of GTS, defining GTS etiology for been exposed to tobacco products within 48 hours. were collected at each contact and cotinine concentration Thai traditional tobacco cultivation and final products farmers and improving working conditions in this area. NicAlertTM Saliva strip zones range from level 0 (0- levels were measured by using NCTS. involve many unique processes which are different 10 ng/mL, non-user of tobacco products) to level 6 from the western countries processes. A farmer works MATERIAL AND METHODS (>1000 ng/mL, use of tobacco products). The cut-off Data Analysis with and produces tobacco plants by himself or with concentration indicating a positive result, was 10 ng/ All data were coded and processed using the Statistical help of family. From previous studies, it was found that Subjects and sampling method mL (zones 1-6). The salivary cotinine concentration Package for Social Sciences (SPSS) version 17. Statistical farmers who were working with tobacco may develop A prospective cohort study was conducted with and the interpretation for each are shown in Table 1 analyses were conducted using frequency and percentage adverse health effects due to nicotine poisoning (GTS) twenty Thai traditional tobacco farmers and twenty [21]. to describe qualitative data. Mean and standard deviation from raw tobacco leaves through skin absorption non-tobacco farmers in Praputtabath Sub-District and were used to quantify data. The prevalence of GTS was [1]. On the other hand, a person can be exposed to Phatow Sub-District in Nan Province. The subjects Table 1. Cotinine concentration and its interpretation for stratified by the farmers’ characteristics at each visit, nicotine through inhalation, which is a possible route were both male and female between 20 and 60 years of each level of the NicAlertTM test amount of dry tobacco production and the GTS subjective of exposure in dry Thai traditional tobacco production. age. A total of 40 participants were randomly selected Cotinine health symptoms. A correlation between GTS, dry There is close contact with vapors of nicotine from raw from tobacco farmers in this area. The participants were Level concentration Interpretation tobacco processing, PPE use and salivary cotinine levels (ng/mL) and dry tobacco and from working long hours each defined in two groups. The case study group was the were analyzed by Spearman’s correlation (Spearman’s day. The gummy juice and sap from tobacco exude Thai traditional tobacco farmers who picked tobacco 0 0-10 non-user of tobacco products rho) at both significant (0.01 and 0.05) probability levels from the leaves produce a pungent odor supporting leaves or produced dried tobacco during the regular 1 10-30 user of tobacco products (REPEAT). the idea of direct exposure the body by inhalation and season and a group of non-tobacco farmers as controls 2 30-100 user of tobacco products collection in mucous membranes of the nasal ducts. who live in the same area of the first group. They 3 100-200 user of tobacco products RESULTS Moreover, the use of bare hands in handling of tobacco were generally healthy local agriculturalists that live 4 200-500 user of tobacco products dust may bring forth the health outcomes in GTS [27]. in the study area (not mobile), with no reported fever 5 500-1000 user of tobacco products There were 40 subjects that participated in the Such is the case with inappropriate personal protective or common cold symptoms, no diarrhea complications 6 >1000 user of tobacco products questionnaire interview who were 42 to 60 years of equipment, supporting nicotine absorption as and no exposure to pesticides. age; 50.0% male and 50.0% female. The average age a potential mechanism involved in pathogenesis [22]. Salivary cotinine levels were recorded after (±SD) of the participants was 50.18 (±4.93) years. The processing of dry Thai traditional tobacco exposes Measurement tool squeezing eight drops from the saliva-containing tube Most of participants (55.0%) were head of a family the farmers to nicotine through contact with hands and The farmers were randomly selected and that is wide at the top and narrow at the bottom (after and 85.0% were educated at the primary school level. inhalation with tobacco dust and can be considered interviewed using face to face questionnaires that were bringing it to room temperature) directly onto the Almost all of the workers were exposed to tobacco in a risk to acquiring nicotine poisoning. Measuring the modified from a previous study by Arcury et al. [1] and white padded end of the strip. Results were read after any given day for approximately 6 to 10 hours (60.0% concentration of nicotine in the body is a costly process environmental surveys. The questionnaire is comprised allowing the strip to develop by laying it on the marked of their day). Only one person was exposed for 5.0% and must be done in a laboratory in a remote location; of individual characteristics (gender, age, family area of the plastic laminated instruction card for 15 to of the day and was not living with a person who was this process has been reported in previous studies. status, level of education, current smoking status and 30 minutes. The lowest numbered zone displaying smoking for 100% of the day, Farmers who had alcohol Cotinine is the major metabolite of nicotine and has alcohol consumption), work related conditions and the a red color was documented as the NicAlertTM Saliva consumption were 10.0% of the group. The Body Mass a relatively long half-life (ten times longer than that of process of dry tobacco production which is consistent trip test result [21]. Index (BMI) of the farmers was normal for 65.0% of nicotine) [8]. Cotinine measurements have been used to with: picking tobacco leaves, transferring tobacco the group. Characteristics of the study population are distinguish between tobacco users and non-users [13, from farm to home, curing tobacco leaves, removing Ethical approval summarized in Table 2. 15, 16, 17] and can be detected in saliva [4]. Quandt stems of tobacco leaves, rolling a bundle of tobacco Written informed consent was obtained from all For all 7 times of sampling, the correlation of et al. found that the level of salivary cotinine among leaves, cutting tobacco leaves with a cutting machine, participants willing to join the study. This study was salivary cotinine levels between tobacco farmers and the workers had a significant positive relationship to putting a slice of tobacco on a bamboo rack, bringing approved by Ethical consideration from the College non-tobacco farmers was different (p<0.05). Moreover, wet conditions, smoking, and work task (picking and a rack of tobacco to dry in the sun, reversing a bamboo of Public Health Sciences, Chulalongkorn University this result was indicated that tobacco farmers have topping (removing of the flower from the plant to rack, spraying a tobacco extract for adjusting tobacco COA No.170/2012. a higher saliva cotinine level than non-tobacco induce plant growth and increase nicotine content) color, storing dried tobacco and packaging. The farmers. All of testing in seven times, the correlation [24]. Salivary cotinine levels can be measured by questionnaire also asked about personal protective Data collection of salivary cotinine levels on Thai traditional tobacco NicAlertTM Saliva strip tests (Nymox Pharmaceutical equipment (PPE) use, hours worked in dried tobacco The interview follow-up was conducted every two farmers was different between non-tobacco farmers Cooperation, St.-Laurent, QC, Canada) which would production, and GTS subjective health symptoms such weeks between 08.00 a.m. and 07.00 p.m. from December and tobacco farmers (p<0.05). In the test of T1, T2, provide the opportunity to classify cotinine levels vomiting, nausea, headaches or dizziness. Salivary 2012 to March 2013. The total number of visits were 7; T3, T4, T5, T6 and T7 was found that in each time between user and non-users of tobacco products. samples were collected at each contact to measure December for 2 times, November for 2 times, January for of testing, tobacco farmers group have a numbers of Because the Thai diagnostic criteria for GTS has not cotinine concentration levels by NicAlertTM Saliva 2 times and March for 1 time. The trained surveyors were salivary cotinine exposure more than non-farmer that been established, the correlation between salivary strip test - NCTS. responsible for conducting interviews for selected groups measured by NCTS strip test. cotinine levels and GTS in Thai traditional tobacco of Thai traditional tobacco farmers and non-tobacco Test 1: totally of testing found on Level 0 (0-10 farmers has yet to be studied. Salivary cotinine evaluation farmers. They conducted interviews two times a month ng/mL of cotinine concentration) were twenty five The purpose of this study is to determine The salivary cotinine levels were evaluated (bi-weekly), with one month for follow-up upon finishing persons (62.5%); farmer groups were seven persons correlation between GTS from dry Thai traditional using NicAlertTM Saliva strip tests - an the tobacco work. Personal interviews are used to collect (35.0%) and non-farmer group were eighteen persons tobacco production and salivary cotinine levels among immunochromatographic assay using monoclonal information to measure the occurrence of the subjective (90.0%). Total of testing found on Level 1 (10-30 Thai traditional tobacco farmers at Praputthabath Sub- antibodies (Nymox Pharmaceutical Cooperation, St.- health symptoms and risk factors for nicotine exposure, ng/mL of cotinine concentration) was seven persons District, Chiangklang District and Phatow Sub-District, Laurent, QC, Canada). The system provides a semi- included smoking status, and process of tobacco work, (17.5%); farmers group were five persons (25.0%) and Thawangpha District, in Nan Province, Thailand. Data quantitative measurement of cotinine in saliva for personal protective equipment (PPE) use and hours non-farmer group were two persons (10.0%). Total of 122 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 123 type [14] and average 10% of all tobacco products from this study can be helpful to expand surveillance the purpose of determining whether an individual has worked in dried tobacco production. Salivary samples and cultivation areas in Thailand. Furthermore, dried and prevention of GTS, defining GTS etiology for been exposed to tobacco products within 48 hours. were collected at each contact and cotinine concentration Thai traditional tobacco cultivation and final products farmers and improving working conditions in this area. NicAlertTM Saliva strip zones range from level 0 (0- levels were measured by using NCTS. involve many unique processes which are different 10 ng/mL, non-user of tobacco products) to level 6 from the western countries processes. A farmer works MATERIAL AND METHODS (>1000 ng/mL, use of tobacco products). The cut-off Data Analysis with and produces tobacco plants by himself or with concentration indicating a positive result, was 10 ng/ All data were coded and processed using the Statistical help of family. From previous studies, it was found that Subjects and sampling method mL (zones 1-6). The salivary cotinine concentration Package for Social Sciences (SPSS) version 17. Statistical farmers who were working with tobacco may develop A prospective cohort study was conducted with and the interpretation for each are shown in Table 1 analyses were conducted using frequency and percentage adverse health effects due to nicotine poisoning (GTS) twenty Thai traditional tobacco farmers and twenty [21]. to describe qualitative data. Mean and standard deviation from raw tobacco leaves through skin absorption non-tobacco farmers in Praputtabath Sub-District and were used to quantify data. The prevalence of GTS was [1]. On the other hand, a person can be exposed to Phatow Sub-District in Nan Province. The subjects Table 1. Cotinine concentration and its interpretation for stratified by the farmers’ characteristics at each visit, nicotine through inhalation, which is a possible route were both male and female between 20 and 60 years of each level of the NicAlertTM test amount of dry tobacco production and the GTS subjective of exposure in dry Thai traditional tobacco production. age. A total of 40 participants were randomly selected Cotinine health symptoms. A correlation between GTS, dry There is close contact with vapors of nicotine from raw from tobacco farmers in this area. The participants were Level concentration Interpretation tobacco processing, PPE use and salivary cotinine levels (ng/mL) and dry tobacco and from working long hours each defined in two groups. The case study group was the were analyzed by Spearman’s correlation (Spearman’s day. The gummy juice and sap from tobacco exude Thai traditional tobacco farmers who picked tobacco 0 0-10 non-user of tobacco products rho) at both significant (0.01 and 0.05) probability levels from the leaves produce a pungent odor supporting leaves or produced dried tobacco during the regular 1 10-30 user of tobacco products (REPEAT). the idea of direct exposure the body by inhalation and season and a group of non-tobacco farmers as controls 2 30-100 user of tobacco products collection in mucous membranes of the nasal ducts. who live in the same area of the first group. They 3 100-200 user of tobacco products RESULTS Moreover, the use of bare hands in handling of tobacco were generally healthy local agriculturalists that live 4 200-500 user of tobacco products dust may bring forth the health outcomes in GTS [27]. in the study area (not mobile), with no reported fever 5 500-1000 user of tobacco products There were 40 subjects that participated in the Such is the case with inappropriate personal protective or common cold symptoms, no diarrhea complications 6 >1000 user of tobacco products questionnaire interview who were 42 to 60 years of equipment, supporting nicotine absorption as and no exposure to pesticides. age; 50.0% male and 50.0% female. The average age a potential mechanism involved in pathogenesis [22]. Salivary cotinine levels were recorded after (±SD) of the participants was 50.18 (±4.93) years. The processing of dry Thai traditional tobacco exposes Measurement tool squeezing eight drops from the saliva-containing tube Most of participants (55.0%) were head of a family the farmers to nicotine through contact with hands and The farmers were randomly selected and that is wide at the top and narrow at the bottom (after and 85.0% were educated at the primary school level. inhalation with tobacco dust and can be considered interviewed using face to face questionnaires that were bringing it to room temperature) directly onto the Almost all of the workers were exposed to tobacco in a risk to acquiring nicotine poisoning. Measuring the modified from a previous study by Arcury et al. [1] and white padded end of the strip. Results were read after any given day for approximately 6 to 10 hours (60.0% concentration of nicotine in the body is a costly process environmental surveys. The questionnaire is comprised allowing the strip to develop by laying it on the marked of their day). Only one person was exposed for 5.0% and must be done in a laboratory in a remote location; of individual characteristics (gender, age, family area of the plastic laminated instruction card for 15 to of the day and was not living with a person who was this process has been reported in previous studies. status, level of education, current smoking status and 30 minutes. The lowest numbered zone displaying smoking for 100% of the day, Farmers who had alcohol Cotinine is the major metabolite of nicotine and has alcohol consumption), work related conditions and the a red color was documented as the NicAlertTM Saliva consumption were 10.0% of the group. The Body Mass a relatively long half-life (ten times longer than that of process of dry tobacco production which is consistent trip test result [21]. Index (BMI) of the farmers was normal for 65.0% of nicotine) [8]. Cotinine measurements have been used to with: picking tobacco leaves, transferring tobacco the group. Characteristics of the study population are distinguish between tobacco users and non-users [13, from farm to home, curing tobacco leaves, removing Ethical approval summarized in Table 2. 15, 16, 17] and can be detected in saliva [4]. Quandt stems of tobacco leaves, rolling a bundle of tobacco Written informed consent was obtained from all For all 7 times of sampling, the correlation of et al. found that the level of salivary cotinine among leaves, cutting tobacco leaves with a cutting machine, participants willing to join the study. This study was salivary cotinine levels between tobacco farmers and the workers had a significant positive relationship to putting a slice of tobacco on a bamboo rack, bringing approved by Ethical consideration from the College non-tobacco farmers was different (p<0.05). Moreover, wet conditions, smoking, and work task (picking and a rack of tobacco to dry in the sun, reversing a bamboo of Public Health Sciences, Chulalongkorn University this result was indicated that tobacco farmers have topping (removing of the flower from the plant to rack, spraying a tobacco extract for adjusting tobacco COA No.170/2012. a higher saliva cotinine level than non-tobacco induce plant growth and increase nicotine content) color, storing dried tobacco and packaging. The farmers. All of testing in seven times, the correlation [24]. Salivary cotinine levels can be measured by questionnaire also asked about personal protective Data collection of salivary cotinine levels on Thai traditional tobacco NicAlertTM Saliva strip tests (Nymox Pharmaceutical equipment (PPE) use, hours worked in dried tobacco The interview follow-up was conducted every two farmers was different between non-tobacco farmers Cooperation, St.-Laurent, QC, Canada) which would production, and GTS subjective health symptoms such weeks between 08.00 a.m. and 07.00 p.m. from December and tobacco farmers (p<0.05). In the test of T1, T2, provide the opportunity to classify cotinine levels vomiting, nausea, headaches or dizziness. Salivary 2012 to March 2013. The total number of visits were 7; T3, T4, T5, T6 and T7 was found that in each time between user and non-users of tobacco products. samples were collected at each contact to measure December for 2 times, November for 2 times, January for of testing, tobacco farmers group have a numbers of Because the Thai diagnostic criteria for GTS has not cotinine concentration levels by NicAlertTM Saliva 2 times and March for 1 time. The trained surveyors were salivary cotinine exposure more than non-farmer that been established, the correlation between salivary strip test - NCTS. responsible for conducting interviews for selected groups measured by NCTS strip test. cotinine levels and GTS in Thai traditional tobacco of Thai traditional tobacco farmers and non-tobacco Test 1: totally of testing found on Level 0 (0-10 farmers has yet to be studied. Salivary cotinine evaluation farmers. They conducted interviews two times a month ng/mL of cotinine concentration) were twenty five The purpose of this study is to determine The salivary cotinine levels were evaluated (bi-weekly), with one month for follow-up upon finishing persons (62.5%); farmer groups were seven persons correlation between GTS from dry Thai traditional using NicAlertTM Saliva strip tests - an the tobacco work. Personal interviews are used to collect (35.0%) and non-farmer group were eighteen persons tobacco production and salivary cotinine levels among immunochromatographic assay using monoclonal information to measure the occurrence of the subjective (90.0%). Total of testing found on Level 1 (10-30 Thai traditional tobacco farmers at Praputthabath Sub- antibodies (Nymox Pharmaceutical Cooperation, St.- health symptoms and risk factors for nicotine exposure, ng/mL of cotinine concentration) was seven persons District, Chiangklang District and Phatow Sub-District, Laurent, QC, Canada). The system provides a semi- included smoking status, and process of tobacco work, (17.5%); farmers group were five persons (25.0%) and Thawangpha District, in Nan Province, Thailand. Data quantitative measurement of cotinine in saliva for personal protective equipment (PPE) use and hours non-farmer group were two persons (10.0%). Total of 124 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 125 testing found on Level 2 (30-100 ng/mL of cotinine and non-farmer group were twelve persons (50.0%). and non-farmer group were seventeen persons Test 7: totally of testing found on Level 0 concentration) was five persons; farmers group were Total of testing found on Level 1 (10-30 ng/mL of (85.0%). Total of testing found on Level 1 (10-30 (0-10 ng/mL of cotinine concentration) were thirty-nine five persons (25.0% ) and none of non-farmer group. cotinine concentration) were six persons (15.0%); ng/mL of cotinine concentration) were six persons persons (97.5%); nineteen persons (95.0%) of farmer Test 2: totally of testing found on Level 0 (0-10 ng/mL farmers group were three person (15.0% ) and non- (15.0%); three persons (15.0%) of farmers group group and non-farmer group were twenty persons of cotinine concentration) were twenty seventeen persons farmer group were three persons (15.0%). Total of and non-farmer group were three persons (15.0%). (100.0%). Total of testing found on Level 1 (10-30 ng/ (42.5%); farmer groups were four persons (20.0%) and testing found on Level 2 (30-100 ng/mL of cotinine Total of testing found on Level 2 (30-100 ng/mL of mL of cotinine concentration) was one person (2.5%); non- farmer group were thirteen persons (65.0%). Total concentration) were eleven persons (27.5%); farmers cotinine concentration) were six persons (15.0%); one person (5.0%) of farmers group and none of non- of testing found on Level 1 (10-30 ng/mL of cotinine group were six persons (30.0% ) and five persons farmers group were six persons (30.0%) and none of farmer group. The results of the test of salivary cotinine concentration) were two persons (5.0%); farmers group (25.0%) of non-farmer group. Total of testing found non-farmer group. Total of testing found on Level 3 levels was found that almost of farmer group have higher was one person (5.0%) and non-farmer group was one on Level 3 (100-200 ng/mL of cotinine concentration) (100-200 ng/mL of cotinine concentration) were levels of cotinine concentration more than non-farmer person (5.0%). Total of testing found on Level 2 (30-100 were nine persons (22.5%); farmers group were nine eleven persons (27.5%); farmers group were eleven group (Table 3). ng/mL of cotinine concentration) were ten persons (25%); persons (45.0% ) and none of non-farmer group. Total persons (55.0% ) and none of non-farmer group. farmers group were five persons (25.0% ) and five persons of testing found on Level 4 (200-500 ng/mL of cotinine (25.0%) of non-farmer group. Total of testing found on concentration) was one person (2.5%); farmers group Table 3. Distribution of salivary cotinine levels on Thai traditional tobacco farmers and non-farmers by time of testing (n=40) Level 3 (100-200 ng/mL of cotinine concentration) were was one person (5.0% ) and none of non-farmer group. Cotinine T1* n (%) T2* n (%) T3* n (%) T4* n (%) eleven persons (27.5%); farmers group were ten persons Test 4: totally of testing found on Level 0 Level concentration NF F Total NF F Total NF F Total NF F Total (50.0% ) and one persons (5.0%) of non-farmer group. (0-10 ng/mL of cotinine concentration) were sixteen (ng/mL) n=20 n=20 N=40 n=20 n=20 N=40 n=20 n=20 N=40 n =20 n=20 N=40 persons (40.0%); farmer group were three persons 0 0-10 18(90.0) 7(35.0) 25(62.5) 13(65.0) 4(20.0) 17(42.5) 12(60.0) 1(5.0) 13(32.5) 13(65.0) 3(15.0) 16(40.0) Table 2. Characteristics of the study population (%) (15.0%) and non-farmer group were thirteen persons 1 10-30 2 (10.0) 5 (25.0) 7 (17.5) 1(5.0) 1(5.0) 2(5.0) 3(15.0) 3(15.0) 6(15.0) 2(10.0) 0(0) 2(5.0) Non-farmer Farmer (65.0%). Total of testing found on Level 1 (10-30 Characteristics 2 30-100 0 (0) 5 (25.0) 5(12.5) 5(25.0) 5(25.0) 10(25.0) 5(25.0) 6(30.0) 11(27.5) 3(15.0) 3(15.0) 6(15.0) (n=20) (n=20) ng/mL of cotinine concentration) were two persons 3 100-200 0 (0) 3 (15.0) 3 (7.5) 1(5.0) 10(50.0) 11(27.5) 0(0) 9(45.0) 9(22.5) 2(10.0) 11(55.0) 13(32.5) Gender (5.0%); none of farmers group and non- farmer group 4 200-500 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 1(5.0) 1(2.5) 0(0) 3(15.0) 3(7.5) Male 10 (50.0) 10 (50.0) were two persons (10.0%). Total of testing found on Female 10 (50.0) 10 (50.0) Level 2 (30-100 ng/mL of cotinine concentration) Cotinine T5* n (%) T6* n (%) T7* n (%) Age group (years) were six persons (15.0%); farmers group were three Level concentration NF F Total NF F Total NF F Total 42 - 50 11 (55.0) 11 (55.0) persons (15.0%) and three persons (15.0%) of non- (ng/mL) n=20 n=20 N=40 n=20 n=20 N=40 n=20 n=20 N=40 51 - 60 9 (45.0) 9 (45.0) farmer group. Total of testing found on Level 3 (100-200 ng/mL of cotinine concentration) were 0 0-10 13(65.0) 5(25.0) 18(45.0) 17(85.0) 0(0) 17(42.5) 20(100.0) 19(95.0) 39(97.5) Mean age = 50.18, SD = 4.93, Min= 42, Max = 60 thirteen persons (32.5%); farmers group were 1 10-30 6(30.0) 3(15.0) 9(22.5) 3(15.0) 3(15.0) 6(15.0) 0(0) 1(5.0) 1(2.5) Status in family eleven persons (55.0% ) and two of non- farmer 2 30-100 1(5.0) 6(30.0) 7(17.5) 0(0) 6(30.00 6(15.0) 0(0) 0(0) 0(0) Head of family 10 (50.0) 11 (55.0) group (10.0%). Total of testing found on Level 4 3 100-200 0(0) 5(25.0) 5(12.5) 0(0) 11(55.0) 11(27.5) 0(0) 0(0) 0(0) Housewife 10 (50.0) 9 (45.0) (200-500 ng/mL of cotinine concentration) were three 4 200-500 0(0) 1(5.0) 1(2.5) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) Education level persons (7.5%); farmers group were three persons (15.0% ) and none of non-farmer group. *P<0.05, T=sequence of time for testing; T7= testing after tobacco work was finished 1 month Primary school 20 (100) 17 (85.0) NF= non-farmer, F=farmer Test 5: totally of testing found on Level 0 Secondary High 0 (0) 3 (15.0) school (0-10 ng/mL of cotinine concentration) were eighteen persons (45.0%); farmer group were five These results indicate that there is a correlation headache was correlated with salivary cotinine levels Smoking persons (25.0%) and non-farmer group were thirteen between salivary cotinine levels and tobacco farming at every test. On the other hand, vomiting was found No 20 (100) 19 (95.0) persons (65.0%). Total of testing found on Level 1 at every test time point, except in time point 7, which to be correlated with salivary cotinine levels in three Yes 0 (0) 1 (5.0) (10-30 ng/mL of cotinine concentration) were had no correlation (p>0.05). The data also indicates tests (T4, T5, and T6), whereas nausea was not found Living with smoking nine persons (22.5%); three persons (15.0%) of a strong correlation between the dry Thai traditional to have a correlation with salivary cotinine levels in No 20 (0) 20 (100) farmers group and non-farmer group were six tobacco process of handling tobacco and salivary all six tests (T1-T6). Finally, dizziness was strongly Yes 0 (0) 0 (0) persons (30.0%). Total of testing found on Level 2 cotinine levels (p<0.01). According to the study correlated with salivary cotinine levels only in the first Alcohol consump- (30-100 ng/mL of cotinine concentration) were seven findings, the correlation between four main symptoms test (T1). The correlation between tobacco farmers’ use tion persons (17.5%); farmers group were six persons of green tobacco sickness (GTS) including headache, of personal protective equipment and salivary cotinine No 19 (95.0) 18(90.0) (30.0% ) and one person (5.0%) of non-farmer group. nausea, vomiting, and dizziness and salivary cotinine levels was highest in the sixth test. The correlation Yes 1 (5.0) 2(10.0) Total of testing found on Level 3 (100-200 ng/mL of levels were found. Simply put, tobacco farmers were between PPE use of wearing a long-sleeved shirt, Work with tobacco cotinine concentration) were five persons (12.5%); likely to have a strong correlation with salivary wearing gloves, and wearing a face mask was found (hours) farmers group were five persons (25.0% ) and none cotinine levels as shown in six out of the seven tests to be high in all of the first six tests (T1-T6) with the 0-5 0 (0) 8(40.0) of non-farmer group. Total of testing found on Level conducted (T1-T6). Furthermore, it was found that p-value of 0.01 (Table 4). 6-10 0 (0) 12(60.0) 4 (200-500 ng/mL of cotinine concentration) was one Mean = 5.26, SD= 4.19, Min= 0, Max = 10 person (2.5%); farmers group was one person (5.0% ) and none of non- farmer group. Test 3: totally of testing found on Level 0 Test 6: totally of testing found on Level (0-10 ng/mL of cotinine concentration) were thirteen 0 (0-10 ng/mL of cotinine concentration) were persons (32.5%); farmer group was one person (5.0%) seventeen persons (42.5%); none of farmer group 124 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 125 testing found on Level 2 (30-100 ng/mL of cotinine and non-farmer group were twelve persons (50.0%). and non-farmer group were seventeen persons Test 7: totally of testing found on Level 0 concentration) was five persons; farmers group were Total of testing found on Level 1 (10-30 ng/mL of (85.0%). Total of testing found on Level 1 (10-30 (0-10 ng/mL of cotinine concentration) were thirty-nine five persons (25.0% ) and none of non-farmer group. cotinine concentration) were six persons (15.0%); ng/mL of cotinine concentration) were six persons persons (97.5%); nineteen persons (95.0%) of farmer Test 2: totally of testing found on Level 0 (0-10 ng/mL farmers group were three person (15.0% ) and non- (15.0%); three persons (15.0%) of farmers group group and non-farmer group were twenty persons of cotinine concentration) were twenty seventeen persons farmer group were three persons (15.0%). Total of and non-farmer group were three persons (15.0%). (100.0%). Total of testing found on Level 1 (10-30 ng/ (42.5%); farmer groups were four persons (20.0%) and testing found on Level 2 (30-100 ng/mL of cotinine Total of testing found on Level 2 (30-100 ng/mL of mL of cotinine concentration) was one person (2.5%); non- farmer group were thirteen persons (65.0%). Total concentration) were eleven persons (27.5%); farmers cotinine concentration) were six persons (15.0%); one person (5.0%) of farmers group and none of non- of testing found on Level 1 (10-30 ng/mL of cotinine group were six persons (30.0% ) and five persons farmers group were six persons (30.0%) and none of farmer group. The results of the test of salivary cotinine concentration) were two persons (5.0%); farmers group (25.0%) of non-farmer group. Total of testing found non-farmer group. Total of testing found on Level 3 levels was found that almost of farmer group have higher was one person (5.0%) and non-farmer group was one on Level 3 (100-200 ng/mL of cotinine concentration) (100-200 ng/mL of cotinine concentration) were levels of cotinine concentration more than non-farmer person (5.0%). Total of testing found on Level 2 (30-100 were nine persons (22.5%); farmers group were nine eleven persons (27.5%); farmers group were eleven group (Table 3). ng/mL of cotinine concentration) were ten persons (25%); persons (45.0% ) and none of non-farmer group. Total persons (55.0% ) and none of non-farmer group. farmers group were five persons (25.0% ) and five persons of testing found on Level 4 (200-500 ng/mL of cotinine (25.0%) of non-farmer group. Total of testing found on concentration) was one person (2.5%); farmers group Table 3. Distribution of salivary cotinine levels on Thai traditional tobacco farmers and non-farmers by time of testing (n=40) Level 3 (100-200 ng/mL of cotinine concentration) were was one person (5.0% ) and none of non-farmer group. Cotinine T1* n (%) T2* n (%) T3* n (%) T4* n (%) eleven persons (27.5%); farmers group were ten persons Test 4: totally of testing found on Level 0 Level concentration NF F Total NF F Total NF F Total NF F Total (50.0% ) and one persons (5.0%) of non-farmer group. (0-10 ng/mL of cotinine concentration) were sixteen (ng/mL) n=20 n=20 N=40 n=20 n=20 N=40 n=20 n=20 N=40 n =20 n=20 N=40 persons (40.0%); farmer group were three persons 0 0-10 18(90.0) 7(35.0) 25(62.5) 13(65.0) 4(20.0) 17(42.5) 12(60.0) 1(5.0) 13(32.5) 13(65.0) 3(15.0) 16(40.0) Table 2. Characteristics of the study population (%) (15.0%) and non-farmer group were thirteen persons 1 10-30 2 (10.0) 5 (25.0) 7 (17.5) 1(5.0) 1(5.0) 2(5.0) 3(15.0) 3(15.0) 6(15.0) 2(10.0) 0(0) 2(5.0) Non-farmer Farmer (65.0%). Total of testing found on Level 1 (10-30 Characteristics 2 30-100 0 (0) 5 (25.0) 5(12.5) 5(25.0) 5(25.0) 10(25.0) 5(25.0) 6(30.0) 11(27.5) 3(15.0) 3(15.0) 6(15.0) (n=20) (n=20) ng/mL of cotinine concentration) were two persons 3 100-200 0 (0) 3 (15.0) 3 (7.5) 1(5.0) 10(50.0) 11(27.5) 0(0) 9(45.0) 9(22.5) 2(10.0) 11(55.0) 13(32.5) Gender (5.0%); none of farmers group and non- farmer group 4 200-500 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 1(5.0) 1(2.5) 0(0) 3(15.0) 3(7.5) Male 10 (50.0) 10 (50.0) were two persons (10.0%). Total of testing found on Female 10 (50.0) 10 (50.0) Level 2 (30-100 ng/mL of cotinine concentration) Cotinine T5* n (%) T6* n (%) T7* n (%) Age group (years) were six persons (15.0%); farmers group were three Level concentration NF F Total NF F Total NF F Total 42 - 50 11 (55.0) 11 (55.0) persons (15.0%) and three persons (15.0%) of non- (ng/mL) n=20 n=20 N=40 n=20 n=20 N=40 n=20 n=20 N=40 51 - 60 9 (45.0) 9 (45.0) farmer group. Total of testing found on Level 3 (100-200 ng/mL of cotinine concentration) were 0 0-10 13(65.0) 5(25.0) 18(45.0) 17(85.0) 0(0) 17(42.5) 20(100.0) 19(95.0) 39(97.5) Mean age = 50.18, SD = 4.93, Min= 42, Max = 60 thirteen persons (32.5%); farmers group were 1 10-30 6(30.0) 3(15.0) 9(22.5) 3(15.0) 3(15.0) 6(15.0) 0(0) 1(5.0) 1(2.5) Status in family eleven persons (55.0% ) and two of non- farmer 2 30-100 1(5.0) 6(30.0) 7(17.5) 0(0) 6(30.00 6(15.0) 0(0) 0(0) 0(0) Head of family 10 (50.0) 11 (55.0) group (10.0%). Total of testing found on Level 4 3 100-200 0(0) 5(25.0) 5(12.5) 0(0) 11(55.0) 11(27.5) 0(0) 0(0) 0(0) Housewife 10 (50.0) 9 (45.0) (200-500 ng/mL of cotinine concentration) were three 4 200-500 0(0) 1(5.0) 1(2.5) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) Education level persons (7.5%); farmers group were three persons (15.0% ) and none of non-farmer group. *P<0.05, T=sequence of time for testing; T7= testing after tobacco work was finished 1 month Primary school 20 (100) 17 (85.0) NF= non-farmer, F=farmer Test 5: totally of testing found on Level 0 Secondary High 0 (0) 3 (15.0) school (0-10 ng/mL of cotinine concentration) were eighteen persons (45.0%); farmer group were five These results indicate that there is a correlation headache was correlated with salivary cotinine levels Smoking persons (25.0%) and non-farmer group were thirteen between salivary cotinine levels and tobacco farming at every test. On the other hand, vomiting was found No 20 (100) 19 (95.0) persons (65.0%). Total of testing found on Level 1 at every test time point, except in time point 7, which to be correlated with salivary cotinine levels in three Yes 0 (0) 1 (5.0) (10-30 ng/mL of cotinine concentration) were had no correlation (p>0.05). The data also indicates tests (T4, T5, and T6), whereas nausea was not found Living with smoking nine persons (22.5%); three persons (15.0%) of a strong correlation between the dry Thai traditional to have a correlation with salivary cotinine levels in No 20 (0) 20 (100) farmers group and non-farmer group were six tobacco process of handling tobacco and salivary all six tests (T1-T6). Finally, dizziness was strongly Yes 0 (0) 0 (0) persons (30.0%). Total of testing found on Level 2 cotinine levels (p<0.01). According to the study correlated with salivary cotinine levels only in the first Alcohol consump- (30-100 ng/mL of cotinine concentration) were seven findings, the correlation between four main symptoms test (T1). The correlation between tobacco farmers’ use tion persons (17.5%); farmers group were six persons of green tobacco sickness (GTS) including headache, of personal protective equipment and salivary cotinine No 19 (95.0) 18(90.0) (30.0% ) and one person (5.0%) of non-farmer group. nausea, vomiting, and dizziness and salivary cotinine levels was highest in the sixth test. The correlation Yes 1 (5.0) 2(10.0) Total of testing found on Level 3 (100-200 ng/mL of levels were found. Simply put, tobacco farmers were between PPE use of wearing a long-sleeved shirt, Work with tobacco cotinine concentration) were five persons (12.5%); likely to have a strong correlation with salivary wearing gloves, and wearing a face mask was found (hours) farmers group were five persons (25.0% ) and none cotinine levels as shown in six out of the seven tests to be high in all of the first six tests (T1-T6) with the 0-5 0 (0) 8(40.0) of non-farmer group. Total of testing found on Level conducted (T1-T6). Furthermore, it was found that p-value of 0.01 (Table 4). 6-10 0 (0) 12(60.0) 4 (200-500 ng/mL of cotinine concentration) was one Mean = 5.26, SD= 4.19, Min= 0, Max = 10 person (2.5%); farmers group was one person (5.0% ) and none of non- farmer group. Test 3: totally of testing found on Level 0 Test 6: totally of testing found on Level (0-10 ng/mL of cotinine concentration) were thirteen 0 (0-10 ng/mL of cotinine concentration) were persons (32.5%); farmer group was one person (5.0%) seventeen persons (42.5%); none of farmer group 126 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 127

Table 4. The salivary cotinine levels in Thai traditional tobacco farmers and non-farmers as a function of tobacco handling The correlation between GTS of the tobacco tobacco farmers absorb nicotine from the tobacco Salivary cotinine levels (ng/mL) farmers and salivary cotinine levels had a strong leaves. Gas chromatography-nitrogen phosphorous Dry tobacco producing process correlation at all testing timepoints (p<0.01). The detection (GC) is a valid, reliable, and commonly used T1 T2 T3 T4 T5 T6 T7*** prevalence of GTS in T1 to T7 was found to increase quantitative method for measuring cotinine in urine Tobacco Farmers (n =20) 0.591** 0.538** 0.680** 0.631** 0.539** 0.894** 0.160 in early testing (T2) and declined during T3 to T5. or saliva [10]. However, GC is a time-consuming Picking tobacco leaves 0.249 0.391* 0.680** 0.641** 0.539** 0.631** NA However, during T7 it was found that there was a 10% and relatively expensive method. There are many Transfer tobacco leaves 0.361* 0.244 0.311 0.476** 0.396* 0.435** NA prevalence of GTS suggesting it to be from one of alternative methods to GC but in this study we chose Grading tobacco leaves 0.415** 0.402* 0.720** 0.414** 0.474** 0.433** NA the tobacco farmers who smoked cigarettes and had the NicAlertTM Saliva strip test (NCTS) because Curing tobacco leaves 0.436** 0.324* 0.545** 0.371* 0.319* 0.303 NA symptoms that met definition of GTS. the test can detect as little as 10 ng/mL cotinine, Removing stem tobacco leaves 0.525** 0.458** 0.616** 0.631** 0.397* 0.433** NA requires minimal training to use reliably, can be used Rolling bundle tobacco leaves 0.429** 0.508** 0.616** 0.631** 0.397* 0.420** NA DISCUSSION anywhere, and provides results in approximately 30 Cutting tobacco leaves 0.238 0.448** 0.465** 0.538** 0.273 0.420** NA minutes. Moreover, providing a urine sample is often Putting tobacco slice on rack 0.526** 0.203 0.355* 0.512** 0.159 0.518** NA The Thai traditional tobacco process produces unacceptable for people and difficult to arrange in some a final product of dried tobacco. Almost all ofthe settings, whereas providing a saliva specimen is likely Reverse bamboo rack 0.404** 0.513** 0.477** 0.364* 0.417** 0.523** NA farmers are located in the northern part of Thailand. The to be more acceptable [23]. The diagnosis accuracy of Spraying tobacco exact 0.133 0.369* 0.231 0.121 NA NA NA unique method and process are carried out by the Thai NCTS has been tested in saliva with a sensitivity of Keeping dried tobacco 0.214 0.419** 0.553** 0.744** 0.487** 0.620** NA traditional tobacco farmers with intensive hard-work 99% and a specificity of 96% [20]. NCTS can detect *Significant at 0.05 probability level, **Significant at 0.01 probability level, ***T7= Control (after finished for 1 month) and family labor. The demographic characteristics of exposure to nicotine from all sources (e.g., nicotine There was a strong correlation between the four correlated with salivary cotinine levels only in the last the study populations are representative of rural areas replacement therapy, chewing tobacco, cigar, and main kinds of GTS subjective health symptoms sample testing timepoints (T4, T5, T6) and nausea in the northern part of Thailand. Almost all of the second-hand smoke; SHS), not just from cigarettes (headache, nausea, vomiting and dizziness) and was not correlated with salivary cotinine levels in any farmers graduated from primary school and followed [7]. From this study it was found that NCTS can salivary cotinine levels (T1-T6). Headache was sampling timepoint (T1-T6). Furthermore, dizziness farming as the traditional occupation. The average age detect cotinine level in both tobacco and non-tobacco correlated with salivary cotinine levels in each was strongly correlated with salivary cotinine levels in of farmers was quite high which is a big proportion of farmers, whereas the correlation between salivary sampling timepoint. Conversely vomiting was only the first test (T1) (Table 5). agriculturalists at the present time in the rural areas. cotinine levels among tobacco farmers were different Thai traditional tobacco cultivation in this area is part from non-farmers with statistical significance. In Table 5. The correlation between subjective health symptoms and salivary cotinine levels among Thai traditional tobacco of the culture and folk life of northern Thailand. From addition, NCTS maybe a physical tool for exposure farmers and non-farmers (n=40) previous studies, health effects of tobacco cultivation surveillance among the non-farmers who do not Salivary cotinine levels (R ) were known to be caused by nicotine, which penetrates work with tobacco, but smoke or live with smoking Dry tobacco producing process T1 T2 T3 T4 T5 T6 T7 through the skin of the hands of workers who cultivate family members or are exposed to second-hand smoke and harvest tobacco [9, 18, 19]. From this study it was (SHS). Our analysis showed that GTS prevalence at Tobacco Farmers (n =20) 0.591** 0.538** 0.680** 0.631** 0.539** 0.894** 0.160 shown that the prevalence of GTS among farmers each timepoint measured to describe the internal dose Headache 0.488** 0.399* 0.455** 0.413** 0.569** 0.504** -0.053 increased in the early testing timepoints (T1 and T2) of nicotine, estimated by salivary cotinine, accounted Nausea 0.264 0.195 0.200 NA NA 0.088 NA and declined during last testing timepoints (T3 to T5). for the relationship between working in the processing Vomiting 0.232 0.059 0.303 0.384* 0.426** 0.416** NA This may support the results in the study conducted of dry Thai traditional tobacco and GTS. This was Dizziness 0.554** 0.019 NA NA NA 0.001 NA by Trapé-Cardoso et al. (2003) who found that corroborated by the study results of Trikunakornwongs *Significant at 0.05 probability level, **Significant at 0.01 probability level, T=time to testing nonsmokers were more likely than smokers to develop et al. [27]. This study found that the nicotine dust possible GTS symptoms and that nonsmokers may be exposure via the dermal route may promote the The correlation between tobacco farmers and levels was also strongly correlated with wearing especially vulnerable to GTS [4, 12]. The reason was absorption of nicotine from dust more than inhalation salivary cotinine levels had the highest correlation a long sleeved shirt, gloves, and masks in all of the test presumably because smokers were tolerant to nicotine because of the moisture from sweating in the summer in test timepoint T6. PPE use and salivary cotinine timepoints (T1-T6) with a p-value of 0.01 (Table 6). and therefore were less likely to have symptoms in a similar way as moisture has promoted GTS among when exposed to additional nicotine [26]. Similarly to the harvesters [11]. In addition, those who work all day Table 6. The correlation between personal protective equipment (PPE) use and salivary cotinine levels among Thai traditional previous studies [4, 5, 11, 12, 13] the use of tobacco and every day may be exposed to nicotine dust through tobacco farmers and non-farmers (n=40) products (smoking or smokeless) appears to decrease both inhalation and dermal contact for prolonged Salivary cotinine levels (R ) PPE use in dry tobacco producing process absorption of nicotine and the dermal absorption periods of time and may develop some symptoms [27] T1 T2 T3 T4 T5 T6 T7*** variable “smoking tobacco” had a significant inverse related to GTS. Moreover, from the tobacco working Tobacco Farmers (n =20) 0.591** 0.860** 0.680** 0.631** 0.539** 0.894** 0.160 relationship to GTS incidence [2]. On the other process, the correlation between improper use of Wearing long sleeved shirt 0.442** 0.692** 0.575** 0.471** 0.529** 0.494** NA hand, from this study it was found that only one of personal protective equipment (PPE) and salivary Wearing long legged pants 0.549** 1.000 0.427** 0.342* 0.511** 0.510** NA farmers who smoked cigarettes had subjective health cotinine level were considered risk factors for GTS. Wearing rain coat -0.120 0.186 NA NA NA NA NA symptoms which met the definition of GTS. Similarly the previous study by Arcury et al. [1] found This study aimed to test the hypothesis that there is that the internal dose of nicotine, as estimated by Wearing plastic apron 0.021 0.489** 0.368* 0.259 0.379* 0.304 NA a positive association between salivary cotinine levels salivary cotinine was correlated with the relationship Wearing gloves 0.411** 0.692** 0.635** 0.631** 0.559** 0.690** NA and GTS among Thai traditional tobacco farmers. between work behaviors and GTS [3]. The detection Wearing boots 0.233 0.603** 0.349* 0.553** 0.575** 0.631** NA In parallel the second purpose was to determine the of nicotine poisoning from dried Thai traditional Mask 0.591** 0.860** 0.680** 0.631** 0.539** 0.894** NA salivary cotinine levels of the tobacco farmers across tobacco production via inhalation, absorption or Changing wet suit during work 0.034 0.440** 0.196 0.333* 0.261 0.496** NA the dry tobacco producing areas and to conduct follow dermal absorption must consider the specific effects * significant at 0.05 probability level, **significant at 0.01 probability level, *** T7= control (after finished for 1 month) up studies to determine whether or not Thai traditional of route of exposure. The results of this study found 126 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 127

Table 4. The salivary cotinine levels in Thai traditional tobacco farmers and non-farmers as a function of tobacco handling The correlation between GTS of the tobacco tobacco farmers absorb nicotine from the tobacco Salivary cotinine levels (ng/mL) farmers and salivary cotinine levels had a strong leaves. Gas chromatography-nitrogen phosphorous Dry tobacco producing process correlation at all testing timepoints (p<0.01). The detection (GC) is a valid, reliable, and commonly used T1 T2 T3 T4 T5 T6 T7*** prevalence of GTS in T1 to T7 was found to increase quantitative method for measuring cotinine in urine Tobacco Farmers (n =20) 0.591** 0.538** 0.680** 0.631** 0.539** 0.894** 0.160 in early testing (T2) and declined during T3 to T5. or saliva [10]. However, GC is a time-consuming Picking tobacco leaves 0.249 0.391* 0.680** 0.641** 0.539** 0.631** NA However, during T7 it was found that there was a 10% and relatively expensive method. There are many Transfer tobacco leaves 0.361* 0.244 0.311 0.476** 0.396* 0.435** NA prevalence of GTS suggesting it to be from one of alternative methods to GC but in this study we chose Grading tobacco leaves 0.415** 0.402* 0.720** 0.414** 0.474** 0.433** NA the tobacco farmers who smoked cigarettes and had the NicAlertTM Saliva strip test (NCTS) because Curing tobacco leaves 0.436** 0.324* 0.545** 0.371* 0.319* 0.303 NA symptoms that met definition of GTS. the test can detect as little as 10 ng/mL cotinine, Removing stem tobacco leaves 0.525** 0.458** 0.616** 0.631** 0.397* 0.433** NA requires minimal training to use reliably, can be used Rolling bundle tobacco leaves 0.429** 0.508** 0.616** 0.631** 0.397* 0.420** NA DISCUSSION anywhere, and provides results in approximately 30 Cutting tobacco leaves 0.238 0.448** 0.465** 0.538** 0.273 0.420** NA minutes. Moreover, providing a urine sample is often Putting tobacco slice on rack 0.526** 0.203 0.355* 0.512** 0.159 0.518** NA The Thai traditional tobacco process produces unacceptable for people and difficult to arrange in some a final product of dried tobacco. Almost all ofthe settings, whereas providing a saliva specimen is likely Reverse bamboo rack 0.404** 0.513** 0.477** 0.364* 0.417** 0.523** NA farmers are located in the northern part of Thailand. The to be more acceptable [23]. The diagnosis accuracy of Spraying tobacco exact 0.133 0.369* 0.231 0.121 NA NA NA unique method and process are carried out by the Thai NCTS has been tested in saliva with a sensitivity of Keeping dried tobacco 0.214 0.419** 0.553** 0.744** 0.487** 0.620** NA traditional tobacco farmers with intensive hard-work 99% and a specificity of 96% [20]. NCTS can detect *Significant at 0.05 probability level, **Significant at 0.01 probability level, ***T7= Control (after finished for 1 month) and family labor. The demographic characteristics of exposure to nicotine from all sources (e.g., nicotine There was a strong correlation between the four correlated with salivary cotinine levels only in the last the study populations are representative of rural areas replacement therapy, chewing tobacco, cigar, and main kinds of GTS subjective health symptoms sample testing timepoints (T4, T5, T6) and nausea in the northern part of Thailand. Almost all of the second-hand smoke; SHS), not just from cigarettes (headache, nausea, vomiting and dizziness) and was not correlated with salivary cotinine levels in any farmers graduated from primary school and followed [7]. From this study it was found that NCTS can salivary cotinine levels (T1-T6). Headache was sampling timepoint (T1-T6). Furthermore, dizziness farming as the traditional occupation. The average age detect cotinine level in both tobacco and non-tobacco correlated with salivary cotinine levels in each was strongly correlated with salivary cotinine levels in of farmers was quite high which is a big proportion of farmers, whereas the correlation between salivary sampling timepoint. Conversely vomiting was only the first test (T1) (Table 5). agriculturalists at the present time in the rural areas. cotinine levels among tobacco farmers were different Thai traditional tobacco cultivation in this area is part from non-farmers with statistical significance. In Table 5. The correlation between subjective health symptoms and salivary cotinine levels among Thai traditional tobacco of the culture and folk life of northern Thailand. From addition, NCTS maybe a physical tool for exposure farmers and non-farmers (n=40) previous studies, health effects of tobacco cultivation surveillance among the non-farmers who do not Salivary cotinine levels (R ) were known to be caused by nicotine, which penetrates work with tobacco, but smoke or live with smoking Dry tobacco producing process T1 T2 T3 T4 T5 T6 T7 through the skin of the hands of workers who cultivate family members or are exposed to second-hand smoke and harvest tobacco [9, 18, 19]. From this study it was (SHS). Our analysis showed that GTS prevalence at Tobacco Farmers (n =20) 0.591** 0.538** 0.680** 0.631** 0.539** 0.894** 0.160 shown that the prevalence of GTS among farmers each timepoint measured to describe the internal dose Headache 0.488** 0.399* 0.455** 0.413** 0.569** 0.504** -0.053 increased in the early testing timepoints (T1 and T2) of nicotine, estimated by salivary cotinine, accounted Nausea 0.264 0.195 0.200 NA NA 0.088 NA and declined during last testing timepoints (T3 to T5). for the relationship between working in the processing Vomiting 0.232 0.059 0.303 0.384* 0.426** 0.416** NA This may support the results in the study conducted of dry Thai traditional tobacco and GTS. This was Dizziness 0.554** 0.019 NA NA NA 0.001 NA by Trapé-Cardoso et al. (2003) who found that corroborated by the study results of Trikunakornwongs *Significant at 0.05 probability level, **Significant at 0.01 probability level, T=time to testing nonsmokers were more likely than smokers to develop et al. [27]. This study found that the nicotine dust possible GTS symptoms and that nonsmokers may be exposure via the dermal route may promote the The correlation between tobacco farmers and levels was also strongly correlated with wearing especially vulnerable to GTS [4, 12]. The reason was absorption of nicotine from dust more than inhalation salivary cotinine levels had the highest correlation a long sleeved shirt, gloves, and masks in all of the test presumably because smokers were tolerant to nicotine because of the moisture from sweating in the summer in test timepoint T6. PPE use and salivary cotinine timepoints (T1-T6) with a p-value of 0.01 (Table 6). and therefore were less likely to have symptoms in a similar way as moisture has promoted GTS among when exposed to additional nicotine [26]. Similarly to the harvesters [11]. In addition, those who work all day Table 6. The correlation between personal protective equipment (PPE) use and salivary cotinine levels among Thai traditional previous studies [4, 5, 11, 12, 13] the use of tobacco and every day may be exposed to nicotine dust through tobacco farmers and non-farmers (n=40) products (smoking or smokeless) appears to decrease both inhalation and dermal contact for prolonged Salivary cotinine levels (R ) PPE use in dry tobacco producing process absorption of nicotine and the dermal absorption periods of time and may develop some symptoms [27] T1 T2 T3 T4 T5 T6 T7*** variable “smoking tobacco” had a significant inverse related to GTS. Moreover, from the tobacco working Tobacco Farmers (n =20) 0.591** 0.860** 0.680** 0.631** 0.539** 0.894** 0.160 relationship to GTS incidence [2]. On the other process, the correlation between improper use of Wearing long sleeved shirt 0.442** 0.692** 0.575** 0.471** 0.529** 0.494** NA hand, from this study it was found that only one of personal protective equipment (PPE) and salivary Wearing long legged pants 0.549** 1.000 0.427** 0.342* 0.511** 0.510** NA farmers who smoked cigarettes had subjective health cotinine level were considered risk factors for GTS. Wearing rain coat -0.120 0.186 NA NA NA NA NA symptoms which met the definition of GTS. Similarly the previous study by Arcury et al. [1] found This study aimed to test the hypothesis that there is that the internal dose of nicotine, as estimated by Wearing plastic apron 0.021 0.489** 0.368* 0.259 0.379* 0.304 NA a positive association between salivary cotinine levels salivary cotinine was correlated with the relationship Wearing gloves 0.411** 0.692** 0.635** 0.631** 0.559** 0.690** NA and GTS among Thai traditional tobacco farmers. between work behaviors and GTS [3]. The detection Wearing boots 0.233 0.603** 0.349* 0.553** 0.575** 0.631** NA In parallel the second purpose was to determine the of nicotine poisoning from dried Thai traditional Mask 0.591** 0.860** 0.680** 0.631** 0.539** 0.894** NA salivary cotinine levels of the tobacco farmers across tobacco production via inhalation, absorption or Changing wet suit during work 0.034 0.440** 0.196 0.333* 0.261 0.496** NA the dry tobacco producing areas and to conduct follow dermal absorption must consider the specific effects * significant at 0.05 probability level, **significant at 0.01 probability level, *** T7= control (after finished for 1 month) up studies to determine whether or not Thai traditional of route of exposure. The results of this study found 128 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 129

that those who had symptoms consistent with GTS did among the tobacco farmers group at any time to testing 6. Centers for Disease Control and Prevention. (CDC). 18. McBride JS., Altman DG., Klein M., White, W.: Green not appear to have any correlation between salivary across the crop season. This study was different from Green tobacco sickness in tobacco harvesters-Kentucky, tobacco sickness. Tobacco Control 1998;7(3): 294-298. cotinine levels and nausea. However, only the first test previous studies that showed that GTS and salivary 1992. MMWR. Morbidity and mortality weekly report. 19. McKnight RH., Koetke CA., Donnelly C.: Familial timepoints demonstrated correlation with dizziness cotinine levels were correlated in workers who worked 1993; 42(13): p. 237. clusters of green tobacco sickness. Journal of and then did not have any correlation, possibly due in humid conditions because the nicotine penetrates 7. Cooke F., Bullen C., Whittaker R., McRobbie H., Chen Agromedicine 1996;3(2): 51-59. M. H., Walker N.: Diagnostic accuracy of NicAlert 20. Montalto N., Wells W., Sloan S., Wolfe D., Wilkinson to tolerance to nicotine poisoning [26]. Additionally through the skin of the hands of workers who cultivate cotinine test strips in saliva for verifying smoking J., Barr M.: Saliva cotinine: A rapid semi-quantitative the tobacco farmers who wore the necessary PPE to and harvest tobacco. Finally, although the short-term status. Nicotine & Tobacco Research 2008;10(4): 607- dipstick method for assessment of self-reported protect from the pungent odor from dried tobacco effects of this exposure may be symptoms of nicotine 612. smoking status. In 13th World Conference on Tobacco were able to reduce inhalation of the vapors. poisoning as defined of GTS, the long-term effects 8. Curvall M., Elwin C. E., Kazemi-Vala E., Warholm or Health: Building capacity for a tobacco-free world. GTS prevention should be based on methods of such exposure should be investigated and health C., Enzell, C. R.: The pharmacokinetics of cotinine Washington, DC. 2006. to reduce nicotine absorption. This study showed education programs with health risk exposure for in plasma and saliva from non-smoking healthy 21. Nuca C. I., Amariei C. I., Badea V. V., Zaharia A. N., that the high correlation between PPE and salivary increased awareness of farmers is recommended. volunteers. European Journal of Clinical Pharmacology Arendt C. T.: Salivary cotinine, self-reported smoking cotinine levels were consistent when wearing long 1990;38(3): 281-287. status and heaviness of smoking index in adults from sleeved shirts, gloves and masks. However, in order Acknowledgement 9. Curwin BD., Hein MJ., Sanderson WT., Nishioka MG., Constanta, Romania. OHDM 2011;10 (1). to be accepted, protective suits and gloves should be Buhler W.: Nicotine exposure and decontamination 22. Onuki M., Yokoyama K., Kimura K., Sato H., Nordin R. lightweight and comfortable allowing the equipment The authors acknowledge the Thai Fogarty ITREOH on tobacco harvesters’ hands. Ann Occup Hyg 2005; B., Naing L., Araki, S.: Assessment of urinary cotinine to be used in hot climates [11, 25]. Center D43 TW007849 Fogarty International Center- 49(5): 407-13. as a marker of nicotine absorption from tobacco leaves: 10. Feyerabend C., Russell M.: A rapid gas-liquid a study on tobacco farmers in Malaysia. Journal of NIH, the NIH-NIEHS CEED P30 ES005022, and the chromatographic method for the determination of Occupational Health 2003; 45(3): 140-145. LIMITATION New Jersey Agricultural Experiment Station, Grant for cotinine and nicotine in biological fluids. Journal of 23. Peralta L., Constantine N., Deeds B. G., Martin, International Research Integration: Chula Research Pharmacy and Pharmacology 1990;42(6): 450-452. L., Ghalib, K.: Evaluation of youth preferences for Some limitations of this study should be noted. Scholar, Ratchadaphiseksomphot Endowment Fund 11. Gehlbach S. H., Williams W. A., Perry L. D., Freeman rapid and innovative human immunodeficiency virus First, individual variability in the metabolism and (GCURS 59.06.79.01) Chulalongkorn University for J. I., Langone J. J., Peta L. V., Van Vunakis H.: Nicotine antibody tests. Archives of Pediatrics & Adolescent clearance of cotinine and nicotine can affect the financial and research support. College of Public absorption by workers harvesting green tobacco. Lancet Medicine, 2001;155(7): 838-843. levels of cotinine detected in saliva. Second, it is Health Sciences, Chulalongkorn University, Bangkok, 1975;305(7905): 478-480. 24. Quandt S. A., Arcury T. A., Preisser J. S., Bernert J. T., also possible that we overestimated the occurrence of Thailand is also gratefully acknowledged. 12. Gehlbach S. H., Williams W. A., Perry L. D., Woodall Norton D.: Environmental and behavioral predictors GTS because the symptoms of GTS are nonspecific, J. S.: Green-tobacco sickness: An illness of tobacco of salivary cotinine in Latino tobacco workers. Journal and some individuals with other subjective health Conflict of interest harvesters. JAMA 1974;229(14): 1880-1883. of Occupational and Environmental Medicine 2001; symptoms such as heat stress or dehydration could The authors declare no conflict of interest. 13. Gehlbach S.,Williams W., Freeman J.: Protective 43(10):844-852. have been mistakenly included. The numbers reported clothing as a means of reducing nicotine absorption in 25. Rao P., Quandt S. A., Arcury T.: Hispanic farmworker tobacco harvesters. Archives of Environmental Health: interpretations of green tobacco sickness. The Journal in the individual studies depend on the case definitions An International Journal 1979;34(2): 111-114. of Rural Health 2002;18(4): 503-511. applied and health belief included the awareness of REFERENCES 14. Ghosh S. K., Parikh J. R., Gokani V. N., Rao M. 26. Trapé-Cardoso M., Bracker A., Grey M., Kaliszewski stakeholders that the condition GTS exists. N., Kashyap S. K., Chatterjee, S. K.: Studies on M., Oncken C., Ohannessian C., Gould B.: Shade 1. Arcury T. A., Quandt S. A., Preisser J. S., Bernert J. T., occupational health problems in agricultural tobacco tobacco and green tobacco sickness in Connecticut. CONCLUSION Norton D., Wang J.: High levels of transdermal nicotine workers. Occupational Medicine 1980;30(3):113-117. Journal of Occupational and Environmental Medicine exposure produce green tobacco sickness in Latino 15. Ghosh S. K., Gokani V. N., Doctor P. B., Parikh J. R., 2003; 45(6): 656-661. This analysis indicated that GTS continues to be farmworkers. Nicotine & Tobacco Research 2003; 5(3): Kashyap S. K.: Intervention studies against “green 27. Trikunakornwongs A., Kongtip P., Chantanakul S., a common occupational disease among Thai traditional 315-321. symptoms” among Indian tobacco harvesters. Archives Yoosook W., Loosereewanich P., Rojanavipart P.: 2. Arcury T.A., Quandt S.A., Preisser J.S.: Measuring tobacco farmers who cultivate and produce dry Thai of Environmental Health: An International Journal Assessment of nicotine inhalation exposure and urinary occupational illness incidence and prevalence in traditional tobacco. It is the first analysis to examine 1991;46(5): 316-317. cotinine of tobacco processing workers. J Med Assoc a difficult to study population: green tobacco sickness 16. Ghosh S. K., Gokani V. N., Parikh J. R., Doctor P. B., Thai 2009;92(7): S121-7. the correlation between salivary cotinine which was among Latino farmworkers in North Carolina. Journal measured by NCTS strip test and dry Thai tobacco Kashyap S. K., Chatterjee B. B.: Protection against 28. Yokoyama K.: Our recent experiences with sarin of Epidemiology and Community Health 2001;55(11): “green symptoms” from tobacco in Indian harvesters: poisoning cases in Japan and pesticide users with production, the use of personal protective equipment, 818-824. a preliminary intervention study. Archives of references to some selected chemicals. Neurotoxicology, and the occurrence of GTS. The NCTS is both a valid 3. Arcury T.A., Quandt S.A., Simmons S.: Farmer health Environmental Health: An International Journal 1987; 2007; 28(2): 364-73. and reliable test compared with the GC saliva test. In beliefs about an occupational illness that affects 42(2): 121-124. addition, measuring cotinine in saliva by NCTS may farmworkers: the case of green tobacco sickness. 17. Ghosh S. K., Parikh J. R., Gokani V. N., Kashyap S. Received: 02.01.2016 support testing in the field in a large population because Journal of Agricultural Safety and Health 2003; 9(1): K., Chatterjee S. K.: Studies on occupational health Accepted: 04.03.2016 NCTS was able to detect exposure to nicotine from all 33-45. problems during agricultural operation of Indian sources (e.g., nicotine replacement therapy, chewing 4. Ballard T., Ehlers, J., Freund E., Auslander M., Brandt tobacco workers: a preliminary survey report. Journal of tobacco, cigar, and second- hand smoke; SHS), not just V., Halperin W.: Green tobacco sickness: occupational Occupational and Environmental Medicine 1979;21(1): nicotine poisoning in tobacco workers. Archives from cigarettes. This study demonstrated that the use 45-47. of Environmental Health: An International Journal of salivary cotinine levels measured by NCTS were 1995;50(5): 384-389. well correlated with farmers who working with dry 5. Benowitz N.L.: Clinical pharmacology and toxicology tobacco production. Salivary cotinine levels were also of cocaine. Pharmacology & Toxicology 1993;72(1): p. significantly correlated with the prevalence of GTS 3-12. 128 T. Saleeon, W. Siriwong, H.L. Maldonado-Pérez et al. No 2 No 2 Salivary cotinine as a biomarker for green tobacco sickness among Thai farmers. 129 that those who had symptoms consistent with GTS did among the tobacco farmers group at any time to testing 6. Centers for Disease Control and Prevention. (CDC). 18. McBride JS., Altman DG., Klein M., White, W.: Green not appear to have any correlation between salivary across the crop season. This study was different from Green tobacco sickness in tobacco harvesters-Kentucky, tobacco sickness. Tobacco Control 1998;7(3): 294-298. cotinine levels and nausea. However, only the first test previous studies that showed that GTS and salivary 1992. MMWR. Morbidity and mortality weekly report. 19. McKnight RH., Koetke CA., Donnelly C.: Familial timepoints demonstrated correlation with dizziness cotinine levels were correlated in workers who worked 1993; 42(13): p. 237. clusters of green tobacco sickness. Journal of and then did not have any correlation, possibly due in humid conditions because the nicotine penetrates 7. Cooke F., Bullen C., Whittaker R., McRobbie H., Chen Agromedicine 1996;3(2): 51-59. M. H., Walker N.: Diagnostic accuracy of NicAlert 20. Montalto N., Wells W., Sloan S., Wolfe D., Wilkinson to tolerance to nicotine poisoning [26]. Additionally through the skin of the hands of workers who cultivate cotinine test strips in saliva for verifying smoking J., Barr M.: Saliva cotinine: A rapid semi-quantitative the tobacco farmers who wore the necessary PPE to and harvest tobacco. Finally, although the short-term status. Nicotine & Tobacco Research 2008;10(4): 607- dipstick method for assessment of self-reported protect from the pungent odor from dried tobacco effects of this exposure may be symptoms of nicotine 612. smoking status. In 13th World Conference on Tobacco were able to reduce inhalation of the vapors. poisoning as defined of GTS, the long-term effects 8. Curvall M., Elwin C. E., Kazemi-Vala E., Warholm or Health: Building capacity for a tobacco-free world. GTS prevention should be based on methods of such exposure should be investigated and health C., Enzell, C. R.: The pharmacokinetics of cotinine Washington, DC. 2006. to reduce nicotine absorption. This study showed education programs with health risk exposure for in plasma and saliva from non-smoking healthy 21. Nuca C. I., Amariei C. I., Badea V. V., Zaharia A. N., that the high correlation between PPE and salivary increased awareness of farmers is recommended. volunteers. European Journal of Clinical Pharmacology Arendt C. T.: Salivary cotinine, self-reported smoking cotinine levels were consistent when wearing long 1990;38(3): 281-287. status and heaviness of smoking index in adults from sleeved shirts, gloves and masks. However, in order Acknowledgement 9. Curwin BD., Hein MJ., Sanderson WT., Nishioka MG., Constanta, Romania. OHDM 2011;10 (1). to be accepted, protective suits and gloves should be Buhler W.: Nicotine exposure and decontamination 22. Onuki M., Yokoyama K., Kimura K., Sato H., Nordin R. lightweight and comfortable allowing the equipment The authors acknowledge the Thai Fogarty ITREOH on tobacco harvesters’ hands. Ann Occup Hyg 2005; B., Naing L., Araki, S.: Assessment of urinary cotinine to be used in hot climates [11, 25]. Center D43 TW007849 Fogarty International Center- 49(5): 407-13. as a marker of nicotine absorption from tobacco leaves: 10. Feyerabend C., Russell M.: A rapid gas-liquid a study on tobacco farmers in Malaysia. Journal of NIH, the NIH-NIEHS CEED P30 ES005022, and the chromatographic method for the determination of Occupational Health 2003; 45(3): 140-145. LIMITATION New Jersey Agricultural Experiment Station, Grant for cotinine and nicotine in biological fluids. Journal of 23. Peralta L., Constantine N., Deeds B. G., Martin, International Research Integration: Chula Research Pharmacy and Pharmacology 1990;42(6): 450-452. L., Ghalib, K.: Evaluation of youth preferences for Some limitations of this study should be noted. Scholar, Ratchadaphiseksomphot Endowment Fund 11. Gehlbach S. H., Williams W. A., Perry L. D., Freeman rapid and innovative human immunodeficiency virus First, individual variability in the metabolism and (GCURS 59.06.79.01) Chulalongkorn University for J. I., Langone J. J., Peta L. V., Van Vunakis H.: Nicotine antibody tests. Archives of Pediatrics & Adolescent clearance of cotinine and nicotine can affect the financial and research support. College of Public absorption by workers harvesting green tobacco. Lancet Medicine, 2001;155(7): 838-843. levels of cotinine detected in saliva. Second, it is Health Sciences, Chulalongkorn University, Bangkok, 1975;305(7905): 478-480. 24. Quandt S. A., Arcury T. A., Preisser J. S., Bernert J. T., also possible that we overestimated the occurrence of Thailand is also gratefully acknowledged. 12. Gehlbach S. H., Williams W. A., Perry L. D., Woodall Norton D.: Environmental and behavioral predictors GTS because the symptoms of GTS are nonspecific, J. S.: Green-tobacco sickness: An illness of tobacco of salivary cotinine in Latino tobacco workers. Journal and some individuals with other subjective health Conflict of interest harvesters. JAMA 1974;229(14): 1880-1883. of Occupational and Environmental Medicine 2001; symptoms such as heat stress or dehydration could The authors declare no conflict of interest. 13. Gehlbach S.,Williams W., Freeman J.: Protective 43(10):844-852. have been mistakenly included. The numbers reported clothing as a means of reducing nicotine absorption in 25. Rao P., Quandt S. A., Arcury T.: Hispanic farmworker tobacco harvesters. Archives of Environmental Health: interpretations of green tobacco sickness. The Journal in the individual studies depend on the case definitions An International Journal 1979;34(2): 111-114. of Rural Health 2002;18(4): 503-511. applied and health belief included the awareness of REFERENCES 14. Ghosh S. K., Parikh J. R., Gokani V. N., Rao M. 26. Trapé-Cardoso M., Bracker A., Grey M., Kaliszewski stakeholders that the condition GTS exists. N., Kashyap S. K., Chatterjee, S. K.: Studies on M., Oncken C., Ohannessian C., Gould B.: Shade 1. Arcury T. A., Quandt S. A., Preisser J. S., Bernert J. T., occupational health problems in agricultural tobacco tobacco and green tobacco sickness in Connecticut. CONCLUSION Norton D., Wang J.: High levels of transdermal nicotine workers. Occupational Medicine 1980;30(3):113-117. Journal of Occupational and Environmental Medicine exposure produce green tobacco sickness in Latino 15. Ghosh S. K., Gokani V. N., Doctor P. B., Parikh J. R., 2003; 45(6): 656-661. This analysis indicated that GTS continues to be farmworkers. Nicotine & Tobacco Research 2003; 5(3): Kashyap S. K.: Intervention studies against “green 27. Trikunakornwongs A., Kongtip P., Chantanakul S., a common occupational disease among Thai traditional 315-321. symptoms” among Indian tobacco harvesters. Archives Yoosook W., Loosereewanich P., Rojanavipart P.: 2. Arcury T.A., Quandt S.A., Preisser J.S.: Measuring tobacco farmers who cultivate and produce dry Thai of Environmental Health: An International Journal Assessment of nicotine inhalation exposure and urinary occupational illness incidence and prevalence in traditional tobacco. It is the first analysis to examine 1991;46(5): 316-317. cotinine of tobacco processing workers. J Med Assoc a difficult to study population: green tobacco sickness 16. Ghosh S. K., Gokani V. N., Parikh J. R., Doctor P. B., Thai 2009;92(7): S121-7. the correlation between salivary cotinine which was among Latino farmworkers in North Carolina. Journal measured by NCTS strip test and dry Thai tobacco Kashyap S. K., Chatterjee B. B.: Protection against 28. Yokoyama K.: Our recent experiences with sarin of Epidemiology and Community Health 2001;55(11): “green symptoms” from tobacco in Indian harvesters: poisoning cases in Japan and pesticide users with production, the use of personal protective equipment, 818-824. a preliminary intervention study. Archives of references to some selected chemicals. Neurotoxicology, and the occurrence of GTS. The NCTS is both a valid 3. Arcury T.A., Quandt S.A., Simmons S.: Farmer health Environmental Health: An International Journal 1987; 2007; 28(2): 364-73. and reliable test compared with the GC saliva test. In beliefs about an occupational illness that affects 42(2): 121-124. addition, measuring cotinine in saliva by NCTS may farmworkers: the case of green tobacco sickness. 17. Ghosh S. K., Parikh J. R., Gokani V. N., Kashyap S. Received: 02.01.2016 support testing in the field in a large population because Journal of Agricultural Safety and Health 2003; 9(1): K., Chatterjee S. K.: Studies on occupational health Accepted: 04.03.2016 NCTS was able to detect exposure to nicotine from all 33-45. problems during agricultural operation of Indian sources (e.g., nicotine replacement therapy, chewing 4. Ballard T., Ehlers, J., Freund E., Auslander M., Brandt tobacco workers: a preliminary survey report. Journal of tobacco, cigar, and second- hand smoke; SHS), not just V., Halperin W.: Green tobacco sickness: occupational Occupational and Environmental Medicine 1979;21(1): nicotine poisoning in tobacco workers. Archives from cigarettes. This study demonstrated that the use 45-47. of Environmental Health: An International Journal of salivary cotinine levels measured by NCTS were 1995;50(5): 384-389. well correlated with farmers who working with dry 5. Benowitz N.L.: Clinical pharmacology and toxicology tobacco production. Salivary cotinine levels were also of cocaine. Pharmacology & Toxicology 1993;72(1): p. significantly correlated with the prevalence of GTS 3-12. Rocz Panstw Zakl Hig 2016;67(2):131-136 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

ORIGINAL ARTICLE

BAKERY PRODUCTS AS A SOURCE OF TOTAL DIETARY FIBRE IN YOUNG ADULTS

Renata Markiewicz-Żukowska*, Justyna Moskwa, Krystyna Gromkowska-Kępka, Emilia Laskowska, Jolanta Soroczyńska, Justyna Tomczuk, Maria Halina Borawska

Medical University of Bialystok, Faculty of Pharmacy with Division of Laboratory Medicine, Department of Bromatology, Białystok, Poland

ABSTRACT Background. Bakery products are a source of bioactive compounds, such as dietary fibre (DF), whose proper supply plays an important role in prevention of civilisation diseases. Objective. The aim of the present study was to determine total dietary fibre (TDF) content in bakery products and their contribution to TDF supply. Material and Methods. The determination of TDF content was performed using enzymatic-gravimetric method in 72 samples of six types of bakery products (wholemeal rye bread, wheat-rye bread, wheat-rye bread with grains, toast bread, crispbread, rolls) included in the young adults diet. Simultaneously, frequency of bakery products consumption and their contribution to TDF supply were assessed based on dietary interview questionnaires carried out among 224 students from Poland. Index of nutritional quality (INQ) of examined bakery products was calculated. Results. Our data indicate that average TDF content depended on the type of bakery products and ranged from 2.19 g/100 g in rolls to 11.80 g/100 g in wholemeal rye bread. All of the tested types of bakery products, except rolls, were a good source of fibre (INQ≥1), but the richest were wholemeal rye and wheat-rye with grains breads. Analysis of questionnaires data showed that bakery products were regularly consumed by 80% of young adults; however, most of whom preferred rolls. Consumption of bakery products covered current recommendations for dietary fibre in 27%. Daily intake of bakery products and TDF was not correlated with student’s BMI, however, women frequently consuming bread had a lower BMI than those who rarely ate it. Conclusion. Wholemeal rye and wheat-rye with grains breads are the rich source of TDF and they should be consumed by young adults in order to achieve the recommended TDF values.

Key words: dietary fibre, bakery products, enzymatic-gravimetric method, dietary interview questionnaire, students

STRESZCZENIE Wprowadzenie. Pieczywo jest źródłem bioaktywnych składników, w tym również błonnika pokarmowego (DF), którego prawidłowa podaż z dietą odgrywa istotną rolę w prewencji chorób cywilizacyjnych. Cel. Oznaczenie zawartości całkowitego błonnika pokarmowego (TDF) w różnych rodzajach pieczywa i określenie udziału tych produktów w dostarczaniu błonnika z dietą. Materiał i Metody. Oznaczenie zawartości TDF metodą enzymatyczno-grawimetryczną wykonano w 72 próbach sześciu rodzajów pieczywa (chleb razowy żytni, chleb mieszany pszenno-żytni, chleb mieszany z ziarnami, chleb tostowy, chleb chrupki i bułki), których konsumpcję deklarowali studenci uczestniczący w badaniu. Częstość i wielkość spożycia poszczególnych rodzajów pieczywa oraz ich udział w dostarczaniu błonnika określono na podstawie wywiadu żywieniowego przeprowadzonego wśród 224 polskich studentów. Wyznaczono również wartość wskaźnika jakości żywieniowej (INQ) badanych produktów. Wyniki. Wykazano, że zawartość błonnika pokarmowego całkowitego zależała od rodzaju pieczywa i wynosiła średnio od 2,19 g/100 g w bułkach do 11,80 g/100 g w chlebie razowym żytnim. Wszystkie badane rodzaje pieczywa, za wyjątkiem bułek, były dobrym źródłem błonnika (INQ≥1), przy czym najbogatszym był chleb razowy żytni i chleb mieszany z ziarnami. Na podstawie analizy danych ankietowych stwierdzono, że 80% studentów regularnie spożywało pieczywo, ale najczęściej wybierali oni bułki. Spożywane przez badanych studentów pieczywo zapewniało pokrycie zapotrzebowania na błonnik w 27%. Nie stwierdzono korelacji pomiędzy ilością błonnika spożywanego z pieczywem a wartościami BMI studentów, jednak kobiety często spożywające pieczywo miały niższe BMI niż spożywające rzadko. Wniosek. Chleby razowy żytni i mieszany z ziarnami są bogatym źródłem błonnika i ich spożycie powinno być młodym osobom zalecane w celu pokrycia zapotrzebowania na ten składnik.

Słowa kluczowe: błonnik pokarmowy, pieczywo, metoda enzymatyczno-grawimetryczna, wywiad żywieniowy, studenci

*Corresponding author: Renata Markiewicz-Żukowska, Medical University of Bialystok, Faculty of Pharmacy with Division of Laboratory Medicine, Department of Bromatology, Mickiewicza street 2D, 15-222 Białystok, Poland, Tel./Fax: +48 857485469, e-mail: [email protected] © Copyright by the National Institute of Public Health - National Institute of Hygiene Rocz Panstw Zakl Hig 2016;67(2):131-136 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

ORIGINAL ARTICLE

BAKERY PRODUCTS AS A SOURCE OF TOTAL DIETARY FIBRE IN YOUNG ADULTS

Renata Markiewicz-Żukowska*, Justyna Moskwa, Krystyna Gromkowska-Kępka, Emilia Laskowska, Jolanta Soroczyńska, Justyna Tomczuk, Maria Halina Borawska

Medical University of Bialystok, Faculty of Pharmacy with Division of Laboratory Medicine, Department of Bromatology, Białystok, Poland

Key words: dietary fibre, bakery products, enzymatic-gravimetric method, dietary interview questionnaire, students

Słowa kluczowe: błonnik pokarmowy, pieczywo, metoda enzymatyczno-grawimetryczna, wywiad żywieniowy, studenci

*Corresponding author: Renata Markiewicz-Żukowska, Medical University of Bialystok, Faculty of Pharmacy with Division of Laboratory Medicine, Department of Bromatology, Mickiewicza street 2D, 15-222 Białystok, Poland, Tel./Fax: +48 857485469, e-mail: [email protected] © Copyright by the National Institute of Public Health - National Institute of Hygiene 132 R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka et al. No 2 No 2 Bakery products as a source of total dietary fibre in young adults 133

INTRODUCTION 22.2±1.7 years) from Medical University of Bialystok Three-day-weighted dietary recording (two Statistical analysis during the period of 2013-2015. Most of them (86%) working days and one day off) was used to obtain Statistical analyses were performed by Statistica Cereal products are a staple food eaten all over the were women. Respondents represented academic information about kind and amount of consumed software version 10.0 PL for Windows (StatSoft, world and they should constitute a dominant portion of community of Faculty of Pharmacy with the Division bakery products (wholemeal rye bread, wheat-rye Cracov, Poland). Normality was determined using a diet. Statistical data [10] indicate that in Poland bread of Laboratory Medicine and Faculty of Health Sciences. bread, wheat-rye bread with grains, toast bread, Shapiro-Wilk test and by visual inspection of normal is consumed in the highest quantity from all cereal- The participants were required to be free of diet-related crispbread, rolls). The amount of bakery products probability plots and histograms. Student’s t-test was based products. It is an integral part of the human diet health problems and to be consuming their usual mixed portions consumed by the students was estimated used to detect any differences in TDF content for as it provides carbohydrates including dietary fibre diets. Participants were informed about the objectives based on the “Photography album of products and various bakery products. Differences between fibre (DF), protein, minerals, vitamins and many other of the study and the questionnaire was also explained. dishes” [24]. Taking into account the obtained results intake from various bakery products was investigated bioactive compounds. TDF was determined in 72 samples collected in (TDF content and amount of consumed portions), the using U Mann-Whitney test. A p-value of less than European Food Safety Authority (EFSA) dietary the north-east Poland in 2013. Six types of bakery quantity of TDF intake was calculated. 0.05 was considered statistically significant. guideline recommendations for fibre intake are various products which consumption was declared by students TDF intake values were referred to the current depending on age [6]. The dietary reference values in their questionnaires were selected (wholemeal rye recommendations 25 g/day (AI) [13] and also assessed RESULTS AND DISCUSSION present established adequate intake (AI) values for bread, wheat-rye bread, wheat-rye bread with grains, how many slices/portions of tested bakery products women and men 19 years or older as 25 g/day [13]. toast bread, crispbread, rolls). Samples of each bakery should adults eat to provide the recommended amount Hamulka et al. [12] evaluated the intake of dietary fibre product were obtained from different producers and of TDF. It was assumed that one standard slice/portion Two hundred and eighteen students (97.3%) in Polish households in years 1996-2005. It has been shops on various dates. Each sample was analysed of wholemeal rye bread is 30 g, wheat-rye bread or declared that they have meals at home. The BMI of 2 shown that the average intake of dietary fibre in total individually by triplicate. wheat-rye bread with grains weighs 35 g, toast bread - young adults varied between 15.9-29.1 kg/m (mean 2 in the period was about 24 g/day per person and varied The following standard and chemicals were used: 26 g, crispbread – 10 g and rolls - 50 g. 21.0±2.5 kg/m ) and was higher (p<0.05) in men 2 2 over a wide range of 19.9 to 28.5 g/day. According to certified reference material (Dried Bran Breakfast Cereal (23.1±2 kg/m ) than women (20.7±3 kg/m ) (Table 1). representative studies of food consumption in Poland ERM-BD518, IRMM, Geel, Belgium), sulphuric acid, Estimation of index of nutritional quality (INQ) Categorisation of BMI values showed normal weight conducted by Szponar et al. [23], the intake of DF in ammonium sulphate, boric acid, sodium hydroxide, Index of nutritional quality (INQ) determines to in most individuals (79%), underweight in 13% and Polish adults varies from 25 to 34 g/day in men and hydrochloric acid (Sigma-Aldrich, Steinheim, Germany). what extent a food product covers the daily energy overweight – 8%. from 19 to 20 g/day in women. It should be noted needs and supplies a specific nutrient. Analysis of responses concerning frequency of bakery that men over 60 years of age consume significantly Ethical considerations INQ=(A x B)/(C x D), where: A - component products eating among our university students showed less DF than men aged 20-30 years. Furthermore, This study was carried out with approval from the content in 100 g; B - standard energy needs (for that 46% and 34% respondents ate these products questionnaire survey indicated that among older people Local Bioethical Committee of Medical University men and women with medium physical activity, age every day and 4-6 times per week, respectively. 14% with diverticulosis of the colon the consumption of of Bialystok (R-I-002/8/2015). Participation was 19-30 years, weight 60 and 70 kg, respectively) of students ate 2-3 times per week and 2% - once per dietary fibre was two times lower (12.6 g/day) than voluntary and anonymous. After having received [13]; C - energy value per 100 g of product [16]; week, while 4% - occasionally (Figure 1). recommended in the standard [27]. verbal and written information, all students signed an D - standard consumption of the component (25 g) Decreased intake of DF is associated with an informed consent form. [13]. We estimated the INQ taking into account the 2% 4% increased risk of overweight and obesity, diabetes, determined dietary fibre content in the tested bakery 14% inflammation, hypertension, cardiovascular diseases, Dietary interview questionnaires development products. INQ value ≥1 indicates that the product can 46% certain cancers and constipation [1, 5, 15, 17, 20, 25, A self-administered questionnaire was used to obtain be considered as a good source of dietary fibre. every day 28]. In accordance with various studies, improved body demographic data, anthropometric measurements, data 4-6 times per week weight management is linked to higher intake of DF. In on the frequency of food consumption and three-day- Total dietary fibre determination 2-3 times per week an observational study, looking at the effects of overall weighted dietary recording. The tested products were cut into small pieces and once per week diet on the body composition in obese and lean subjects, The demographic data included age and sex. The placed in an oven at 105 °C until a constant weight 34% occasionally it was demonstrated that lean men and women showed students were also asked about eating places (at or was attained, i.e. when there was no change in a mass away from home). Anthropometric variables such as after one hour in an oven at 105 °C. Dry products Figure 1. Frequency of bakery products consumption by significantly higher fibre intake as opposed to obese men and women (27.0 g/day and 22.7 g/day vs 22.0 g/day height, weight were measured to the nearest 0.5 cm and were then ground to a size that would pass through Figure 1. youngFrequency adults of bakery products consumption by young adults and 15.0 g/day, respectively) [18]. Chuang et al. [4] in 0.1 kg respectively using height-measuring equipment a 0.3 - 0.5 mm mesh. An efficient grinding procedure the international research assessed the relation between connected to an electronic scale (AXIS B 150L, Seca, increases the surface area of the sample and improves The frequency of bakery consumption in this study are fibre intake, mortality and cause–specific mortality. Gdańsk, Poland). The students were wearing light the accuracy of results obtained. similar to those reported by Bagordo et al. [3], in which Higher fibre intake was connected with lower mortality. clothing and no shoes. Body mass index (BMI) was TDF in bread was determined by enzymatic- was shown that Italian university students, living at or The above association was more obvious for fibre from calculated as the ratio of weight (kg) to height squared gravimetric method using FOSS Fibertec E system away from home, consumed bread/cereals 6.2 servings cereals and vegetables than from fruit. (m2). BMI was used to assess percentage of students [2]. The protein examination was carried out by the per week. The main sources of DF in a daily diet are The aim of the present study was to determine with underweight (<18.5 kg/m2), normal weight (18.5- classical Kjeldahl method using Digester K-424 and cereal products, vegetables, fruit, legume seeds and TDF content in different types of bakery products and 24.9 kg/m2), overweight (25-29.9 kg/m2) and obesity Distillation Unit K-350 (Buchi, Flawil, Switzerland). nuts [19]. Analysis of consumption of DF in Poland their contribution to TDF supply in young adults diet. (≥30 kg/m2) according to WHO criteria [26]. The method of TDF determination was verified in the last decade showed that an important source of The food frequency questionnaire was designed to using certified reference material ERM-BD518 the total supply of DF derived from cereal products is MATERIALS AND METHODS assess habitual intake of bakery products by students. (IRMM, Belgium). Results of the quality control bread (84%), including wheat-rye bread (82%), wheat Consumption frequency was measured as occasionally, analyses were consistently categorized as being in bread (14%) and rye bread (4%) [9]. In accordance Dietary interview questionnaires were carried out once per week, 2-3 times per week, 4-6 times per week good agreement with reference values. The accuracy with research by Glodek et al. [7] also in the students among 224 students aged between 19 and 26 (mean age and every day and frequency ≥4 was recognised as was 0.39% and coefficient of variance was 1.58% diet the main source of DF was white and dark bread. regularly. 132 R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka et al. No 2 No 2 Bakery products as a source of total dietary fibre in young adults 133

INTRODUCTION 22.2±1.7 years) from Medical University of Bialystok Three-day-weighted dietary recording (two Statistical analysis during the period of 2013-2015. Most of them (86%) working days and one day off) was used to obtain Statistical analyses were performed by Statistica Cereal products are a staple food eaten all over the were women. Respondents represented academic information about kind and amount of consumed software version 10.0 PL for Windows (StatSoft, world and they should constitute a dominant portion of community of Faculty of Pharmacy with the Division bakery products (wholemeal rye bread, wheat-rye Cracov, Poland). Normality was determined using a diet. Statistical data [10] indicate that in Poland bread of Laboratory Medicine and Faculty of Health Sciences. bread, wheat-rye bread with grains, toast bread, Shapiro-Wilk test and by visual inspection of normal is consumed in the highest quantity from all cereal- The participants were required to be free of diet-related crispbread, rolls). The amount of bakery products probability plots and histograms. Student’s t-test was based products. It is an integral part of the human diet health problems and to be consuming their usual mixed portions consumed by the students was estimated used to detect any differences in TDF content for as it provides carbohydrates including dietary fibre diets. Participants were informed about the objectives based on the “Photography album of products and various bakery products. Differences between fibre (DF), protein, minerals, vitamins and many other of the study and the questionnaire was also explained. dishes” [24]. Taking into account the obtained results intake from various bakery products was investigated bioactive compounds. TDF was determined in 72 samples collected in (TDF content and amount of consumed portions), the using U Mann-Whitney test. A p-value of less than European Food Safety Authority (EFSA) dietary the north-east Poland in 2013. Six types of bakery quantity of TDF intake was calculated. 0.05 was considered statistically significant. guideline recommendations for fibre intake are various products which consumption was declared by students TDF intake values were referred to the current depending on age [6]. The dietary reference values in their questionnaires were selected (wholemeal rye recommendations 25 g/day (AI) [13] and also assessed RESULTS AND DISCUSSION present established adequate intake (AI) values for bread, wheat-rye bread, wheat-rye bread with grains, how many slices/portions of tested bakery products women and men 19 years or older as 25 g/day [13]. toast bread, crispbread, rolls). Samples of each bakery should adults eat to provide the recommended amount Hamulka et al. [12] evaluated the intake of dietary fibre product were obtained from different producers and of TDF. It was assumed that one standard slice/portion Two hundred and eighteen students (97.3%) in Polish households in years 1996-2005. It has been shops on various dates. Each sample was analysed of wholemeal rye bread is 30 g, wheat-rye bread or declared that they have meals at home. The BMI of 2 shown that the average intake of dietary fibre in total individually by triplicate. wheat-rye bread with grains weighs 35 g, toast bread - young adults varied between 15.9-29.1 kg/m (mean 2 in the period was about 24 g/day per person and varied The following standard and chemicals were used: 26 g, crispbread – 10 g and rolls - 50 g. 21.0±2.5 kg/m ) and was higher (p<0.05) in men 2 2 over a wide range of 19.9 to 28.5 g/day. According to certified reference material (Dried Bran Breakfast Cereal (23.1±2 kg/m ) than women (20.7±3 kg/m ) (Table 1). representative studies of food consumption in Poland ERM-BD518, IRMM, Geel, Belgium), sulphuric acid, Estimation of index of nutritional quality (INQ) Categorisation of BMI values showed normal weight conducted by Szponar et al. [23], the intake of DF in ammonium sulphate, boric acid, sodium hydroxide, Index of nutritional quality (INQ) determines to in most individuals (79%), underweight in 13% and Polish adults varies from 25 to 34 g/day in men and hydrochloric acid (Sigma-Aldrich, Steinheim, Germany). what extent a food product covers the daily energy overweight – 8%. from 19 to 20 g/day in women. It should be noted needs and supplies a specific nutrient. Analysis of responses concerning frequency of bakery that men over 60 years of age consume significantly Ethical considerations INQ=(A x B)/(C x D), where: A - component products eating among our university students showed less DF than men aged 20-30 years. Furthermore, This study was carried out with approval from the content in 100 g; B - standard energy needs (for that 46% and 34% respondents ate these products questionnaire survey indicated that among older people Local Bioethical Committee of Medical University men and women with medium physical activity, age every day and 4-6 times per week, respectively. 14% with diverticulosis of the colon the consumption of of Bialystok (R-I-002/8/2015). Participation was 19-30 years, weight 60 and 70 kg, respectively) of students ate 2-3 times per week and 2% - once per dietary fibre was two times lower (12.6 g/day) than voluntary and anonymous. After having received [13]; C - energy value per 100 g of product [16]; week, while 4% - occasionally (Figure 1). recommended in the standard [27]. verbal and written information, all students signed an D - standard consumption of the component (25 g) Decreased intake of DF is associated with an informed consent form. [13]. We estimated the INQ taking into account the 2% 4% increased risk of overweight and obesity, diabetes, determined dietary fibre content in the tested bakery 14% inflammation, hypertension, cardiovascular diseases, Dietary interview questionnaires development products. INQ value ≥1 indicates that the product can 46% certain cancers and constipation [1, 5, 15, 17, 20, 25, A self-administered questionnaire was used to obtain be considered as a good source of dietary fibre. every day 28]. In accordance with various studies, improved body demographic data, anthropometric measurements, data 4-6 times per week weight management is linked to higher intake of DF. In on the frequency of food consumption and three-day- Total dietary fibre determination 2-3 times per week an observational study, looking at the effects of overall weighted dietary recording. The tested products were cut into small pieces and once per week diet on the body composition in obese and lean subjects, The demographic data included age and sex. The placed in an oven at 105 °C until a constant weight 34% occasionally it was demonstrated that lean men and women showed students were also asked about eating places (at or was attained, i.e. when there was no change in a mass away from home). Anthropometric variables such as after one hour in an oven at 105 °C. Dry products Figure 1. Frequency of bakery products consumption by significantly higher fibre intake as opposed to obese men and women (27.0 g/day and 22.7 g/day vs 22.0 g/day height, weight were measured to the nearest 0.5 cm and were then ground to a size that would pass through Figure 1. youngFrequency adults of bakery products consumption by young adults and 15.0 g/day, respectively) [18]. Chuang et al. [4] in 0.1 kg respectively using height-measuring equipment a 0.3 - 0.5 mm mesh. An efficient grinding procedure the international research assessed the relation between connected to an electronic scale (AXIS B 150L, Seca, increases the surface area of the sample and improves The frequency of bakery consumption in this study are fibre intake, mortality and cause–specific mortality. Gdańsk, Poland). The students were wearing light the accuracy of results obtained. similar to those reported by Bagordo et al. [3], in which Higher fibre intake was connected with lower mortality. clothing and no shoes. Body mass index (BMI) was TDF in bread was determined by enzymatic- was shown that Italian university students, living at or The above association was more obvious for fibre from calculated as the ratio of weight (kg) to height squared gravimetric method using FOSS Fibertec E system away from home, consumed bread/cereals 6.2 servings cereals and vegetables than from fruit. (m2). BMI was used to assess percentage of students [2]. The protein examination was carried out by the per week. The main sources of DF in a daily diet are The aim of the present study was to determine with underweight (<18.5 kg/m2), normal weight (18.5- classical Kjeldahl method using Digester K-424 and cereal products, vegetables, fruit, legume seeds and TDF content in different types of bakery products and 24.9 kg/m2), overweight (25-29.9 kg/m2) and obesity Distillation Unit K-350 (Buchi, Flawil, Switzerland). nuts [19]. Analysis of consumption of DF in Poland their contribution to TDF supply in young adults diet. (≥30 kg/m2) according to WHO criteria [26]. The method of TDF determination was verified in the last decade showed that an important source of The food frequency questionnaire was designed to using certified reference material ERM-BD518 the total supply of DF derived from cereal products is MATERIALS AND METHODS assess habitual intake of bakery products by students. (IRMM, Belgium). Results of the quality control bread (84%), including wheat-rye bread (82%), wheat Consumption frequency was measured as occasionally, analyses were consistently categorized as being in bread (14%) and rye bread (4%) [9]. In accordance Dietary interview questionnaires were carried out once per week, 2-3 times per week, 4-6 times per week good agreement with reference values. The accuracy with research by Glodek et al. [7] also in the students among 224 students aged between 19 and 26 (mean age and every day and frequency ≥4 was recognised as was 0.39% and coefficient of variance was 1.58% diet the main source of DF was white and dark bread. regularly. 134 R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka et al. No 2 No 2 Bakery products as a source of total dietary fibre in young adults 135

Among the cereal products, whole grains and bran oligosaccharides or fibre was used. However, since 1.11±1.38 g/day of TDF, which was significantly analysed bakery products, beside rolls (Table 3). Based are the richest sources of DF [16]. The DF content adding these ingredients affects the properties of less compared to other tested products (p<0.05). on these results we concluded that the tested bread is in bread depends on the type of flour used, but also dough and bread, it is necessary to modify the bread- Whereas, wheat-rye bread and wholemeal rye bread a good source of TDF in university students diets. on the applied technological processes. Using refined making process to achieve desirable effects [22]. provided significantly more TDF (2.11±2.96 and flour decreases the DF content and the amount of Determining DF content in products can be carried out 3.01±4.40 g/day) than others (p<0.05) and were associated bioactive compounds in bread. Therefore, by various methods, which could be also a source of consumed in amounts 29.9±41.9 g/day and CONCLUSIONS bread enriched with other sources of fibre such as the differences in the results. 25.5±37.3 g/day, respectively. It was interesting to wholemeal flour, bran, resistant starch, fructan/fructo- note that even though the consumption of rolls was In conclusion, this study provides interesting the largest, it realised norm (AI) only in 4.4%, while insights into the field of TDF content in bakery Table 1. Consumption frequency of bakery products and young women and men Body Mass Index - BMI (kg/m2) wheat-rye bread - 8.4% and wholemeal rye bread – products. Our data indicate that wholemeal rye and Female (F) Male (M) 12.0%. It is worrying, that the daily consumption of wheat-rye with grains breads are a rich source of TDF Consumption frequency percentage BMI (kg/m2) percentage BMI (kg/m2) rolls is about 2 times higher than bread’s. In accordance in young adults diets and it should be encouraged in of respondents mean±SD of respondents mean±SD with statistical data [10, 11], in the period between order to achieve the recommended TDF values. The 1981 and 2012 in Poland, the consumption of bread every day 47 20.6 ± 2 45 23.0 ± 3 results of our study can help young people improve per capita decreased by about 49% - from 104 kg to their diets through a selection of the best source of 4-6 times per week 34 20.4 ± 2 26 22.9 ± 3 53 kg. Countries with bread consumption higher than dietary fibre among bakery products. ≤ 3 times per week 19 21.7 ± 3a 29 23.5 ± 3 in Poland include Germany, the Czech Republic and Total 100 20.7 ± 3b 100 23.1 ± 2 Bulgaria. On the contrary, in Great Britain, Norway Acknowledgements and Sweden people consume about 20 kg less bread ap ; bp <0.05 This work was funded by a grant from Polish Ministry 3/1,2 F/M than in Poland. The highest annual bread consumption of Science and Higher Education (No. 133 16522F) in the world has been observed in North America and and carried out using equipment co-financed by Table 2. Total dietary fibre (TDF) intake with consumed bakery products among young adults amounted to about 200 kg per capita [8]. the European Regional Development Fund and the Consumption b Fibre intake Taking into account determined TDF content a Content of TDF c Norm state budget under the Operational Programme of bakery product per person from bakery product Bakery product n (g/100 g) mean±SD realisation in bakery products (Table 2) we have found that Development of Eastern Poland 2007-2013. (g/day) mean±SD (g/day) mean±SD (range) (%) the products totally supply 6.81 g/day of TDF. (range) (range) Additionally, we estimated that 23, 22 and 19 slices/ Conflict of interest 11.80±0.71 3.01±4.40 Wholemeal rye 25.5±37.3 portions of rolls, crispbread and toast bread should be The authors declare no conflict of interest. 12 (8.97-14.79) (0.00-23.60) 12.0 bread (0.0-200.0) consumed to cover the daily AI. In case of the wheat- p <0.05 p <0.05 1/2,4,6 1/2,3,4,5,6 rye bread the same would be achieved by consuming 7.06±0.94 2.11±2.96 REFERENCES 29.9±41.9 10 slices of bread, and in case of wheat-rye bread with Wheat-rye bread 12 (5.62-8.58) (0.00-14.12) 8.4 (0.0-200.0) grains and wholemeal rye bread – 7 slices. p <0.05 p <0.05 2/3,4,5,6 2/3,4,5,6 1. Anderson J.W., Allgood L.D., Lawrence A., Altringer 10.59±0.91 0.34±1.27 Table 3. Evaluation of different types of bakery products as Wheat-rye bread 3.2±12.0 L.A., Jerdack G.R., Hengehold D.A., Morel J.G.: 12 (6.79-14.55) (0.00-8.83) 1.4 a source of dietary fibre in young adults diet on the with grains (0.0-83.3) Cholesterol-lowering effects of psyllium intake p <0.05 p <0.05 base of Index of Nutritional Quality (INQ) 3/4,6 3/5,6 adjunctive to diet therapy in men and women with 4.94±0.30 0.18±0.65 hypercholesterolemia: meta-analysis of 8 controlled 3.7±13.1 INQ±SD Toast bread 12 (3.88-5.93) (0.00-4.15) 0.7 Type of bread trials. Am J Clin Nutr 2000;71:472-479. (0.0-84.0) Female Male p4/5,6 <0.05 p4/5,6<0.05 2. AOAC: Official Method 991.43. Total, Soluble, and 11.44±2.07 0.06±0.30 Wholemeal rye bread 5.3±0.9 6.8±1.2 Insoluble Dietary Fiber in Foods Enzymatic-Gravimetric 0.6±2.7 Crispbread 12 (8.80-15.00) (0.00-2.27) 0.2 Method, MES-TRIS Buffer. In: Official Methods of (0.0-20.0) Wheat-rye bread 2.7±0.4 3.4±0.5 p5/6 <0.05 p5/6<0.05 Analysis of the Association of Official Analytical Wheat-rye bread with grains 4.2±0.9 5.4±1.2 th 50.8±62.9 2.19±1.52 1.11±1.38 Chemists, 15 ed. Arlington, VA, USA: AOAC Int., Rolls 12 4.4 (0.0-325.3) (1.00-6.70) (0.00-7.12) Toast bread 1.6±0.2 2.0±0.3 1992. aValues are statistically significantly different according toStudent’s t-test (p<0.05) Crisp bread 3.1±0.6 4.0±0.7 3. Bagordo F., Grassi T., Serio F., Idolo A., De Donno A.: b Dietary habits and health among university students Values are statistically significantly different according toU Mann-Whitney’s test (p<0.05) Rolls 0.8±0.5 1.0±0.7 cNorm as fibre adequate intake (AI) value for women and men 19 years or older is 25 g/day. living at or away from home in southern Italy. J Food n - number of samples SD - standard deviation Nutr Res 2013;52:164-171. SD - standard deviation Furthermore, we calculated that BMI for all 4. Chuang S.C., Norat T., Murphy N., Olsen A., Tjønneland A., Overvad K., Boutron–Ruault M.C., Perquier F., students did not correlate (r=0.08; p=0.25) with daily In this study TDF content in the tested bakery showed similar results for wheat-rye bread, while the Dartois L., Kaaks R., Teucher B., Bergmann M.M., products samples (Table 2) varied between wholemeal rye bread and wheat-rye bread with grains consumption of bakery products. Moreover, among Boeing H., Trichopoulou A., Lagiou, P., Trichopoulos 2.19±1.52 g/100 g and 11.80±0.71 g/100 g. Among show slightly higher values of TDF in comparison to female students (also did not correlate r=-0.08; p=0.30) D., Grioni S., Sacerdote C., Panico S., Palli D., Tumino all the analysed samples the statistically (p<0.05) our results. who frequently consumed bread BMI was lower than R., Peeters P.H.M., Bueno–de–Mesquita B., Ros M.M., lowest average content of fibre was found in the rolls The average consumption of bakery products among those who rarely ate it (Table 1). Brustad M., Åsli L.A., Skeie G., Quirós J.R., González and the highest in the wholemeal rye bread. In the per person was presented in Table 2. The obtained Additionally, in this study we evaluated the INQ C.A., Sánchez M.J., Navarro C., Aicua, E.A., Dorronsoro studies by Kasprzak & Rzedzicki [14] and Rzedzicki data showed that respondents consumed rolls in and found that it was higher than 1 in most of the & Kasprzak [21], the authors examined different types the largest amount (50.8±62.9 g/day). It provided of bread using the same method as in this study and 136 R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):137-146 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ M., Drake I., Sonestedt E., Johansson I., Hallmans G., 16. Kunachowicz H., Nadolna I., Iwanow K., Przygoda Key T., Crowe F., Khaw K.T., Wareham N., Ferrari P., B.: The nutritional value of selected foods and typical Slimani N., Romieu I., Gallo V., Riboli E., Vineis P.: dishes. Warszawa, PZWL, 2008 (in Polish). ORIGINAL ARTICLE Fiber intake and total and cause – specific mortality in 17. Liu Y., Colditz G.A., Cotterchio M., Boucher B.A., the European Prospective Investigation into Cancer and Kreiger N.: Adolescent dietary fiber, vegetable fat, THE EFFECTIVENESS OF THE LOW ENERGY DIET Nutrition cohort. Am J Clin Nutr 2012;96:164-174. vegetable protein, and nut intakes and breast cancer 5. Chuang S.C., Vermeulen R., Sharabiani M.T., Sacerdote risk. Breast Cancer Res Tr 2014;145:461-470. IN OVERWEIGHT AND OBESE ADULTS C., Fatemeh S.H., Berrino F., Krogh V., Palli D., Panico 18. Miller W.C., Niederpruem M.G., Wallace J.P., Lindeman S., Tumino R., Athersuch T.J., Vineis P.: The intake A.K.: Dietary fat, sugar, and fiber predict body fat Beata Całyniuk1, Elżbieta Grochowska-Niedworok1, Małgorzata Muc-Wierzgoń2, of grain fibers modulates cytokine levels in blood. content. J Am Diet Assoc 1994;94:612-615. Ewa Nowakowska-Zajdel2, Marcin Osowski1* Biomarkers 2011;16:504–510. 19. Paczkowska M., Kunachowicz H., Rutkowska U.: 6. EFSA (European Food Safety Authority) 2010. Nutrition quality of typical Polish diet – analytical Scientific Opinion on Dietary Reference Values for studies and theoretical evaluation. Part IV. Dietary 1Faculty of Public Health, Department of Human Nutrition, Medical University of Silesia, Zabrze, Poland carbohydrates and dietary fibre. EFSA Panel on Dietetic fibre. Żyw Człow 2000;27:12-19 (in Polish; English 2Faculty of Public Health, Department of Internal Diseases, Medical University of Silesia, Bytom, Poland Products, Nutrition, and Allergies (NDA). EFSA J abstract). 2010;8(3):1462-1477. doi:10.2903/j.efsa.2010.1462. 20. Park Y., Hunter D.J., Spiegelman D., Bergkvist L., ABSTRACT Available from: www.efsa.europa.eu (accessed Berrino F., van den Brandt P.A., Buring J.E., Colditz G.A., Background. Excess body weight is one of the most common health and economic problems of the contemporary world. 11.01.2016). Freudenheim J.L., Fuchs C.S., Giovannucci E., Goldbohm According to the assessments of the World Health Organization (WHO), almost billion adults are overweight and at 7. Głodek E., Gil M., Rudy M., Pawlos M.: Ocena R.A., Graham S., Harnack L., Hartman A.M., Jacobs least 300 million were diagnosed with clinical obesity. Health consequences of overweight are: ischemic heart disease, częstotliwości spożycia przez studentów wybranych D.R.Jr., Kato I., Krogh V., Leitzmann M.F., McCullough congestive cardiac failure, hypertension, arteriosclerotic vascular disease, diabetes mellitus type 2, tumours, degenerative źródeł błonnika pokarmowego [Assessment of M.L., Miller A.B., Pietinen P., Rohan T.E., Schatzkin A., joint disease and many more. frequency of consumption of selected sources of Willett W.C., Wolk A., Zeleniuch-Jacquotte A., Zhang Objective. The aim of the study was to evaluate the effectiveness of the low-energy diet used in the period of 5 months by dietary fibre by students]. Rocz Panstw Zakl Hig S.M., Smith-Warner S.A.: Dietary fiber intake and risk of women and men treated from overweight or obesity in the diet centre. 2011;62(4):409-412 (in Polish) [PMID: 22435296; colorectal cancer: a pooled analysis of prospective cohort Material and Methods. The research included 296 overweight or obese patients, treated in the diet centre: (1) 104 women http://www.ncbi.nlm.nih.gov/pubmed/22435296]. studies. J Am Med Assoc 2005;294:2849-2857. without co-morbidities, between 18 to 61 years old; (2) 58 women with the accompanying insulin resistance between 19 to 8. Goryńska-Goldman E.: Tendencies of bread 21. Rzedzicki Z., Kasprzak M.: Study of chemical 61 years old; (3) 49 women additionally suffering from hypothyroidism, between 19 to 61 years old; (4) 85 men without consumption in Poland. Acta Sci Pol Oeconomia composition selected assortments of bread. Bromat co-morbidities, between 19 to 62 years old. Treated patients were recommended the use of the low-energy diet, where 20% 2010;9:73-86 (in Polish; English abstract). ChemToksykol 2009;42:277-281 (in Polish; English of energy came from protein, 30% of energy from fat and 50% of energy from carbohydrates. The energy content of the diet 9. Górecka D., Janus P., Borysiak-Marzec P., Dziedzic K.: abstract). was considered to be dependent on the individual daily demand that was estimated taking into consideration the physical Analysis of consumption of dietary fiber and its fractions 22. Sivam A.S., Sun-Waterhouse D., Waterhouse G.I., Quek activity and that was reduced with 1000 kcal. Patients applied suggested reductive diet for 5 months. in Poland in the last decade based on the statistical S., Perera C.O.: Physicochemical properties of bread Results. The use of diet in each group brought positive results. In all groups, body fat decreased significantly after 5 months yearbook data. Probl Hig Epidemiol 2011;92:705-708 dough and finished bread with added pectin fiber and of dietary treatment. It has been shown to increase the average percentage of water content in the body of subjects. There (in Polish; English abstract). phenolic antioxidants. J Food Sci 2011;76:97-107. was also an average reduction in total cholesterol, LDL, TG, glucose levels and increasing HDL for each group. 10. GUS (Główny Urząd Statystyczny - Central Statistical 23. Szponar L., Sekuła W., Nelson M., Weisell R.C.: The Conclusions. Diet proceedings consisting in reduced energy value of the diet has a beneficial effect on reducing body mass, Office). Household budgets in 2013. Warszawa, Główny household food consumption and anthropometric metabolic age, reducing BMI and influences the percentage change in body fat, causing its reduction, change in percentage Urząd Statystyczny, 2014 (in Polish). survey in Poland. Public Health Nutr 2001;4:1183- of water content, leading to a slight increase in its levels in the body . In addition, favourably nutritional proceedings 11. GUS (Główny Urząd Statystyczny - Central Statistical 1186. influenced the changes in blood levels of lipid indicators, thus reducing risk factors for coronary heart disease. Office). Household budgets according to selected types 24. Szponar L., Wolnicka K., Rychlik E.: Photo album of of families during 1993-1996. Warszawa, Główny products and dishes. Warszawa, IŻŻ, 2000 (in Polish). Key words: low-energy diet, overweight, obesity, metabolic age, biochemical parameters Urząd Statystyczny, 1997 (in Polish). 25. Weng L.C., Lee N.J., Yeh W.T., Ho LT, Pan WH.: Lower 12. Hamułka J., Wawrzyniak A., Sosińska S.: Ocena intake of magnesium and dietary fiber increases the STRESZCZENIE spożycia błonnika pokarmowego oraz jego frakcji incidence of type 2 diabetes in Taiwanese. J Formos Wprowadzenie. Nadmierna masa ciała, to jeden z najczęściej występujących problemów zdrowotnych i ekonomicznych w dospodarstwach domowych w Polsce w latach 1996- Med Assoc 2012;111:651-659. współczesnego świata. Według szacunków Światowej Organizacji Zdrowia, prawie miliard osób dorosłych ma nadwagę, 2005. [Evaluation of dietary fibre, soluble and insoluble 26. WHO (World Health Organization): Obesity and a u co najmniej 300 mln występuje otyłość kliniczna (BMI ≥ 40). Następstwami zdrowotnymi otyłości są m.in. choroba fibre food intake in Polish households in years 1996- overweight. Fact Sheet No311, Geneva, WHO, 2013. niedokrwienna serca, niewydolność mięśnia sercowego, nadciśnienie tętnicze, miażdżyca, cukrzyca typu 2, nowotwory, 2005]. Rocz Panstw Zakl Hig 2008;59(3):211-221 (in 27. Wroński K., Bocian R.: Dietary fiber intake of patients choroby zwyrodnieniowe stawów. Polish) [PMID: 18807920; http://www.ncbi.nlm.nih. with diverticulosis colon. Nowa Med 2011;4:57-61 (in Cel. Celem badań była ocena skuteczności niskoenergetycznej diety stosowanej przez 5 miesięcy przez kobiety i mężczyzn gov/pubmed/18807920]. Polish; English abstract). z nadwagą i otyłością leczonych w poradni dietetycznej. 13. Jarosz M.: Nutrition norms for the Polish population – 28. Yang J., Wang H.P., Zhou L., Xu C.F.: Effect of Materiał i Metody. Badaniem objęto 296 pacjentów z nadwagą lub otyłością, leczonych w poradni dietetycznej: (1) 104 amendment. Warszawa, IŻŻ, 2012 (in Polish). dietary fiber on constipation: a metaanalysis. World J kobiety bez schorzeń towarzyszących, w wieku od 18 do 61 lat; (2) 58 kobiet chorujących z towarzyszącą insulinoopornością, 14. Kasprzak M., Rzedzicki Z.: Analysis of physical Gastroenterol 2012;18:7378–7383. w wieku od 19 do 61 lat; (3) 49 kobiet chorujących z dodatkowo występującą niedoczynnością tarczycy, w wieku od 19 properties and chemical composition of bread. Bromat do 61 lat; (4) 85 mężczyzn bez schorzeń towarzyszących, w wieku od 19 do 62 lat. Badanym osobom zalecono stosowanie Chem Toksykol 2009;42: 270-276 (in Polish; English Received: 11.02.2016 diety ubogoenergetycznej, w której 20% energii pochodziło z białka, 30% z tłuszczu, 50% z węglowodanów. Wartość abstract). Accepted: 25.04.2016 energetyczną diety uzależniono od indywidualnego dziennego zapotrzebowania, które obliczono uwzględniając aktywność 15. Khan S., Campo J., Bridge J.A., Chiappetta L.C., Wald fizyczną i pomniejszono o 1000 kcal. Pacjenci stosowali zaproponowaną dietę redukcyjną przez 5 miesięcy. A., di Lorenzo C.: Long-term outcome of functional childhood constipation. Dig Dis Sci 2007;52: 64-69. *Corresponding author: Marcin Osowski, Faculty of Public Health, Department of Human Nutrition, Medical University of Silesia, Jordana 19, 41-808 Zabrze, Poland, phone number: +48 514 002 989, e-mail: [email protected]

© Copyright by the National Institute of Public Health - National Institute of Hygiene 136 R. Markiewicz-Żukowska, J. Moskwa, K. Gromkowska-Kępka et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):137-146 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ M., Drake I., Sonestedt E., Johansson I., Hallmans G., 16. Kunachowicz H., Nadolna I., Iwanow K., Przygoda Key T., Crowe F., Khaw K.T., Wareham N., Ferrari P., B.: The nutritional value of selected foods and typical Slimani N., Romieu I., Gallo V., Riboli E., Vineis P.: dishes. Warszawa, PZWL, 2008 (in Polish). ORIGINAL ARTICLE Fiber intake and total and cause – specific mortality in 17. Liu Y., Colditz G.A., Cotterchio M., Boucher B.A., the European Prospective Investigation into Cancer and Kreiger N.: Adolescent dietary fiber, vegetable fat, THE EFFECTIVENESS OF THE LOW ENERGY DIET Nutrition cohort. Am J Clin Nutr 2012;96:164-174. vegetable protein, and nut intakes and breast cancer 5. Chuang S.C., Vermeulen R., Sharabiani M.T., Sacerdote risk. Breast Cancer Res Tr 2014;145:461-470. IN OVERWEIGHT AND OBESE ADULTS C., Fatemeh S.H., Berrino F., Krogh V., Palli D., Panico 18. Miller W.C., Niederpruem M.G., Wallace J.P., Lindeman S., Tumino R., Athersuch T.J., Vineis P.: The intake A.K.: Dietary fat, sugar, and fiber predict body fat Beata Całyniuk1, Elżbieta Grochowska-Niedworok1, Małgorzata Muc-Wierzgoń2, of grain fibers modulates cytokine levels in blood. content. J Am Diet Assoc 1994;94:612-615. Ewa Nowakowska-Zajdel2, Marcin Osowski1* Biomarkers 2011;16:504–510. 19. Paczkowska M., Kunachowicz H., Rutkowska U.: 6. EFSA (European Food Safety Authority) 2010. Nutrition quality of typical Polish diet – analytical Scientific Opinion on Dietary Reference Values for studies and theoretical evaluation. Part IV. Dietary 1Faculty of Public Health, Department of Human Nutrition, Medical University of Silesia, Zabrze, Poland carbohydrates and dietary fibre. EFSA Panel on Dietetic fibre. Żyw Człow 2000;27:12-19 (in Polish; English 2Faculty of Public Health, Department of Internal Diseases, Medical University of Silesia, Bytom, Poland Products, Nutrition, and Allergies (NDA). EFSA J abstract). 2010;8(3):1462-1477. doi:10.2903/j.efsa.2010.1462. 20. Park Y., Hunter D.J., Spiegelman D., Bergkvist L., ABSTRACT Available from: www.efsa.europa.eu (accessed Berrino F., van den Brandt P.A., Buring J.E., Colditz G.A., Background. Excess body weight is one of the most common health and economic problems of the contemporary world. 11.01.2016). Freudenheim J.L., Fuchs C.S., Giovannucci E., Goldbohm According to the assessments of the World Health Organization (WHO), almost billion adults are overweight and at 7. Głodek E., Gil M., Rudy M., Pawlos M.: Ocena R.A., Graham S., Harnack L., Hartman A.M., Jacobs least 300 million were diagnosed with clinical obesity. Health consequences of overweight are: ischemic heart disease, częstotliwości spożycia przez studentów wybranych D.R.Jr., Kato I., Krogh V., Leitzmann M.F., McCullough congestive cardiac failure, hypertension, arteriosclerotic vascular disease, diabetes mellitus type 2, tumours, degenerative źródeł błonnika pokarmowego [Assessment of M.L., Miller A.B., Pietinen P., Rohan T.E., Schatzkin A., joint disease and many more. frequency of consumption of selected sources of Willett W.C., Wolk A., Zeleniuch-Jacquotte A., Zhang Objective. The aim of the study was to evaluate the effectiveness of the low-energy diet used in the period of 5 months by dietary fibre by students]. Rocz Panstw Zakl Hig S.M., Smith-Warner S.A.: Dietary fiber intake and risk of women and men treated from overweight or obesity in the diet centre. 2011;62(4):409-412 (in Polish) [PMID: 22435296; colorectal cancer: a pooled analysis of prospective cohort Material and Methods. The research included 296 overweight or obese patients, treated in the diet centre: (1) 104 women http://www.ncbi.nlm.nih.gov/pubmed/22435296]. studies. J Am Med Assoc 2005;294:2849-2857. without co-morbidities, between 18 to 61 years old; (2) 58 women with the accompanying insulin resistance between 19 to 8. Goryńska-Goldman E.: Tendencies of bread 21. Rzedzicki Z., Kasprzak M.: Study of chemical 61 years old; (3) 49 women additionally suffering from hypothyroidism, between 19 to 61 years old; (4) 85 men without consumption in Poland. Acta Sci Pol Oeconomia composition selected assortments of bread. Bromat co-morbidities, between 19 to 62 years old. Treated patients were recommended the use of the low-energy diet, where 20% 2010;9:73-86 (in Polish; English abstract). ChemToksykol 2009;42:277-281 (in Polish; English of energy came from protein, 30% of energy from fat and 50% of energy from carbohydrates. The energy content of the diet 9. Górecka D., Janus P., Borysiak-Marzec P., Dziedzic K.: abstract). was considered to be dependent on the individual daily demand that was estimated taking into consideration the physical Analysis of consumption of dietary fiber and its fractions 22. Sivam A.S., Sun-Waterhouse D., Waterhouse G.I., Quek activity and that was reduced with 1000 kcal. Patients applied suggested reductive diet for 5 months. in Poland in the last decade based on the statistical S., Perera C.O.: Physicochemical properties of bread Results. The use of diet in each group brought positive results. In all groups, body fat decreased significantly after 5 months yearbook data. Probl Hig Epidemiol 2011;92:705-708 dough and finished bread with added pectin fiber and of dietary treatment. It has been shown to increase the average percentage of water content in the body of subjects. There (in Polish; English abstract). phenolic antioxidants. J Food Sci 2011;76:97-107. was also an average reduction in total cholesterol, LDL, TG, glucose levels and increasing HDL for each group. 10. GUS (Główny Urząd Statystyczny - Central Statistical 23. Szponar L., Sekuła W., Nelson M., Weisell R.C.: The Conclusions. Diet proceedings consisting in reduced energy value of the diet has a beneficial effect on reducing body mass, Office). Household budgets in 2013. Warszawa, Główny household food consumption and anthropometric metabolic age, reducing BMI and influences the percentage change in body fat, causing its reduction, change in percentage Urząd Statystyczny, 2014 (in Polish). survey in Poland. Public Health Nutr 2001;4:1183- of water content, leading to a slight increase in its levels in the body . In addition, favourably nutritional proceedings 11. GUS (Główny Urząd Statystyczny - Central Statistical 1186. influenced the changes in blood levels of lipid indicators, thus reducing risk factors for coronary heart disease. Office). Household budgets according to selected types 24. Szponar L., Wolnicka K., Rychlik E.: Photo album of of families during 1993-1996. Warszawa, Główny products and dishes. Warszawa, IŻŻ, 2000 (in Polish). Key words: low-energy diet, overweight, obesity, metabolic age, biochemical parameters Urząd Statystyczny, 1997 (in Polish). 25. Weng L.C., Lee N.J., Yeh W.T., Ho LT, Pan WH.: Lower 12. Hamułka J., Wawrzyniak A., Sosińska S.: Ocena intake of magnesium and dietary fiber increases the STRESZCZENIE spożycia błonnika pokarmowego oraz jego frakcji incidence of type 2 diabetes in Taiwanese. J Formos Wprowadzenie. Nadmierna masa ciała, to jeden z najczęściej występujących problemów zdrowotnych i ekonomicznych w dospodarstwach domowych w Polsce w latach 1996- Med Assoc 2012;111:651-659. współczesnego świata. Według szacunków Światowej Organizacji Zdrowia, prawie miliard osób dorosłych ma nadwagę, 2005. [Evaluation of dietary fibre, soluble and insoluble 26. WHO (World Health Organization): Obesity and a u co najmniej 300 mln występuje otyłość kliniczna (BMI ≥ 40). Następstwami zdrowotnymi otyłości są m.in. choroba fibre food intake in Polish households in years 1996- overweight. Fact Sheet No311, Geneva, WHO, 2013. niedokrwienna serca, niewydolność mięśnia sercowego, nadciśnienie tętnicze, miażdżyca, cukrzyca typu 2, nowotwory, 2005]. Rocz Panstw Zakl Hig 2008;59(3):211-221 (in 27. Wroński K., Bocian R.: Dietary fiber intake of patients choroby zwyrodnieniowe stawów. Polish) [PMID: 18807920; http://www.ncbi.nlm.nih. with diverticulosis colon. Nowa Med 2011;4:57-61 (in Cel. Celem badań była ocena skuteczności niskoenergetycznej diety stosowanej przez 5 miesięcy przez kobiety i mężczyzn gov/pubmed/18807920]. Polish; English abstract). z nadwagą i otyłością leczonych w poradni dietetycznej. 13. Jarosz M.: Nutrition norms for the Polish population – 28. Yang J., Wang H.P., Zhou L., Xu C.F.: Effect of Materiał i Metody. Badaniem objęto 296 pacjentów z nadwagą lub otyłością, leczonych w poradni dietetycznej: (1) 104 amendment. Warszawa, IŻŻ, 2012 (in Polish). dietary fiber on constipation: a metaanalysis. World J kobiety bez schorzeń towarzyszących, w wieku od 18 do 61 lat; (2) 58 kobiet chorujących z towarzyszącą insulinoopornością, 14. Kasprzak M., Rzedzicki Z.: Analysis of physical Gastroenterol 2012;18:7378–7383. w wieku od 19 do 61 lat; (3) 49 kobiet chorujących z dodatkowo występującą niedoczynnością tarczycy, w wieku od 19 properties and chemical composition of bread. Bromat do 61 lat; (4) 85 mężczyzn bez schorzeń towarzyszących, w wieku od 19 do 62 lat. Badanym osobom zalecono stosowanie Chem Toksykol 2009;42: 270-276 (in Polish; English Received: 11.02.2016 diety ubogoenergetycznej, w której 20% energii pochodziło z białka, 30% z tłuszczu, 50% z węglowodanów. Wartość abstract). Accepted: 25.04.2016 energetyczną diety uzależniono od indywidualnego dziennego zapotrzebowania, które obliczono uwzględniając aktywność 15. Khan S., Campo J., Bridge J.A., Chiappetta L.C., Wald fizyczną i pomniejszono o 1000 kcal. Pacjenci stosowali zaproponowaną dietę redukcyjną przez 5 miesięcy. A., di Lorenzo C.: Long-term outcome of functional childhood constipation. Dig Dis Sci 2007;52: 64-69. *Corresponding author: Marcin Osowski, Faculty of Public Health, Department of Human Nutrition, Medical University of Silesia, Jordana 19, 41-808 Zabrze, Poland, phone number: +48 514 002 989, e-mail: [email protected]

© Copyright by the National Institute of Public Health - National Institute of Hygiene 138 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 139

Wyniki. Stosowanie diety w każdej z badanych grup przyniosło pozytywne rezultaty. We wszystkich czterech grupach Treated patients were recommended the use of RESULTS zawartość tłuszczu w organizmie zmniejszyła się istotnie statystycznie po 5 miesiącach stosowania diety. Wykazano wzrost the low-energy diet, where 20% of energy came from średniej procentowej zawartości wody w organizmie osób badanych. Zanotowano również obniżenie średniego stężenia protein, 30% of energy from fat and 50% of energy Table 1 contains mean values of body weight cholesterolu całkowitego, frakcji LDL, TG, glukozy na czczo oraz wzrost stężenia frakcji HDL dla każdej grupy. from carbohydrates. The energy content of the diet (kg), BMI (kg/m2), fat content (%), water content (%) Wnioski. Postępowanie dietetyczne polegające na obniżeniu wartości energetycznej diety ma korzystny wpływ na obniżenie was considered to be dependent on the individual daily and the metabolic age (years) at the beginning of the masy ciała, wieku metabolicznego, zmniejszenie wartości wskaźnika BMI oraz wpływa na zmiany procentowej zawartości demand that was estimated taking into consideration the tłuszczu w organizmie, powodując jego obniżenie, zmiany procentowej zawartości wody, prowadząc do nieznacznego therapy and after 5 months of using the diet. wzrostu jej poziomu w organizmie. Ponadto wpłynęło korzystnie na zmiany stężenia we krwi wskaźników lipidowych, physical activity and that was reduced with 1000 kcal. In Table 2 are present mean values of the powodując zmniejszenie czynników ryzyka choroby niedokrwiennej serca. Patients applied suggested reductive diet for 5 months. concentration in the blood of total cholesterol (mg/dl), All examined patients had their body weight HDL cholesterol fractions (mg/dl), LDL cholesterol Słowa kluczowe: dieta niskoenergetyczna, nadwaga, otyłość, czynniki metaboliczny, parametry biochemiczne (kg), body height (cm) established on their first visit, fractions (mg/dl), triglycerides TG (mg/dl) and besides the analysis of their body composition was glucose on an empty stomach (mg/dl) at the beginning carried out (the proportional adipose tissue content and after 5 months of using the diet by the examined INTRODUCTION influence the improvement of the metabolic parameters, and proportional water content were marked and the people. and at the same time, reducing the risk factors of the metabolic age was established). The analysis of the Table 3 shows relations between the average body Excess body weight is one of the most common cardiovascular diseases as well as maintaining the body content was carried out through the method of weight reduction in case of examined people and health and economic problems of the contemporary results obtained as a result of dieting [6]. the bioelectric impendence analysis, with the use of changes in the fasting concentration in the blood of world. According to the assessments of the World The task of the low-energy diet, apart from reducing the TANITA SC – 330 apparatus (direct current with the the total cholesterol, HDL cholesterol fractions, LDL Health Organization (WHO), almost billion adults are the body weight (by slow limitation of delivered frequency of 50 kHz and the impedance of 500 mA). In cholesterol fractions, triglycerides (TG) and glucose. overweight and at least 300 million were diagnosed energy), ensuring patient’s good frame of mind (both order to receive the reliable result of the examination Table 4 shows values of relations between the with clinical obesity (BMI ≥ 40) [13]. Among European physical and mental health) and reducing the feeling of of the bioelectrical impedance method, the patients average body weight reduction in case of examined countries more than 50% people are overweight and hunger, is, when accompanied by [6, 25, 31, 38]: were requested to abstain from drinking any liquids people and changes to the content of fat, water in the 30% were diagnosed with obesity [2, 10]. • diabetes: reducing the fasting glucose and eating 3 hours before the examination. organism, as well as the metabolic age. Ischemic heart disease, congestive cardiac failure, concentration in the blood and at the same time The value of the body mass index (BMI) was In order to examine change of body weight during hypertension, arteriosclerotic vascular disease, reducing the need for the oral hypoglycaemic estimated and interpreted in accordance with the the 5 months therapy in the examined groups, the diabetes mellitus type 2, tumours, degenerative joint agents; WHO recommendations [36]. The measurement of univariate analysis of variance for the dependent disease, they are just some of the health-related • arterial hypertension: lowering blood pressure the body weight and the body composition, with the samples was carried out. The results for each group consequences of obesity [25, 26, 38]. and as a consequence reducing the need for the consideration of the metabolic age, were carried out were significant on the p<0.001 level. In conjunction The excess body weight influences almost every antihypertensive drugs; every month during the follow up visit. with time, the statistically significant weight loss was aspect of life, therefore it is necessary to eliminate it • hyperlipidemia: reducing the fraction of the Examined patients who reported to the centre, observed (both after the first and the fifth month of at an early stage. The treatment of obesity is difficult. LDL cholesterol concentration in blood serum, already had the results of the biochemical testing the treatment). In all examined groups, each of the It is a result of the fact that the disease also concerns triglycerides (TG) and the increase of the HDL performed by the order of a general practitioner: comparisons between successive measurements was the psychological sphere. Very often bad state of cholesterol concentration; total concentration of cholesterol in the blood, LDL statistically significant, on the level of at least p<0.01. mind and lowered self-esteem are observed in case of • sleep apnoea syndrome: relieving of the and HDL cholesterol fraction, triglycerides (TG) The biggest decrease of the body mass was observed overweight patients. With regard to that, the overweight symptoms; and glucose - fasting. The tests were repeated after 5 in group of obese women and the smallest in group of and obesity treatment should be performed under the • degenerative joint disease: increase of the months when the treatment was finished. women suffering from insulin resistance. surveillance of a physician, dietician, psychologist. movement capacity. In order to check the execution of the nutritional After 5 months the body mass index BMI statistically Many overweight people reduce the body weight Low-energy diet should be balanced with regard to recommendations, the patients were advised to keep significantly lowered its value in case of examined people without the assistance from experts, by using various its content of protein, fat, carbohydrates, vitamins and the nutritional diary, where they were writing up in all four groups (p<0.001). There were statistically diets and diet programs, published in the magazines, minerals. The energy content should be simultaneously the menu from the last week before the scheduled significant differences between the examined groups newspapers or the Internet [34]. The diet therapy for lower than individual complete energy demand. appointment. Patients who took part in the test did in the proportional reduction of the value of the BMI people with obesity problem should first of all be The aim of the study was the assessment of the not practice any additional forms of physical activity, index (p<0.0001). The greatest reduction of the BMI based on the education of patients in the scope of the effectiveness of the low-energy diet used in the during the slimming diet the physical activity in the demonstrated in the group of obese women, the lowest changes to the nutritional habits [12, 20, 21]. period of 5 months by women and men treated from examined group did not undergo a change. All obtained – in the group of women suffering from hypothyroidism. Low-energy diet, also called the reductive diet overweight or obesity in the diet centre. data was gathered in the Microsoft Office Excel 2007 While analysing the efficiency of the diet, in is the basis for the dietary obesity treatment [22, Spread Sheet. Data, gathered in the progress of carried connection with the level of the fat content in the 28]. Every diet, also the low-energy one should be MATERIAL AND METHODS out examination, underwent the statistical analysis organism, the univariate analysis of variance for the individualized. While preparing the diet, not only the through the use of the SPSS Statistics 17.0PL package. dependent samples was carried out in each of the anthropometrical data (body weight, height) is taken The research included 296 overweight or obese In order to receive the answers for the research groups singled out on the basis of the sex and health into consideration, but also other various aspects, first patients, treated in the diet centre: (1) 104 women questions and the confirmation of the hypothesis, the condition. The acquired results show that the use of of all such as: age, gender, physical activity, nutritional without co-morbidities, between 18 to 61 years old; (2) univariate and multivariate (POST HOC) analysis the diet in each of the examined groups gave positive likings and habits, associated illnesses, the type of 58 women with the accompanying insulin resistance, of variance. The statistical relevance of the received results (statistical significance p<0.001). In all four performed work or the culinary skills. between 19 to 61 years old; (3) 49 women additionally results was estimated through the t-Student test. The groups the fat content in the organism was lowered The task of the diet is first of all broadly defined suffering from hypothyroidism, between 19 to 61 occurrence of relevant dependences between the statistically significantly after 5 months of using the improvement of the patients health condition. Body years old; (4) 85 men without co-morbidities, between features was estimated on the basis of the measure of diet. A group of men has become the largest reduction weight loss, being the result of the diet therapy, should 19 to 62 years old. the Pearson product-moment correlation coefficient. in body fat content, in contrast to group of women Statistical significance p<0.05 level was established. suffering from hypothyroidism. 138 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 139

Wyniki. Stosowanie diety w każdej z badanych grup przyniosło pozytywne rezultaty. We wszystkich czterech grupach Treated patients were recommended the use of RESULTS zawartość tłuszczu w organizmie zmniejszyła się istotnie statystycznie po 5 miesiącach stosowania diety. Wykazano wzrost the low-energy diet, where 20% of energy came from średniej procentowej zawartości wody w organizmie osób badanych. Zanotowano również obniżenie średniego stężenia protein, 30% of energy from fat and 50% of energy Table 1 contains mean values of body weight cholesterolu całkowitego, frakcji LDL, TG, glukozy na czczo oraz wzrost stężenia frakcji HDL dla każdej grupy. from carbohydrates. The energy content of the diet (kg), BMI (kg/m2), fat content (%), water content (%) Wnioski. Postępowanie dietetyczne polegające na obniżeniu wartości energetycznej diety ma korzystny wpływ na obniżenie was considered to be dependent on the individual daily and the metabolic age (years) at the beginning of the masy ciała, wieku metabolicznego, zmniejszenie wartości wskaźnika BMI oraz wpływa na zmiany procentowej zawartości demand that was estimated taking into consideration the tłuszczu w organizmie, powodując jego obniżenie, zmiany procentowej zawartości wody, prowadząc do nieznacznego therapy and after 5 months of using the diet. wzrostu jej poziomu w organizmie. Ponadto wpłynęło korzystnie na zmiany stężenia we krwi wskaźników lipidowych, physical activity and that was reduced with 1000 kcal. In Table 2 are present mean values of the powodując zmniejszenie czynników ryzyka choroby niedokrwiennej serca. Patients applied suggested reductive diet for 5 months. concentration in the blood of total cholesterol (mg/dl), All examined patients had their body weight HDL cholesterol fractions (mg/dl), LDL cholesterol Słowa kluczowe: dieta niskoenergetyczna, nadwaga, otyłość, czynniki metaboliczny, parametry biochemiczne (kg), body height (cm) established on their first visit, fractions (mg/dl), triglycerides TG (mg/dl) and besides the analysis of their body composition was glucose on an empty stomach (mg/dl) at the beginning carried out (the proportional adipose tissue content and after 5 months of using the diet by the examined INTRODUCTION influence the improvement of the metabolic parameters, and proportional water content were marked and the people. and at the same time, reducing the risk factors of the metabolic age was established). The analysis of the Table 3 shows relations between the average body Excess body weight is one of the most common cardiovascular diseases as well as maintaining the body content was carried out through the method of weight reduction in case of examined people and health and economic problems of the contemporary results obtained as a result of dieting [6]. the bioelectric impendence analysis, with the use of changes in the fasting concentration in the blood of world. According to the assessments of the World The task of the low-energy diet, apart from reducing the TANITA SC – 330 apparatus (direct current with the the total cholesterol, HDL cholesterol fractions, LDL Health Organization (WHO), almost billion adults are the body weight (by slow limitation of delivered frequency of 50 kHz and the impedance of 500 mA). In cholesterol fractions, triglycerides (TG) and glucose. overweight and at least 300 million were diagnosed energy), ensuring patient’s good frame of mind (both order to receive the reliable result of the examination Table 4 shows values of relations between the with clinical obesity (BMI ≥ 40) [13]. Among European physical and mental health) and reducing the feeling of of the bioelectrical impedance method, the patients average body weight reduction in case of examined countries more than 50% people are overweight and hunger, is, when accompanied by [6, 25, 31, 38]: were requested to abstain from drinking any liquids people and changes to the content of fat, water in the 30% were diagnosed with obesity [2, 10]. • diabetes: reducing the fasting glucose and eating 3 hours before the examination. organism, as well as the metabolic age. Ischemic heart disease, congestive cardiac failure, concentration in the blood and at the same time The value of the body mass index (BMI) was In order to examine change of body weight during hypertension, arteriosclerotic vascular disease, reducing the need for the oral hypoglycaemic estimated and interpreted in accordance with the the 5 months therapy in the examined groups, the diabetes mellitus type 2, tumours, degenerative joint agents; WHO recommendations [36]. The measurement of univariate analysis of variance for the dependent disease, they are just some of the health-related • arterial hypertension: lowering blood pressure the body weight and the body composition, with the samples was carried out. The results for each group consequences of obesity [25, 26, 38]. and as a consequence reducing the need for the consideration of the metabolic age, were carried out were significant on the p<0.001 level. In conjunction The excess body weight influences almost every antihypertensive drugs; every month during the follow up visit. with time, the statistically significant weight loss was aspect of life, therefore it is necessary to eliminate it • hyperlipidemia: reducing the fraction of the Examined patients who reported to the centre, observed (both after the first and the fifth month of at an early stage. The treatment of obesity is difficult. LDL cholesterol concentration in blood serum, already had the results of the biochemical testing the treatment). In all examined groups, each of the It is a result of the fact that the disease also concerns triglycerides (TG) and the increase of the HDL performed by the order of a general practitioner: comparisons between successive measurements was the psychological sphere. Very often bad state of cholesterol concentration; total concentration of cholesterol in the blood, LDL statistically significant, on the level of at least p<0.01. mind and lowered self-esteem are observed in case of • sleep apnoea syndrome: relieving of the and HDL cholesterol fraction, triglycerides (TG) The biggest decrease of the body mass was observed overweight patients. With regard to that, the overweight symptoms; and glucose - fasting. The tests were repeated after 5 in group of obese women and the smallest in group of and obesity treatment should be performed under the • degenerative joint disease: increase of the months when the treatment was finished. women suffering from insulin resistance. surveillance of a physician, dietician, psychologist. movement capacity. In order to check the execution of the nutritional After 5 months the body mass index BMI statistically Many overweight people reduce the body weight Low-energy diet should be balanced with regard to recommendations, the patients were advised to keep significantly lowered its value in case of examined people without the assistance from experts, by using various its content of protein, fat, carbohydrates, vitamins and the nutritional diary, where they were writing up in all four groups (p<0.001). There were statistically diets and diet programs, published in the magazines, minerals. The energy content should be simultaneously the menu from the last week before the scheduled significant differences between the examined groups newspapers or the Internet [34]. The diet therapy for lower than individual complete energy demand. appointment. Patients who took part in the test did in the proportional reduction of the value of the BMI people with obesity problem should first of all be The aim of the study was the assessment of the not practice any additional forms of physical activity, index (p<0.0001). The greatest reduction of the BMI based on the education of patients in the scope of the effectiveness of the low-energy diet used in the during the slimming diet the physical activity in the demonstrated in the group of obese women, the lowest changes to the nutritional habits [12, 20, 21]. period of 5 months by women and men treated from examined group did not undergo a change. All obtained – in the group of women suffering from hypothyroidism. Low-energy diet, also called the reductive diet overweight or obesity in the diet centre. data was gathered in the Microsoft Office Excel 2007 While analysing the efficiency of the diet, in is the basis for the dietary obesity treatment [22, Spread Sheet. Data, gathered in the progress of carried connection with the level of the fat content in the 28]. Every diet, also the low-energy one should be MATERIAL AND METHODS out examination, underwent the statistical analysis organism, the univariate analysis of variance for the individualized. While preparing the diet, not only the through the use of the SPSS Statistics 17.0PL package. dependent samples was carried out in each of the anthropometrical data (body weight, height) is taken The research included 296 overweight or obese In order to receive the answers for the research groups singled out on the basis of the sex and health into consideration, but also other various aspects, first patients, treated in the diet centre: (1) 104 women questions and the confirmation of the hypothesis, the condition. The acquired results show that the use of of all such as: age, gender, physical activity, nutritional without co-morbidities, between 18 to 61 years old; (2) univariate and multivariate (POST HOC) analysis the diet in each of the examined groups gave positive likings and habits, associated illnesses, the type of 58 women with the accompanying insulin resistance, of variance. The statistical relevance of the received results (statistical significance p<0.001). In all four performed work or the culinary skills. between 19 to 61 years old; (3) 49 women additionally results was estimated through the t-Student test. The groups the fat content in the organism was lowered The task of the diet is first of all broadly defined suffering from hypothyroidism, between 19 to 61 occurrence of relevant dependences between the statistically significantly after 5 months of using the improvement of the patients health condition. Body years old; (4) 85 men without co-morbidities, between features was estimated on the basis of the measure of diet. A group of men has become the largest reduction weight loss, being the result of the diet therapy, should 19 to 62 years old. the Pearson product-moment correlation coefficient. in body fat content, in contrast to group of women Statistical significance p<0.05 level was established. suffering from hypothyroidism. 140 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 141

Table 1. Mean values: body weight (kg), BMI (kg/m2), fat content (%), water content (%) and the metabolic age (years) at Table 2. Mean values of the total cholesterol, HDL and LDL cholesterol fractions, triglycerides (TG) and glucose at the the beginning of the therapy and after 5 months of using the diet beginning and after 5 months of using the diet by the examined people Body weight at the beginning Body weight after Mean reduction of the body Total cholesterol at the Total cholesterol Mean reduction n =296 of the therapy (kg) 5 months (kg) weight after 5 months (%) n=296 beginning of the therapy after 5 months of the total cholesterol _ _ _ (mg/dl) (mg/dl) after 5 months (%) n X SD X SD X SD _ _ _ n SD SD SD Obese women 104 86.1 15.00 70.2 13.3 18.6 4.0 X X X Obese women 104 211.1 30.2 185.1 27.9 10.9 9.3 Obese women suffering from 49 79.4 10.5 67.3 10.31 15.4 3.3 hypothyroidism Obese women suffering from 49 203.1 22.1 184.1 25.6 8.3 7.3 hypothyroidism Obese women suffering from 58 91.8 17.3 75.2 16.4 18.3 6.1 Obese women suffering from insulin resistance 58 219.5 31.3 192.1 29.6 10.8 9.8 insulin resistance Obese men 85 111.3 13.2 93.5 12.9 16.2 4.1 Obese men 85 216.3 30.9 190.2 27.5 10.9 8.8 BMI at the beginning of the BMI after 5 months Mean reduction of the BMI HDL at the beginning of the HDL after 5 months Mean increase of the HDL therapy (kg/m2) (kg/m2) after 5 months (%) therapy (mg/dl) (mg/dl) after 5 months (%) ______n X SD X SD X SD n X SD X SD X SD Obese women 104 31.5 5.2 25.7 4.5 18.6 4.1 Obese women 104 50.6 15.1 61.4 12.1 23.1 20.3 Obese women suffering from Obese women suffering from 49 29.4 4.1 28.2 3.8 15.7 3.2 49 50.9 13.5 59.5 12.2 17.8 15.9 hypothyroidism hypothyroidism Obese women suffering from Obese women suffering from 58 51.1 12.1 58.7 10.1 15.9 14.0 58 33.5 6.2 27.4 5.7 18.4 6.1 insulin resistance insulin resistance Obese men 85 46.1 14.3 54.5 11.4 19.5 17.9 Obese men 85 33.5 3.3 28.2 3.2 16.1 4.1 LDL at the beginning of the LDL after 5 months Mean reduction of the Fat content at the beginning Fat content after Mean decrease of the fat therapy (mg/dl) (mg/dl) LDL after 5 months (%) _ _ _ of the therapy (%) 5 months (%) content after 5 months (%) n SD SD SD _ _ _ X X X n X SD X SD X SD Obese women 104 142.5 32.7 120.6 20.7 14.2 9.0 Obese women 104 39.0 7.0 28.1 5.7 23.5 7.7 Obese women suffering from 49 132.9 29.5 116.1 18.9 11.9 8.9 hypothyroidism Obese women suffering from 49 36.5 5.0 27.4 5.2 21.5 7.9 Obese women suffering from hypothyroidism 58 144.2 27.4 124.5 21.0 12.6 9.8 insulin resistance Obese women suffering from 58 41.0 8.7 29.9 6.7 22.7 6.8 Obese men 85 140.2 38.8 122.4 16.1 11.9 8.5 insulin resistance TG at the beginning of the TG after 5 months Mean reduction of the TG Obese men 85 33.7 5.4 21.2 4.4 31.6 7.1 therapy (mg/dl) (mg/dl) after 5 months (%) _ _ _ The content of water at the The content of water after Mean increase of the water n X SD X SD X SD beginning of the therapy (%) 5 months (%) content after 5 months (%) _ _ _ Obese women 104 142.9 110.7 110.9 48.5 20.3 12.8 n X SD X SD X SD Obese women suffering from 49 129.7 99.8 106.5 38.9 15.5 9.9 Obese women 104 43.1 6.5 47.4 5.6 10.1 9.0 hypothyroidism Obese women suffering from Obese women suffering from 58 146.5 79.9 122.8 40.2 14.7 10.0 49 43.1 5.9 47.6 5.4 11.5 12.4 insulin resistance hypothyroidism Obese men 85 168.0 88.0 143.1 39.9 14.0 11.2 Obese women suffering from 58 41.5 7.4 45.9 6.8 10.8 11.8 insulin resistance Glucose at the beginning of the Glucose after 5 months Mean reduction of the therapy (mg/dl) (mg/dl) glucose after 5 months (%) Obese men 85 44.8 6.4 49.1 4.7 12.1 10.1 _ _ _ Metabolic age at the n X SD X SD X SD Metabolic age after 5 Mean decrease of metabolic beginning of the therapy months (years) age after 5 months (%) Obese women 104 83.0 25.1 78.2 16.5 4.9 12.0 _ (years) _ _ Obese women suffering from n X SD X SD X SD 49 79.7 21.1 75.2 10.3 4.6 12.1 hypothyroidism Obese women 104 49.6 14.6 42.6 14.3 14.7 9.2 Obese women suffering from 58 82.0 40.7 79.8 20.4 2.0 7.9 Obese women suffering from insulin resistance 49 48.8 13.7 42.5 13.7 13.5 8.9 hypothyroidism Obese men 85 81.5 23.5 77.7 16.6 4.4 11.1 Obese women suffering from n- number of examined people, - mean, SD - standard deviation 58 49.34 14.5 42.9 14.6 13.8 9.2 insulin resistance

Obese men 85 46.2 14.6 42.2 13.9 8.7 4.9 n- number of examined people, - mean, SD - standard deviation, 140 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 141

Obese men 85 46.2 14.6 42.2 13.9 8.7 4.9 n- number of examined people, - mean, SD - standard deviation, 142 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 143

Table 3. Relations between the average body weight reduction in case of examined people and changes in the fasting Lowering of average concentration of total weeks), the reduction of the body weight was achieved concentration in the blood of the total cholesterol, HDL and LDL cholesterol fractions, triglycerides (TG) and cholesterol, LDL fractions, TG, glucose on an empty and it was identical with the diet based on the products glucose stomach and the increase of the concentration of HDL with low glycaemic index. In the Melanson et al. ↓ Total fraction was statistically significant for each group research [20] the examined group consisted of healthy n=296 ↑ HDL ↓ LDL ↓ TG ↓Glucose cholesterol after 5 months of using the (p<0.05). The biggest overweight or obese adults, also using regular, group Pearson’s lowering of the examined parameters was observed nutritional education. 0.32 0.22 0.32 0.32 0.02 correlation in the group of women without concomitant diseases Similar results of the body weight reduction with Obese women ↓ body weight of obesity. The study showed differences in lowering the use of the reductive diet were indicated in the study p 0.001 0.027 0.001 0.001 0.866 of the fasting blood glucose concentration between of Krempf et al. [18], Andersson et al. [1], Ashley et n 104 a group of women suffering from insulin resistance al. [4]. Pearson’s and all of the other groups. Hession et al. [13] analysed the research from 0.19 -0.09 0.13 0.03 0.03 Obese women correlation The statistical analysis indicated that there were 2000-2007 that lasted for at least 6 months and that suffering from ↓ body weight p 0.152 0.487 0.340 0.837 0.822 statistically significant differences on the p<0,05 concerned the comparison of the low-carbohydrates insulin resistance level, only in the value of lowering the average TG and high-protein diet with low-fat and low-energy diet n 58 concentration. The POST HOC tests (with the correction in case of adults with the index BMI≥28 kg/m2. It was Pearson’s for the unequal variances of Games-Howell) indicated stated that low-carbohydrates diet were more effective -0.07 0.08 0.15 0.17 -0.11 Obese women correlation that lowering of triglycerides in case of obese women after 6 months, and after a year they are comparable to suffering from ↓ body weight p 0.645 0.565 00.312 0.240 0.434 (20.30%) was significantly higher than in case of each other in the reduction of weight loss and influence hypothyroidism women suffering from the insulin resistance (14.67%) on risk factors of the cardio-vascular diseases. n 49 or obese men (14.03%) and insignificantly higher from The study conducted among residing in the 3-week Pearson’s 0.40 0.36 0.33 0.24 -0.12 the result of women suffering from hypothyroidism stay in a sanatorium have shown, that a short period correlation (15.50%). In the remaining comparisons between of treatment and mismatch diet (without individual Obese men ↓ body weight p 0.000 0.001 0.002 0.029 0.291 groups, no significant differences were observed. program), caused an increase in body mass and BMI, despite of increased physical activity [23]. n 85 DISCUSSION Research of de Jonge [7] indicated that the use n- number of examined people, p – significance of the low-energy and at the same time low-fat diet Obesity is a non-infectious, chronic metabolic (carbohydrates participation 55%) lowered the body Table 4. Relations between the average body weight reduction in case of examined people and changes to the content of fat, disease. It is diagnosed in case of people belonging to weight of the examined group below 60% of the initial water in the organism, as well as the metabolic age all age groups [14]. In the USA it is considered to be values, which wasn’t observed in case of people using n=296 ↓ Content of fat ↑ Content of water ↓ Metabolic age an epidemic, in Poland the problem of overweight and the high fat diet. Pearson’s correlation 0.51 0.02 0.19 obesity concerns 50% of population [2, 10, 15]. Previously cited various studies have shown the ↓ body It has been noticed that the community’s awareness efficiency of rationally composed low-energy diet Obese women p 0.000 0.842 0.049 weight concerning this problem is growing and the preventive (20% energy from protein, 30% from fat and 50% n 104 measures are being undertaken [5, 21]. All around the from carbohydrate) compared with alternative diets Pearson’s correlation 0.38 -0.18 0.03 world people are searching for the effective method to [13, 37]. It shows from own research that the use of the Obese women suffering ↓ body treat the obesity. The biggest results are brought by the low-energy diet for 5 months, both in case of women p 0.003 0.168 0.842 from insulin resistance weight methods connected with the change of nutrition habits, and men, resulted in considerable reduction of the fat n 58 nutrition habits and the increase of physical activity [21]. percentage content in the organism. The content of this Pearson’s correlation 0.13 -0.12 0.04 According to the recommendations of WHO and scientific component before using the slimming therapy in case Obese women suffering ↓ body associations, it is necessary to use low-energy 1000-1800 of women amounted to 38.99%, and in case of men p 0.380 0.423 0.798 from hypothyroidism weight kcal diets in the treatment of overweight and obesity. The 33.72%, after the slimming therapy was finished the n 49 content of fat in the diet should be within the limits of 23- result formed appropriately at the level of 28.09% and 21.15%. The average loss of the body fat percentage Pearson’s correlation 0.22 0.09 -0.08 35% of total energy, protein 15-20% and carbohydrates ↓ body 50-60% [16, 25]. content in case of the examined group of women and Obese men p 0.043 0.397 0.485 weight The analysis of obtained results allows to claim men amounted to 27.56% (Table 1). n 85 that the changes of examined parameters under the In the study of Shishkova et al. [29] the results were similar if they were related to the similar time of using the n- number of examined people, p – significance influence of using the five months slimming therapy are significant. In the examined group of 296 adults diet. In case of those who were using the low-energy diet, after 2 weeks of the slimming therapy, the decrease of The increase of the body water percentage in the POST HOC test showed that the average decrease in who used the low-energy diet for 5 months, the the percentage of fatty tissue was observed; it decreased organisms of examined people was indicated. Highly the metabolic age of obese women (14.66%), women average reduction of the body weight was achieved from the value of 41.25% to the value of 31.3%. statistically significant differences were noticed in suffering from insulin resistance (13.79%) and women in the group of all women with 22.98% (14.58 kg), Fats like carbohydrate is mainly energetic material. case all examined groups (p<0.001). suffering from hypothyroidism (13.48%) was similar. obese women with 18.57% (15.90 kg) and in case of Unfortunately, the body reaches for adipose tissue The analysis of the percentage value of lowering the Significantly smallest decrease of metabolic age in the men with 16.16% (17.89%) (Table 1). This result was last. Adipose tissue plays a very important role in the average metabolic age of examined people indicated process of 5 months was observed in case of men and achieved only through the use of the low-energy diet. body. Cushions the main organs (heart, liver, kidneys), the occurrence of statistically highly significant it was equal on average 8.72%. In the similar studies carried out by Melanson et provides a protective barrier against loss of heat, it differences (p<0.001) between compared groups. The al. [20] with the use of therapy of low-energy diet (12 144 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 145 supplies the body with vitamins, which dissolve only the slimming therapy amounted to 211.10 mg/dl and in Diverse results are the effect of differences in REFERENCES in its presence. In a low-energy diet, control body fat is the group of men it formed on the level of 216.34 mg/dl. the degree of the fulfilment of the recommended crucial, because weight loss is not always unambiguous After 5 months of using the diet, the concentration of diet, individual differences as well as methods of 1. 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Int J Obes Relat Metab to establish how the hitherto prevailing style of life [3]. on decreasing the body mass, metabolic age, Disord J Int Assoc Study Obes 2001;25(6):793-797. influenced the ageing of the body. This is a very reliable The research of Trafalska et al. demonstrated that lowering the value of the BMI index and has 10. Elmadfa I. (ed): European nutrition and health report and mobilizing factor when the lifestyle changes into patient with lower body mass were characterized by influence on changes of the percentage fat content 2009. Basel, Switzerland, New York: Karger; 2009. the healthy one. lower values of blood pressure, superior lipid profile in the organism, causing its reduction, on changes 11. Gallagher D., Kovera A.J., Clay-Williams G., Agin The assessment of the dislipemia in case of parameters (regarding the level of HDL-cholesterol of the percentage water content, leading to the D., Leone P., Albu J., Matthews D.E., Heymsfield S.B.: overweight people was the subject of numerous and triglycerides) [32]. The lack of the influence slight increase of its level in the organism. Weight loss in postmenopausal obesity: no adverse studies. The most often ascertained changes include: or the insignificant influence of the reduction of 2. The use of the low-energy diet by the examined alterations in body composition and protein metabolism. the increase of the triglycerides concentrations, the body weight on the concentration of the HDL group of women and men favourably influenced Am J Physiol Endocrinol Metab 2000;279(1):E124-131. increase of the total cholesterol and the LDL fractions cholesterol fractions were indicated by other studies the changes in the concentration of the lipid indexes 12. Greenwald A.: Current Nutritional Treatments of and the decrease of the HDL concentration in the [19]. Favourable increase in the concentration of this in the blood causing the decrease of the risk factors Obesity. In: Vaidya V. (ed.). Advances in Psychosomatic Medicine. Basel: KARGER; 2006 p. 24-41. blood serum [8, 25, 26, 38]. The literature data says fraction of the cholesterol was observed in the research of the ischemic heart disease (concentration of the 13. Hession M., Rolland C., Kulkarni U., Wise A., Broom that the increase of the obesity degree is the factor that carried out by Ryan [27], however, only when the diet total cholesterol, LDL cholesterol fractions and J.: Systematic review of randomized controlled trials enlarges the intensity of abnormalities in the scope of with considerable energy deficiency was applied (after TG, as well as the increase of the concentration in of low-carbohydrate vs. low-fat/low-calorie diets in the the lipid disorders. 6 months of slimming therapy). the serum HDL cholesterol). The effect of the diet management of obesity and its comorbidities. Obes Rev In the own research, after 5 months, both in case Acquired changes in the concentrations of total was also a slight decrease of the fasting glucose 2009;10(1):36-50. of women and men, regardless of age, the significant cholesterol, its LDL fractions, TG, showed positive concentration in the blood in case of all examined 14. James W.P.T.: The epidemiology of obesity: the size of decrease of the concentration of lipid indexes in the correlation with the reduction of the body weight people. the problem. J Intern Med 2008;263(4):336-352. blood was observed (total cholesterol, TG, LDL both in the own study and in the studies of other 3. In case of the obese women and women suffering 15. Jarosz M., Barysz A.: Obesity, nutrition, physical cholesterol fraction) as well as the decrease of the authors (Table 3, 4). In the research of Bellou et al. from hypothyroidism decreasing of the body mass activity, health Poles: diagnosis of nutritional status, glucose concentration on an empty stomach. On [5] the reduction of the body weight connected to the was observed with the simultaneous decreasing of physical activity and dietary risk factors for obesity and the other hand, the HDL cholesterol fractions level physical activity influenced on the reduction of the the percentage fat content in the body. chronic non-communicable diseases in Poland (1960- insignificantly increased. Mean value of the total concentration of triglycerides, total cholesterol and 2005). Warszawa: Instytut Żywności i Żywienia; 2006. cholesterol in the group of obese women before starting LDL cholesterol fractions. (in Polish) 144 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 No 2 The effectiveness of the low energy diet in overweight and obese adults 145 supplies the body with vitamins, which dissolve only the slimming therapy amounted to 211.10 mg/dl and in Diverse results are the effect of differences in REFERENCES in its presence. 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Effect of Diet Composition and Weight at the beginning of the slimming therapy amounted to results concerning the concentration of lipid indexes CONCLUSIONS Loss on Resting Energy Expenditure in the POUNDS appropriately: 49.60 years, 46.15 years; whereas after after applying the low-energy diet were achieved in LOST Study. Obesity 2012;20(12):2384-2389. 9. Dixon JB, O’Brien P.: A disparity between conventional the 5 months of using the diet there was a decrease with the studies carried out by Bellou et al. [5], Ryan [27], 1. Dietary procedure, consisting in reducing the 14.66% and 8.72% (Table 1). The measurement allows Melanson et al. [20], Pinkney et al. [24], Aronne et al. lipid and insulin resistance markers at body mass index energy value of the diet has a favourable influence levels greater than 34 kg/m(2). Int J Obes Relat Metab to establish how the hitherto prevailing style of life [3]. on decreasing the body mass, metabolic age, Disord J Int Assoc Study Obes 2001;25(6):793-797. influenced the ageing of the body. This is a very reliable The research of Trafalska et al. demonstrated that lowering the value of the BMI index and has 10. Elmadfa I. (ed): European nutrition and health report and mobilizing factor when the lifestyle changes into patient with lower body mass were characterized by influence on changes of the percentage fat content 2009. Basel, Switzerland, New York: Karger; 2009. the healthy one. lower values of blood pressure, superior lipid profile in the organism, causing its reduction, on changes 11. Gallagher D., Kovera A.J., Clay-Williams G., Agin The assessment of the dislipemia in case of parameters (regarding the level of HDL-cholesterol of the percentage water content, leading to the D., Leone P., Albu J., Matthews D.E., Heymsfield S.B.: overweight people was the subject of numerous and triglycerides) [32]. The lack of the influence slight increase of its level in the organism. Weight loss in postmenopausal obesity: no adverse studies. The most often ascertained changes include: or the insignificant influence of the reduction of 2. The use of the low-energy diet by the examined alterations in body composition and protein metabolism. the increase of the triglycerides concentrations, the body weight on the concentration of the HDL group of women and men favourably influenced Am J Physiol Endocrinol Metab 2000;279(1):E124-131. increase of the total cholesterol and the LDL fractions cholesterol fractions were indicated by other studies the changes in the concentration of the lipid indexes 12. Greenwald A.: Current Nutritional Treatments of and the decrease of the HDL concentration in the [19]. Favourable increase in the concentration of this in the blood causing the decrease of the risk factors Obesity. In: Vaidya V. (ed.). Advances in Psychosomatic Medicine. Basel: KARGER; 2006 p. 24-41. blood serum [8, 25, 26, 38]. The literature data says fraction of the cholesterol was observed in the research of the ischemic heart disease (concentration of the 13. Hession M., Rolland C., Kulkarni U., Wise A., Broom that the increase of the obesity degree is the factor that carried out by Ryan [27], however, only when the diet total cholesterol, LDL cholesterol fractions and J.: Systematic review of randomized controlled trials enlarges the intensity of abnormalities in the scope of with considerable energy deficiency was applied (after TG, as well as the increase of the concentration in of low-carbohydrate vs. low-fat/low-calorie diets in the the lipid disorders. 6 months of slimming therapy). the serum HDL cholesterol). The effect of the diet management of obesity and its comorbidities. Obes Rev In the own research, after 5 months, both in case Acquired changes in the concentrations of total was also a slight decrease of the fasting glucose 2009;10(1):36-50. of women and men, regardless of age, the significant cholesterol, its LDL fractions, TG, showed positive concentration in the blood in case of all examined 14. James W.P.T.: The epidemiology of obesity: the size of decrease of the concentration of lipid indexes in the correlation with the reduction of the body weight people. the problem. J Intern Med 2008;263(4):336-352. blood was observed (total cholesterol, TG, LDL both in the own study and in the studies of other 3. In case of the obese women and women suffering 15. Jarosz M., Barysz A.: Obesity, nutrition, physical cholesterol fraction) as well as the decrease of the authors (Table 3, 4). In the research of Bellou et al. from hypothyroidism decreasing of the body mass activity, health Poles: diagnosis of nutritional status, glucose concentration on an empty stomach. On [5] the reduction of the body weight connected to the was observed with the simultaneous decreasing of physical activity and dietary risk factors for obesity and the other hand, the HDL cholesterol fractions level physical activity influenced on the reduction of the the percentage fat content in the body. chronic non-communicable diseases in Poland (1960- insignificantly increased. Mean value of the total concentration of triglycerides, total cholesterol and 2005). Warszawa: Instytut Żywności i Żywienia; 2006. cholesterol in the group of obese women before starting LDL cholesterol fractions. (in Polish) 146 B. Całyniuk, E. Grochowska-Niedworok, M. Muc-Wierzgoń et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):147-153 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ 16. Joint WHO-FAO Expert Consultation on diet, nutrition, 27. Ryan A.S., Nicklas B.J., Berman D.M., Dennis K.E.: and the prevention of chronic diseases: report of a WHO- Dietary restriction and walking reduce fat deposition FAO Expert Consultation. Joint WHO-FAO Expert in the midthigh in obese older women. Am J Clin Nutr ORIGINAL ARTICLE Consultation on Diet, Nutrition, and the Prevention of 2000;72(3):708-713. Chronic Diseases, 2002, Geneva, Switzerland]. Geneva: 28. Scholl J.: Traditional dietary recommendations for the EMPLOYMENT DISCRIMINATION AGAINST OBESE WOMEN World Health Organization; 2003. prevention of cardiovascular disease: Do they meet the 17. Knowler W.C., Barrett-Connor E., Fowler S.E., needs of our patients? Cholesterol 2012;2012:1-9. IN OBESITY CLINIC’S PATIENTS PERSPECTIVE Hamman R.F., Lachin J.M., Walker E.A., Nathan D.M.: 29. Shishkova A., Petrova P., Tonev A., Mihneva D., Bahlova Reduction in the incidence of type 2 diabetes with P.: Analysis of body composition in overweight and Małgorzata Obara-Gołębiowska* lifestyle intervention or metformin. N Engl J Med. 2002 obese women using bioimpedance (BIA) system. Journal Feb 7;346(6):393–403. of International Medical Association Bulgaria - Annual University of Warmia and Mazury, 18. Krempf M., Louvet J-P., Allanic H., Miloradovich T., Proceeding (Scientific Papers) 2007;13(1):8-12. Department of Psychology of Development and Education, Olsztyn, Poland Joubert J-M., Attali J-R.: Weight reduction and long- 30. Szyguła Z., Pilch W., Borkowski Z.L., Bryła A.: Wpływ term maintenance after 18 months treatment with terapii dietetycznoruchowej na skład ciała u średnio orlistat for obesity. Int J Obes. 2003;27(5):591-597. otyłych kobiet i mężczyzn [The influence of diet and ABSTRACT 19. Malá H., Zadák Z., Sobotka L., Malý J.: Changes in physical activity therapy on the body’s composition of Background. The workplace is one of many areas of life where obese people are unfairly treated. According to the litera- selected biochemical parameters during a low-calorie medium obesity women and men]. Rocz Panstw Zakl ture obese women are particularly susceptible to discrimination in employment. There is a lack of polish researches of this reducing diet. Sborník Lékar̆ský. 2000;101(1):105-108. Hig 2006;57(3):283-294 (in Polish) [PMID: 17193749; subject. 20. Melanson K.J, Summers A., Nguyen V., Brosnahan http://www.ncbi.nlm.nih.gov/pubmed/17193749]. Objective. The main objective of this study was to analyze personal, subjective experiences related to weight bias and J., Lowndes J., Angelopoulos T.J., Rippe J.M.: Body 31. Taylor V.H.: Weighty matters: the association between discrimination against obese people in the workplace of obese Polish women. composition, dietary composition, and components of mental health, pregnancy, and obesity. J Popul Ther Material and Methods. The study was carried out in a hospital clinic for obesity management. A total of 420 women metabolic syndrome in overweight and obese adults Clin Pharmacol J Thérapeutique Popul Pharamcologie with BMI>30, aged 21 to 72, participated in group interviews focused on the weight bias and discrimination against obese after a 12-week trial on dietary treatments focused on Clin 2012;19(3):483-487. people in the workplace. portion control, energy density, or glycemic index. Nutr 32. Trafalska E., Figwer M., Komorowska H.: Nutritional Results. In the group of clinically obese women, 5.3% of subjects had experienced employment discrimination and 10.5% J 2012;11(1):57. status and prognostic factors in patients with chronic had been victims of verbal and social abuse in the workplace. The most common psycho-physical consequences of the 21. Mesas A.E., Guallar-Castillon P., Leon-Munoz heart failure. Probl Hig Epidemiol 2011;92(1): 89-93 weight stigma were emotional problems, lack of motivation and overeating in response to stress. L.M., Graciani A., Lopez-Garcia E., Gutierrez-Fisac (in Polish) Conclusions. Weight-based discrimination in the workplace poses a problem in Poland. The weight stigma and occupa- J.L., Banegas J.R., Rodriguez-Artalejo F.: Obesity- 33. UK Prospective Diabetes Study 7: response of fasting tional discrimination lead to psycho-physical discomfort which exacerbates overeating and obesity. related eating behaviors are associated with low plasma glucose to diet therapy in newly presenting physical activity and poor diet quality in Spain. J Nutr type II diabetic patients, UKPDS Group. Metabolism Key words: obesity, woman, obese woman, employment, discrimination in the workplace, stigmatization 2012;142(7):1321-1328. 1990;39(9):905-912. 22. Pérez-Escamilla R., Obbagy J.E., Altman J.M., Essery 34. Vranešic Bender D., Krznaric I. Nutritional and STRESZCZENIE E.V., McGrane M.M., Wong Y.P., Spahn J.M., Williams Behavioral Modification Therapies of Obesity: Facts Wprowadzenie. Zjawisko dyskryminacji zawodowej osób otyłych a w szczególności kobiet jest dobrze udokumentowane C.L.: Dietary energy density and body weight in adults and Fiction. Dig Dis 2012;30(2):163-167. w licznych badaniach amerykańskich oraz brytyjskich. Niestety brakuje opracowań tego tematu w Polsce. and children: A systematic review. J Acad Nutr Diet 35. Wang C.C.L., Adochio R.L., Leitner J.W., Abeyta I.M., Cel. Celem badań było analiza subiektywnych doświadczeń dotyczących stygmatyzacji oraz dyskryminacji zawodowej 2012;112(5):671-684. Draznin B., Cornier M-A.: Acute effects of different diet osób otyłych w grupie otyłych polskich kobiet. 23. Pilch W., Bałajewicz G.: Ocena bilansu energetycznego compositions on skeletal muscle insulin signaling in Materiał i metody. Badanie odbyło się w szpitalnym oddziale leczenia otyłości. 420 kobiet z BMI>30 w wieku od 21 do u kuracjuszy podczas 21-dniowego turnusu obese individuals during caloric restriction. Metabolism 72 lat wzięło udział w wywiadach grupowych zogniskowanych na temacie stygmatyzacji oraz dyskryminacji osób otyłych sanatoryjnego [The evaluation of the energy balance 2013;62(4):595-603. w miejscu pracy. of health resort visitors during 21-days staying in the 36. WHO Expert Committee on Physical Status: the usese Wyniki. W grupie klinicznej otyłych kobiet 5,3% doświadczyło dyskryminacji zawodowej natomiast 10,5% kobiet było sanatorium]. Rocz Panstw Zakl Hig 2009;60(1):69-73 and interpretation of anthropometry, editor. Physical stygmatyzowanych w sposób werbalno-relacyjny w miejscu pracy. Najpowszechniejszymi konsekwencjami psychofizycz- (in Polish) [PMID: 19579773; http://www.ncbi.nlm. status: the use and interpretation of anthropometry: nymi okazały się problemy emocjonalno-motywacyjne oraz objadanie się jako reakcja na stres. nih.gov/pubmed/19579773]. Report of a WHO Expert Committee. World Health Wnioski. Wyniki badań sygnalizują, że podobnie jak w krajach gdzie odsetek ludzi otyłych jest najwyższy, również 24. Pinkney J.H., Sjöström C.D., Gale E.A.: Should Organization, Geneva 1995, p. 452. i w Polsce istnieje zjawisko zawodowej dyskryminacji osób otyłych. Stygmatyzacja oraz wynikająca z niej dyskryminacja surgeons treat diabetes in severely obese people? Lancet 37. Wyka J., Malczyk E., Misiarz M., Zołoteńka-Synowiec w miejscy pracy powodują dyskomfort psychofizyczny, który sam w sobie utrwala otyłość. 2001;357(9265):1357-1359. M., Całyniuk B., Baczyńska S.: Assessment of food 25. Poirier P.: Obesity and cardiovascular disease: intakes for women adopting the high protein Dukan Słowa kluczowe: otyłość, kobiety, otyłe kobiety, zatrudnienie, dyskryminacja w miejscu pracy pathophysiology, evaluation, and effect of weight loss: diet. Rocz Panstw Zakl Hig 2015,66(2):137-142 an update of the 1997 American Heart Association [PMID: 26024402; http://www.ncbi.nlm.nih.gov/ Scientific statement on obesity and heart disease from pubmed/26024402]. INTRODUCTION success. Moreover overweight workers are at higher the Obesity Committee of the Council on Nutrition, 38. Zhang C., Rexrode K.M., van Dam R.M., Li T.Y., risk of encountering stereotypes related to their work Physical Activity, and Metabolism. Circulation Hu F.B.: Abdominal obesity and the risk of all- The workplace is one of many areas of life where competences and for general unequal treatment in the 2006;113(6):898-918. cause, cardiovascular, and cancer mortality: sixteen work setting. For instance Puhl and Brownell [22] 26. Renehan A.G., Tyson M., Egger M., Heller R.F., Zwahlen years of follow-up in US women. Circulation obese people are unfairly treated [20]. According M.: Body-mass index and incidence of cancer: a systematic 2008;117(13):1658-1667. to Giel et al. [10], obesity is a general barrier to surveyed 2249 obese women to reveal that 25% of review and meta-analysis of prospective observational employment, certain professions and professional the subjects had experienced discrimination in the studies. The Lancet 2008;371(9612):569-578. Received: 08.11.2015

Accepted: 01.03.2016 *Corresponding author: Malgorzata Obara-Gołębiowska University of Warmia and Mazury, Department of Psychology of Development and Education, Prawochenskiego street 13, 10-725 Olsztyn, Poland, phone +48 88 6793736, e-mail: [email protected] © Copyright by the National Institute of Public Health - National Institute of Hygiene 148 M. Obara-Gołębiowska No 2 No 2 Employment discrimination against obese women in obesity clinic’s patients perspective 149 workplace, whereas 43% had been stigmatized by be regarded as devaluation of the feminine because the 2011 and July 2012 until May 2014. All patients gave discrimination. Simultaneously they were encouraged their employers or superiors. In a study of 3437 obese female body has a naturally higher fat content than the verbal consent to participate in the study. to free expression of their beliefs and feelings individuals, Carr and Friedman [4] found that 26% male body. During pregnancy, females also naturally accompanying above painful situations. Then the employees had been unfairly treated on account of accumulate more reserve fat to protect the mother and Table 1. General characteristics of surveyed group (n=420) moderator initiated a discussion on the topics listed in their weight, whereas 31% of the subjects had been the child against the danger of malnutrition. The obesity Elementary 5 (1.2) the interview scenario: Vocational 35 (8.3) discriminated in the workplace due to their weight and stigma and the resulting discrimination lead to social Education n (%) • What was the nature of stigmatization and low levels of perceived physical attractiveness. isolation and contribute to devalued social identity of Secondary 120 (28.6) discrimination in the workplace? Higher 250 (59.5) Discrimination against people with BMI>30 overweight people. Stress and low self-esteem increase • What was the perpetrator’s age and sex? is particularly visible during recruitment. Obese the probability of emotional overeating and adopting Married 272 (64.7) • What was the victim’s relationship with the Divorced 45 (10.7) Marital status n (%) candidates are less likely to be employed or promoted a sedentary lifestyle [18]. Those behaviors perpetuate Widow 25 (5.9) perpetrator? than their slimmer colleagues despite the fact that they obesity and create an additional risk of somatic disease Single 78 (18.5) • What was the effect of stigmatization and have identical qualifications [25]. The prevalence of caused by weight gain [21]. Big city 144 (34.3) discrimination on the victim’s psychological the weight bias was illustrated by an experiment in The majority of the cited studies into weight-based Average city 123 (29.3) and physical well-being? Inhabitancy n (%) which obese candidates were offered less attractive discrimination in the workplace have been conducted Small city 78 (18.6) jobs and lower wages than leaner candidates [16]. in countries with the highest prevalence of obesity, Village 75 (17.8) Table 3. Description of perpetrators discriminating against According to Baum and Ford [2], both obese men and including the United States and Great Britain. In obese women women earn less during 20 years of their professional those countries, the obesity stigma receives significant Table 2. Description of obese women who experienced 6 woman employment discrimination Perpetrator’s sex careers, and the wage penalty for overweight people attention. However the number of overweight people 16 men Number of obese women who was determined between 0.7% and 6.3%. Crawley [6] continues to grow steadily around the world. In Poland, 22 Professional relationship be- employer or staff member re- experienced discrimination found that obesity lowers wages by approximately 9%. half of the adult population is overweight, and every tween the perpetrator and the sponsible for recruitment / po- victim tential employee Obese women are particularly susceptible to sixth person is obese [28]. Studies of Polish children and Mean BMI 35.5 discrimination in the workplace [7]. Women are adolescents produce alarming results – 16,4 of them are Mean age 32.65 During focused interviews, it was the moderator’s expected to meet much more stringent criteria in terms overweight and obese [13]. A study into the prevalence 5 - university degree task to ensure that the discussion did not go off topic. The of their physical appearance than men. Women are also of the weight bias in Poland demonstrated that 20% of Education 7 - secondary school diploma 10 - university students moderator also made sure that every respondent had an more severely judged for even the slightest deviation 55 women admitted to an obesity management clinic opportunity to contribute to the discussion. The surveyed from the ideal figure. According to statistical data, 60% had been victimized on account of their weight, whereas Survey procedure women were asked to share their personal experiences women vs. 40% men claim to have experienced weight- 25% of the subjects had witnessed such events [14]. The surveyed subjects participated in group regarding weight bias in employment settings. The aim based discrimination [9]. The above is directly correlated Also qualitative pilot study over work discrimination interviews focusing on stigmatization and of the person conducting the interviews was to elicit with weight-related differences in wages between men of obese people in Poland shows that in a group of discrimination against obese people in the workplace. the information related to the nature of stigmatization and women. According to Fikkan and Rothbloom 88 obese women there were multiple cases of obesity Interviews were held in focus groups of approximately and discrimination in the workplace as well as related [8] and Judge and Cable [12], the wage penalty for stigmatization and discrimination in employment [15]. 10 participants and lasted 1.5 hours. The women to the effect of stigmatization and discrimination on the women begins at surprisingly low body weight levels. Weight-related discrimination poses a growing problem participated in the study after a 10-day stay in an victim’s psychological and physical well-being. Also Women in the “normal-weight” category earn less and in Poland, and it should be addressed more frequently by obesity clinic during which they got to meet other the victim’s relationship with the perpetrator and the are promoted less frequently than slim and very slim Polish researchers. In view of the growing prevalence of group members by participating in therapy sessions. perpetrator’s age and sex were taken into consideration. women who are considered to be more attractive. The obesity in Poland and the general scarcity of published We assume that the interview was carried out in an At the end of the session, the moderator summed up above studies indicate that BMI is inversely correlated studies into employment discrimination against Polish atmosphere of psychological comfort and mutual trust the discussion to make sure that all participants agreed with wages and promotional opportunities. The women with BMI>30, the objective of this study was that was conducive to obtaining reliable results. The with the conclusions. Immediately after each meeting, above correlation was not observed in obese males. to investigate personal, subjective experiences of obese interview was conducted by a moderator the same for the moderator attended a debriefing session without the Overweight and borderline obese men generated even Polish women related to weight bias and discrimination all the sessions. She was employed as a counseling participants’ involvement to express and write down his higher incomes and were more likely to advance in the workplace. psychologist at the clinic. At the beginning of the observations. After the completion of all sessions, the their careers than men with normal weight. A reverse program, the moderator provided the participants with moderator’s notes and transcripts were collected and correlation was noted for morbidly obese as well as MATERIALS AND METHODS basic information about the sessions and requested their analysed. underweight men who earned less than colleagues with consent to take notes during the interview. Obviously a healthy weight [12, 26]. BMI-based differences in the Surveyed population the subjects were introduced with the concept of RESULTS occupational status of men and women are most clearly The survey was carried out on 420 women aged 21 obesity stigmatization as weight-related attitudes and demonstrated with regard to overweight. Although to 72 (51.8 mean age) with BMI>30 which is indicative beliefs that were manifested by stereotypes, rejection The surveyed victims of weight-based obesity is generally stigmatized in the workplace of obesity (36.7 mean BMI). All subjects had been and prejudice towards individuals because they were discrimination were divided into two groups according regardless of gender, women characterized by different admitted to an obesity management clinic which overweight [22]. There were also given common to their answers: levels of overweight are more likely to be victimized organizes weight loss programs that teach patients to examples of obesity discrimination in employment Group 1 – women who experienced problems with than men [5]. The above studies clearly demonstrate that make healthy lifestyle choices with the assistance of an as a consequence of obesity stigma in society where finding employment or becoming promoted due to more stringent criteria of physical attractiveness apply interdisciplinary team of experts, including a dietician, heavyweight employees were judged negatively by weight-based discrimination and unfair treatment in to women. The bar is set very high for women who want physician, psychologist, physiotherapists and physical co-workers, supervisors and employers [17, 24]. The the workplace; to conform to the common stereotype that only slim education trainers. Considering woman’s superiority surveyed women were asked to be possibly objective Group 2 – women who experienced verbal and people can be attractive [18]. This stereotype directly in numbers in weight loss programs, only female while interpreting and then classifying their personal social discrimination in the workplace, including influences women’s employment status. Workplace participants were included into this survey. The survey experiences as acts of obesity stigmatization and ridicule, teasing or isolation. devaluation on account of higher body weight can also was carried out from January 2010 until September 148 M. Obara-Gołębiowska No 2 No 2 Employment discrimination against obese women in obesity clinic’s patients perspective 149 workplace, whereas 43% had been stigmatized by be regarded as devaluation of the feminine because the 2011 and July 2012 until May 2014. All patients gave discrimination. Simultaneously they were encouraged their employers or superiors. In a study of 3437 obese female body has a naturally higher fat content than the verbal consent to participate in the study. to free expression of their beliefs and feelings individuals, Carr and Friedman [4] found that 26% male body. During pregnancy, females also naturally accompanying above painful situations. Then the employees had been unfairly treated on account of accumulate more reserve fat to protect the mother and Table 1. General characteristics of surveyed group (n=420) moderator initiated a discussion on the topics listed in their weight, whereas 31% of the subjects had been the child against the danger of malnutrition. The obesity Elementary 5 (1.2) the interview scenario: Vocational 35 (8.3) discriminated in the workplace due to their weight and stigma and the resulting discrimination lead to social Education n (%) • What was the nature of stigmatization and low levels of perceived physical attractiveness. isolation and contribute to devalued social identity of Secondary 120 (28.6) discrimination in the workplace? Higher 250 (59.5) Discrimination against people with BMI>30 overweight people. Stress and low self-esteem increase • What was the perpetrator’s age and sex? is particularly visible during recruitment. Obese the probability of emotional overeating and adopting Married 272 (64.7) • What was the victim’s relationship with the Divorced 45 (10.7) Marital status n (%) candidates are less likely to be employed or promoted a sedentary lifestyle [18]. Those behaviors perpetuate Widow 25 (5.9) perpetrator? than their slimmer colleagues despite the fact that they obesity and create an additional risk of somatic disease Single 78 (18.5) • What was the effect of stigmatization and have identical qualifications [25]. The prevalence of caused by weight gain [21]. Big city 144 (34.3) discrimination on the victim’s psychological the weight bias was illustrated by an experiment in The majority of the cited studies into weight-based Average city 123 (29.3) and physical well-being? Inhabitancy n (%) which obese candidates were offered less attractive discrimination in the workplace have been conducted Small city 78 (18.6) jobs and lower wages than leaner candidates [16]. in countries with the highest prevalence of obesity, Village 75 (17.8) Table 3. Description of perpetrators discriminating against According to Baum and Ford [2], both obese men and including the United States and Great Britain. In obese women women earn less during 20 years of their professional those countries, the obesity stigma receives significant Table 2. Description of obese women who experienced 6 woman employment discrimination Perpetrator’s sex careers, and the wage penalty for overweight people attention. However the number of overweight people 16 men Number of obese women who was determined between 0.7% and 6.3%. Crawley [6] continues to grow steadily around the world. In Poland, 22 Professional relationship be- employer or staff member re- experienced discrimination found that obesity lowers wages by approximately 9%. half of the adult population is overweight, and every tween the perpetrator and the sponsible for recruitment / po- victim tential employee Obese women are particularly susceptible to sixth person is obese [28]. Studies of Polish children and Mean BMI 35.5 discrimination in the workplace [7]. Women are adolescents produce alarming results – 16,4 of them are Mean age 32.65 During focused interviews, it was the moderator’s expected to meet much more stringent criteria in terms overweight and obese [13]. A study into the prevalence 5 - university degree task to ensure that the discussion did not go off topic. The of their physical appearance than men. Women are also of the weight bias in Poland demonstrated that 20% of Education 7 - secondary school diploma 10 - university students moderator also made sure that every respondent had an more severely judged for even the slightest deviation 55 women admitted to an obesity management clinic opportunity to contribute to the discussion. The surveyed from the ideal figure. According to statistical data, 60% had been victimized on account of their weight, whereas Survey procedure women were asked to share their personal experiences women vs. 40% men claim to have experienced weight- 25% of the subjects had witnessed such events [14]. The surveyed subjects participated in group regarding weight bias in employment settings. The aim based discrimination [9]. The above is directly correlated Also qualitative pilot study over work discrimination interviews focusing on stigmatization and of the person conducting the interviews was to elicit with weight-related differences in wages between men of obese people in Poland shows that in a group of discrimination against obese people in the workplace. the information related to the nature of stigmatization and women. According to Fikkan and Rothbloom 88 obese women there were multiple cases of obesity Interviews were held in focus groups of approximately and discrimination in the workplace as well as related [8] and Judge and Cable [12], the wage penalty for stigmatization and discrimination in employment [15]. 10 participants and lasted 1.5 hours. The women to the effect of stigmatization and discrimination on the women begins at surprisingly low body weight levels. Weight-related discrimination poses a growing problem participated in the study after a 10-day stay in an victim’s psychological and physical well-being. Also Women in the “normal-weight” category earn less and in Poland, and it should be addressed more frequently by obesity clinic during which they got to meet other the victim’s relationship with the perpetrator and the are promoted less frequently than slim and very slim Polish researchers. In view of the growing prevalence of group members by participating in therapy sessions. perpetrator’s age and sex were taken into consideration. women who are considered to be more attractive. The obesity in Poland and the general scarcity of published We assume that the interview was carried out in an At the end of the session, the moderator summed up above studies indicate that BMI is inversely correlated studies into employment discrimination against Polish atmosphere of psychological comfort and mutual trust the discussion to make sure that all participants agreed with wages and promotional opportunities. The women with BMI>30, the objective of this study was that was conducive to obtaining reliable results. The with the conclusions. Immediately after each meeting, above correlation was not observed in obese males. to investigate personal, subjective experiences of obese interview was conducted by a moderator the same for the moderator attended a debriefing session without the Overweight and borderline obese men generated even Polish women related to weight bias and discrimination all the sessions. She was employed as a counseling participants’ involvement to express and write down his higher incomes and were more likely to advance in the workplace. psychologist at the clinic. At the beginning of the observations. After the completion of all sessions, the their careers than men with normal weight. A reverse program, the moderator provided the participants with moderator’s notes and transcripts were collected and correlation was noted for morbidly obese as well as MATERIALS AND METHODS basic information about the sessions and requested their analysed. underweight men who earned less than colleagues with consent to take notes during the interview. Obviously a healthy weight [12, 26]. BMI-based differences in the Surveyed population the subjects were introduced with the concept of RESULTS occupational status of men and women are most clearly The survey was carried out on 420 women aged 21 obesity stigmatization as weight-related attitudes and demonstrated with regard to overweight. Although to 72 (51.8 mean age) with BMI>30 which is indicative beliefs that were manifested by stereotypes, rejection The surveyed victims of weight-based obesity is generally stigmatized in the workplace of obesity (36.7 mean BMI). All subjects had been and prejudice towards individuals because they were discrimination were divided into two groups according regardless of gender, women characterized by different admitted to an obesity management clinic which overweight [22]. There were also given common to their answers: levels of overweight are more likely to be victimized organizes weight loss programs that teach patients to examples of obesity discrimination in employment Group 1 – women who experienced problems with than men [5]. The above studies clearly demonstrate that make healthy lifestyle choices with the assistance of an as a consequence of obesity stigma in society where finding employment or becoming promoted due to more stringent criteria of physical attractiveness apply interdisciplinary team of experts, including a dietician, heavyweight employees were judged negatively by weight-based discrimination and unfair treatment in to women. The bar is set very high for women who want physician, psychologist, physiotherapists and physical co-workers, supervisors and employers [17, 24]. The the workplace; to conform to the common stereotype that only slim education trainers. Considering woman’s superiority surveyed women were asked to be possibly objective Group 2 – women who experienced verbal and people can be attractive [18]. This stereotype directly in numbers in weight loss programs, only female while interpreting and then classifying their personal social discrimination in the workplace, including influences women’s employment status. Workplace participants were included into this survey. The survey experiences as acts of obesity stigmatization and ridicule, teasing or isolation. devaluation on account of higher body weight can also was carried out from January 2010 until September 150 M. Obara-Gołębiowska No 2 No 2 Employment discrimination against obese women in obesity clinic’s patients perspective 151

Table 4. Consequences of employment discrimination “I was hoping to get a summer job as a waitress Table 6. Description of perpetrators of verbal and social dis confirm the observations made in this study that obese against obese women in a cafe. During the interview, the manager told me crimination against obese women people face discrimination not only from employers 22 women – negative emotions, in- that they had strict policies regarding the physical Perpetrator’s sex 28 women but also from work colleagues, both male and female. Emotional consequences cluding humiliation, sadness, anger appearance of their staff, and that they couldn’t employ 25 men That is the effect of deeply rooted negative stereotype at self and others, sense of injustice me because they didn’t have uniforms for my size.” Professional relationship be- 12 cases: superior/subordinate of overweight person in society [3] and impact of 18 women – loss of motivation to tween the perpetrator and the 32 cases: co-workers automatic bias on real hiring discrimination against find work Professional conse- Table 5. Description of women who experienced verbal and victim obese [1]. 4 woman – increased motivation to quences social discrimination in work setting find work to improve self-esteem Results obtained also show that the victims of and get respect from others Number of obese women “Whenever I go on a new diet, my female employment stigmatization and discrimination were who experienced verbal 44 Non-constructive ways of 14 women – overeating colleagues from work tease me by saying that it won’t relatively young (mean age - 38.1) who embarked and social stigmatization coping with stress caused 4 woman – crash dieting which re- work as usual.” on their professional careers in the 21st century or by employment discrimi- sulted in overeating Mean BMI 37.04 “I am too embarrassed to eat with other people towards the end of the 20th century. The age structure nation 4 woman – smoking Mean age 43.50 at work. On several occasions, a female colleague of the surveyed group could indicate according to the 20 women -university degree, remarked in front of the others that I shouldn’t eat too subject’s literature that the importance of body image Group 1 results 12 women -secondary school di- Education much.” and physical beauty has risen in recent years, leading In group 1 there were 22 (10.5%) obese women ploma “I work in a law firm. I once overheard my 2 women - elementary education to less tolerant attitudes towards people with BMI>30 (mean BMI= 35.5; mean age= 32.6) who experienced colleagues talk about me. One of them said that in comparison with several decades ago [27]. employment discrimination. 5 of them had a university I would have more clients if I lost weight.” Group 2 results Findings also reveal that perceived weight degree, 7 - secondary school diploma and 10 were discrimination increase the health risks of obesity university students. 22 women experienced emotional In group 1 there were 44 (5.3%) obese women (mean BMI=37.1; mean age=43.5 ) who experienced Table 7. Consequences of verbal and social discrimination associated with functional disability and self-rated consequences of employment discrimination including against obese women health. Weight-based stigma shapes weight perceptions, humiliation, sadness, anger at self and others, sense verbal and social stigmatization. 20 of them had a university degree, 12 - secondary school diploma 44 women – negative emotions, which mediate the relationship between perceived of injustice. 18 women lost their motivation to find including humiliation, sadness, and 2 had elementary education. 44 women Emotional consequences discrimination and health [26]. Therefore successful work and 4 women increased their motivation to find anger at self and others, sense of obesity management requires an in-depth analysis experienced emotional consequences of employment injustice work in order to improve self-esteem and get respect of the psychological and emotional consequences discrimination including humiliation, sadness, anger 44 women – loss of motivation to from others. Besides there were non-constructive Professional consequences of the weight bias. All of the surveyed subjects had at self and others, sense of injustice. 44 women lost perform the job ways of coping with stress caused by employment experienced significant mood disturbances as the their motivation to perform the job. Besides there were Non-constructive ways of discrimination observed in group 1:14 women were 38 women - overeating non-constructive ways of coping with stress caused by coping with stress caused by result of employment discrimination, which in itself overeating, 4 women were crash dieting which 6 women – smoking verbal and social stigmatization observed in group employment discrimination perpetuates obesity. According to Carr et al. [5] or resulted in overeating and 4 women were smoking. Puhl et al. [19], emotional discomfort of people with There were women and men among perpetrators 2: 38 women were overeating and 6 women were smoking. There were women as well as men among DISCUSSION BMI>30 leads to social isolation and decreases their discriminating against obese women from group 1 and physical activity levels. Stress also contributes to they were mostly victim’s employers or staff members perpetrators of verbal and social discrimination against In this study, the problem of employment overeating which delivers mood-boosting benefits. responsible for recruitment. obese women from group 2 and they were victim’s co- discrimination against obese women in Poland has The women interviewed in this study admitted to Selected responses of employment discrimination workers or superiors. been discussed from the victims’ point of view. In overeating or going on restrictive weight-loss diets victims (Group 1) were: Selected responses from victims of verbal and most research published around the world, the weight that produced the yo-yo effect. In the long-term, “I was looking for work at university, and I called social discrimination in the workplace (Group 2) were: bias has been discussed in various areas of life based unhealthy eating habits lead to weight gain and about a job in a pub. I was invited to an interview, but “I had been working in a fashion store in on analyses of the attitudes and behaviors displayed by emotional problems. From the therapeutic point of when the manager saw me, he said that they had already a shopping mall for several years. I returned to work people with normal body weight [19]. view, the effectiveness of programs promoting healthy found someone and cut me short. A few days later, my from maternity leave 20 kg heavier, and ever since then, Considering results obtained in the research, lifestyle choices is highly correlated with self-efficacy slim friend from the dorm went to the same pub because the manager has been hinting that I am not suited for in the group of 420 surveyed women, 5.3% had which is determined by the patient’s self-esteem and the ad was still up there, and she got the job.” the job because sales attendants should look good.” experienced discrimination, mostly problems with general well-being. The psychological and social “I work for a pharmaceutical company. I was hoping “My colleague teases me about my weight.” finding employment or smaller chances of promotion consequences of the weight bias in the workplace to be promoted to project manager. I lost my promotion “Up to a certain point, I always thought that I had due to high body weight. The results of the study prevent obese people from acquiring healthy eating to a slim friend who was identically qualified but had good relations with other people in the office. One day, corroborate published findings which indicate that habits and becoming more physically active. For this two years less professional experience than me.” a colleague told me that all employees had been going obese people have lower opportunities of employment reason, the victims of persistent discrimination should “I was trying to get a job as a driving instructor. on regular outings to the spa for several months. I was and promotion [23, 25]. However in the research receive psychological counseling to speed up the I had had several years of experience and the required never invited. My colleague tried to explain that they verbal and social stigmatization occurred more recovery process and to develop self-control in their qualifications. The employer who was the owner of had never invited me because I would probably feel common than problems with finding employment eating habits. the driving school checked my qualifications, then uncomfortable in a spa.” or smaller chances of promotion due to high body Results of group interviews with female patients he looked me over and said that they preferred male “I work in a grocery store. The manager is rough weight. Nearly 11% of the subjects had experienced of an obesity management clinic indicate that instructors. He said that they employed women only on most employees, but he puts additional pressure ridicule, teasing, social isolation in the workplace. The weight-based discrimination in the workplace poses if they were ‘hot babes who attracted customers’. He on me, even though I work as well as the others. One perpetrators of discrimination were superiors and co- a problem. Above findings are especially important also joked that ‘the suspension won’t last long with day he said: ‘don’t just sit there doing nothing, move workers, both men and women. Puhl and Brownell [22] because of the fact that the percentage of overweight your weight’.” a little for exercise. You would lose weight, and that would only do you good’.” demonstrated that obese employees face aggression Poles continues to increase every year. Therefore and social exclusion in the workplace. Their findings weight-based stigmatization and discrimination in the 150 M. Obara-Gołębiowska No 2 No 2 Employment discrimination against obese women in obesity clinic’s patients perspective 151

Table 4. Consequences of employment discrimination “I was hoping to get a summer job as a waitress Table 6. Description of perpetrators of verbal and social dis confirm the observations made in this study that obese against obese women in a cafe. During the interview, the manager told me crimination against obese women people face discrimination not only from employers 22 women – negative emotions, in- that they had strict policies regarding the physical Perpetrator’s sex 28 women but also from work colleagues, both male and female. Emotional consequences cluding humiliation, sadness, anger appearance of their staff, and that they couldn’t employ 25 men That is the effect of deeply rooted negative stereotype at self and others, sense of injustice me because they didn’t have uniforms for my size.” Professional relationship be- 12 cases: superior/subordinate of overweight person in society [3] and impact of 18 women – loss of motivation to tween the perpetrator and the 32 cases: co-workers automatic bias on real hiring discrimination against find work Professional conse- Table 5. Description of women who experienced verbal and victim obese [1]. 4 woman – increased motivation to quences social discrimination in work setting find work to improve self-esteem Results obtained also show that the victims of and get respect from others Number of obese women “Whenever I go on a new diet, my female employment stigmatization and discrimination were who experienced verbal 44 Non-constructive ways of 14 women – overeating colleagues from work tease me by saying that it won’t relatively young (mean age - 38.1) who embarked and social stigmatization coping with stress caused 4 woman – crash dieting which re- work as usual.” on their professional careers in the 21st century or by employment discrimi- sulted in overeating Mean BMI 37.04 “I am too embarrassed to eat with other people towards the end of the 20th century. The age structure nation 4 woman – smoking Mean age 43.50 at work. On several occasions, a female colleague of the surveyed group could indicate according to the 20 women -university degree, remarked in front of the others that I shouldn’t eat too subject’s literature that the importance of body image Group 1 results 12 women -secondary school di- Education much.” and physical beauty has risen in recent years, leading In group 1 there were 22 (10.5%) obese women ploma “I work in a law firm. I once overheard my 2 women - elementary education to less tolerant attitudes towards people with BMI>30 (mean BMI= 35.5; mean age= 32.6) who experienced colleagues talk about me. One of them said that in comparison with several decades ago [27]. employment discrimination. 5 of them had a university I would have more clients if I lost weight.” Group 2 results Findings also reveal that perceived weight degree, 7 - secondary school diploma and 10 were discrimination increase the health risks of obesity university students. 22 women experienced emotional In group 1 there were 44 (5.3%) obese women (mean BMI=37.1; mean age=43.5 ) who experienced Table 7. Consequences of verbal and social discrimination associated with functional disability and self-rated consequences of employment discrimination including against obese women health. Weight-based stigma shapes weight perceptions, humiliation, sadness, anger at self and others, sense verbal and social stigmatization. 20 of them had a university degree, 12 - secondary school diploma 44 women – negative emotions, which mediate the relationship between perceived of injustice. 18 women lost their motivation to find including humiliation, sadness, and 2 had elementary education. 44 women Emotional consequences discrimination and health [26]. Therefore successful work and 4 women increased their motivation to find anger at self and others, sense of obesity management requires an in-depth analysis experienced emotional consequences of employment injustice work in order to improve self-esteem and get respect of the psychological and emotional consequences discrimination including humiliation, sadness, anger 44 women – loss of motivation to from others. Besides there were non-constructive Professional consequences of the weight bias. All of the surveyed subjects had at self and others, sense of injustice. 44 women lost perform the job ways of coping with stress caused by employment experienced significant mood disturbances as the their motivation to perform the job. Besides there were Non-constructive ways of discrimination observed in group 1:14 women were 38 women - overeating non-constructive ways of coping with stress caused by coping with stress caused by result of employment discrimination, which in itself overeating, 4 women were crash dieting which 6 women – smoking verbal and social stigmatization observed in group employment discrimination perpetuates obesity. According to Carr et al. [5] or resulted in overeating and 4 women were smoking. Puhl et al. [19], emotional discomfort of people with There were women and men among perpetrators 2: 38 women were overeating and 6 women were smoking. There were women as well as men among DISCUSSION BMI>30 leads to social isolation and decreases their discriminating against obese women from group 1 and physical activity levels. Stress also contributes to they were mostly victim’s employers or staff members perpetrators of verbal and social discrimination against In this study, the problem of employment overeating which delivers mood-boosting benefits. responsible for recruitment. obese women from group 2 and they were victim’s co- discrimination against obese women in Poland has The women interviewed in this study admitted to Selected responses of employment discrimination workers or superiors. been discussed from the victims’ point of view. In overeating or going on restrictive weight-loss diets victims (Group 1) were: Selected responses from victims of verbal and most research published around the world, the weight that produced the yo-yo effect. In the long-term, “I was looking for work at university, and I called social discrimination in the workplace (Group 2) were: bias has been discussed in various areas of life based unhealthy eating habits lead to weight gain and about a job in a pub. I was invited to an interview, but “I had been working in a fashion store in on analyses of the attitudes and behaviors displayed by emotional problems. From the therapeutic point of when the manager saw me, he said that they had already a shopping mall for several years. I returned to work people with normal body weight [19]. view, the effectiveness of programs promoting healthy found someone and cut me short. A few days later, my from maternity leave 20 kg heavier, and ever since then, Considering results obtained in the research, lifestyle choices is highly correlated with self-efficacy slim friend from the dorm went to the same pub because the manager has been hinting that I am not suited for in the group of 420 surveyed women, 5.3% had which is determined by the patient’s self-esteem and the ad was still up there, and she got the job.” the job because sales attendants should look good.” experienced discrimination, mostly problems with general well-being. The psychological and social “I work for a pharmaceutical company. I was hoping “My colleague teases me about my weight.” finding employment or smaller chances of promotion consequences of the weight bias in the workplace to be promoted to project manager. I lost my promotion “Up to a certain point, I always thought that I had due to high body weight. The results of the study prevent obese people from acquiring healthy eating to a slim friend who was identically qualified but had good relations with other people in the office. One day, corroborate published findings which indicate that habits and becoming more physically active. For this two years less professional experience than me.” a colleague told me that all employees had been going obese people have lower opportunities of employment reason, the victims of persistent discrimination should “I was trying to get a job as a driving instructor. on regular outings to the spa for several months. I was and promotion [23, 25]. However in the research receive psychological counseling to speed up the I had had several years of experience and the required never invited. My colleague tried to explain that they verbal and social stigmatization occurred more recovery process and to develop self-control in their qualifications. The employer who was the owner of had never invited me because I would probably feel common than problems with finding employment eating habits. the driving school checked my qualifications, then uncomfortable in a spa.” or smaller chances of promotion due to high body Results of group interviews with female patients he looked me over and said that they preferred male “I work in a grocery store. The manager is rough weight. Nearly 11% of the subjects had experienced of an obesity management clinic indicate that instructors. He said that they employed women only on most employees, but he puts additional pressure ridicule, teasing, social isolation in the workplace. The weight-based discrimination in the workplace poses if they were ‘hot babes who attracted customers’. He on me, even though I work as well as the others. One perpetrators of discrimination were superiors and co- a problem. Above findings are especially important also joked that ‘the suspension won’t last long with day he said: ‘don’t just sit there doing nothing, move workers, both men and women. Puhl and Brownell [22] because of the fact that the percentage of overweight your weight’.” a little for exercise. You would lose weight, and that would only do you good’.” demonstrated that obese employees face aggression Poles continues to increase every year. Therefore and social exclusion in the workplace. Their findings weight-based stigmatization and discrimination in the 152 M. Obara-Gołębiowska No 2 No 2 Employment discrimination against obese women in obesity clinic’s patients perspective 153

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Roehling P.V.: Weight-based discrimination in doro%C5%9Bli%20dane.pdf (17.11.2015) is a part of wider survey project also covering obese 9. Fonda S.J., Fultz N.H., Jenkins K.R., Wheeler L.M., employment: Psychological and legal aspects. males work discrimination experiences and inter- Wray L.A.: Relationship of body mass and net worth Personnel Psychology 1999;52(4):969-1016, doi. Received: 12.10.2015 for retirement-aged men and women. Res Aging org/10.1111/j.1744-6570.1999.tb00186.x. Accepted: 14.01.2016 gender comparisons in this area which are planned 2004;26:153-176, doi: 10.1177/0164027503258739. 25. Rudolph C.W., Wells C.L., Weller M.D., Baltes B.B.: to be published in the future. Further work and new 10. Giel K.E., Thiel A., Teufel M., Mayer J., Zipfel S.: Weight A meta-analises of empirical studies of weight based researches could also analyze employers attitudes bias in work settings - a qualitative review. Obes Facts towards obese people and could propose effective 2010;3(1):33-40, doi: 10.1159/000276992. methods for minimizing potential employers’ bias 11. Griffin A.W.: Women and weight-based employment towards obese people. Another avenue for future discrimination. Cardozo Journal of Law and Gender research would be to carry out psychological and legal 2007;13:631-656. analyses demonstrating how obese people can pursue 12. Judge T.A., Cable D.M.: When it comes to pay, do the their rights to equal treatment in the workplace. thin win? The effect on pay for man and woman. J Appl Psychol 2011;96: 95-112, doi: 10.1037/a0020860. CONCLUSIONS 13. Kulaga Z., Litwin M., Tkaczyk M., Różdżyńska A., Barwicka K., Grajda A., Świąder A., Gurzkowska B., 1. Weight-based discrimination in the workplace Napieralska E., Pan H.: The height-, weight-, and BMI- for-age of Polish school-aged children and adolescents poses a problem in Poland. relative to international and local growth references. 2. In the group of clinically obese women, 5.3% BMC Public Health 2010;10:109-120. of subjects had experienced employment 14. Obara-Golebiowska M: Obesity as civilizational discrimination and 10.5% had been victims of disease of 21st century. Phenomenon of obese people’s verbal and social abuse in the workplace. stigmatization. In: Wesolowska E. (ed.): Psychology in 3. Emotional problems, lack of motivation and university and practice, Olsztyn, UWM Press, 2013. overeating in response to stress were the most 15. Obara-Golebiowska M., Przybylowicz K.E.: Employment common psycho-physical consequences of the discrimination against obese women in Poland: A focus body mass stigma. study involving patients of an obesity management clinic. Iran J Public Health 2014;43(5):1-2. Conflict of interest 16. O’Brien K.S., Halberstadt J., Hunter J.A., Anderson J., Caputi P.: Do antifat attitudes predict antifat behaviors? The author declares no conflict of interest. Obesity (Supplement 2) 2008: S87-S92. 17. Paul R.J., Townsend J.B.: Shape up or ship out? REFERENCES Employment discrimination against the overweight. Employee Responsibilities and Rights Journal 1. Agerstrom J., Rooth D.: The role of automatic obesity 1995;8(2):133-145. stereotypes in real hiring discrimination. J Appl Psychol 18. Przybyłowicz K.E., Jesiołowska D., Obara-Gołębiowska 2011;96(4):790-805, doi: 10.1037/t03782-000. M., Antoniak L.: A Subjective dissatisfaction with 2. Baum C.L., Ford W.F.: The wage effects of obesity: body weight in young women: Do eating behaviors a longitudinal study. Health Econ 2004;13 :885-899. play a role? Rocz Panstw Zakl Hig 2014;65(3):243- 3. Brylinsky J.A., Moore J.C.: The identification of built 249 [PMID: 25247805; http://www.ncbi.nlm.nih.gov/ stereotypes in young children. J Res Pers 1994;28:170- pubmed/25247805]. 181 19. Puhl R.M., Andreyeva T., Brownell K.D.: Perceptions 4. Carr D., Friedman M.A.: Is obesity stigmatizing? body of weight discrimination: prevalence and comparison weight, perceived discrimination and psychological 152 M. Obara-Gołębiowska No 2 No 2 Employment discrimination against obese women in obesity clinic’s patients perspective 153 workplace are likely to intensify in the future. The well-being in the united States. J Health Soc Behav to race and gender discrimination in America. Int J bias in the workplace. J Vocat Behav 2009;74:1-10, doi: fact that the study was performed in an obesity clinic 2005;46:244-259, doi: 10.1177/002214650504600303. Obesity 2008;32:992-1000, doi: 10.1038/ijo.2008.22. 10.1016/j.jvb.2008.09.008. could have influenced the results, which probably 5. Carr D., Friedman M.A., Jaffe K.: Understanding 20. Puhl R.M., Brownell K.D.: Bias, discrimination, and 26. Schafer M.H., Ferraro K.F.: The stigma of obesity: cannot be reliably generalized to the entire population the relationship between obesity and positive and obesity. Obes Res 2001;9(12):788-805. Does perceived weight discrimination affect identity of obese women in Poland. The programs offered by negative affect. The role of psychosocial mechanisms. 21. Puhl R.M., Brownell K.D.: Psychosocial origins of and physical health? Soc Psychol Quart 2011;74(1):76- Body Image 2007;4:241-260, doi:10.1016/j. obesity stigma: toward changing a powerful and 97, doi: 10.1177/0190272511398197. obesity clinics are usually attended by people who bodyim.2007.02.004. pervasive bias. Obes Rev 2003;4:213-227, doi: 27. Sides-Moore L., Tochkov K.: The thinner the better? have a history of unsuccessful weight loss attempts. 6. Cawley J.: The impact of obesity on wages. J Hum 10.1046/j.1467-789X.2003.00122.x. Competitiveness, depression and body image among Those persons are also highly determined to change Resour 2004;39:451-474. 22. Puhl R.M., Brownell K.D.: Confronting and coping college student women. College Student Journal their eating habits and lose weight. Perhaps, it was the 7. Fikkan J.L., Rothbloom E.D.: Weight bias in with weight stigma: an investigation of overweight 2011;45(2): 439-448. accumulation of negative social experiences which employment. In: Brownell K.D., Puhl R.M., Schwartz and obese adults. Obesity 2006;14:1802-1815, doi: 28. The problem of the excess weight and obesity in motivated those persons to participate in a specialist M.B, Rud L. (eds.), Weight bias: nature, consequences 10.1038/oby.2006.208. Poland amongst adults - epidemiological data - weight loss program supervised by members of an and remedies. Guilford Press, 2005. 23. Puhl R.M., Heuer C.A.: The stigma of obesity: A review according to the report GUS. Available from: http:// interdisciplinary team. This aspect should be analyzed 8. Fikkan J.L., Rothbloom E.D.: Is fat a feminist issue? and update. Obesity 2009;17:941-964, doi: 10.1038/ www.gis.gov.pl/ckfinder/userfiles/files/Nadwaga%20 in future studies of discrimination against obese Exploring the gendered nature of weight bias. Sex Roles oby.2008.636. i%20oty%C5%82o%C5%9B%C4%87%20 employees in Poland. It should be noted that the study 2012;66:575–592, doi: 10.1007/s11199-011-0022-5. 24. Roehling P.V.: Weight-based discrimination in doro%C5%9Bli%20dane.pdf (17.11.2015) is a part of wider survey project also covering obese 9. Fonda S.J., Fultz N.H., Jenkins K.R., Wheeler L.M., employment: Psychological and legal aspects. males work discrimination experiences and inter- Wray L.A.: Relationship of body mass and net worth Personnel Psychology 1999;52(4):969-1016, doi. Received: 12.10.2015 for retirement-aged men and women. Res Aging org/10.1111/j.1744-6570.1999.tb00186.x. Accepted: 14.01.2016 gender comparisons in this area which are planned 2004;26:153-176, doi: 10.1177/0164027503258739. 25. Rudolph C.W., Wells C.L., Weller M.D., Baltes B.B.: to be published in the future. Further work and new 10. Giel K.E., Thiel A., Teufel M., Mayer J., Zipfel S.: Weight A meta-analises of empirical studies of weight based researches could also analyze employers attitudes bias in work settings - a qualitative review. Obes Facts towards obese people and could propose effective 2010;3(1):33-40, doi: 10.1159/000276992. methods for minimizing potential employers’ bias 11. Griffin A.W.: Women and weight-based employment towards obese people. Another avenue for future discrimination. Cardozo Journal of Law and Gender research would be to carry out psychological and legal 2007;13:631-656. analyses demonstrating how obese people can pursue 12. Judge T.A., Cable D.M.: When it comes to pay, do the their rights to equal treatment in the workplace. thin win? The effect on pay for man and woman. J Appl Psychol 2011;96: 95-112, doi: 10.1037/a0020860. CONCLUSIONS 13. Kulaga Z., Litwin M., Tkaczyk M., Różdżyńska A., Barwicka K., Grajda A., Świąder A., Gurzkowska B., 1. Weight-based discrimination in the workplace Napieralska E., Pan H.: The height-, weight-, and BMI- for-age of Polish school-aged children and adolescents poses a problem in Poland. relative to international and local growth references. 2. In the group of clinically obese women, 5.3% BMC Public Health 2010;10:109-120. of subjects had experienced employment 14. Obara-Golebiowska M: Obesity as civilizational discrimination and 10.5% had been victims of disease of 21st century. Phenomenon of obese people’s verbal and social abuse in the workplace. stigmatization. In: Wesolowska E. (ed.): Psychology in 3. Emotional problems, lack of motivation and university and practice, Olsztyn, UWM Press, 2013. overeating in response to stress were the most 15. Obara-Golebiowska M., Przybylowicz K.E.: Employment common psycho-physical consequences of the discrimination against obese women in Poland: A focus body mass stigma. study involving patients of an obesity management clinic. Iran J Public Health 2014;43(5):1-2. Conflict of interest 16. O’Brien K.S., Halberstadt J., Hunter J.A., Anderson J., Caputi P.: Do antifat attitudes predict antifat behaviors? The author declares no conflict of interest. Obesity (Supplement 2) 2008: S87-S92. 17. Paul R.J., Townsend J.B.: Shape up or ship out? REFERENCES Employment discrimination against the overweight. Employee Responsibilities and Rights Journal 1. Agerstrom J., Rooth D.: The role of automatic obesity 1995;8(2):133-145. stereotypes in real hiring discrimination. J Appl Psychol 18. Przybyłowicz K.E., Jesiołowska D., Obara-Gołębiowska 2011;96(4):790-805, doi: 10.1037/t03782-000. M., Antoniak L.: A Subjective dissatisfaction with 2. Baum C.L., Ford W.F.: The wage effects of obesity: body weight in young women: Do eating behaviors a longitudinal study. Health Econ 2004;13 :885-899. play a role? Rocz Panstw Zakl Hig 2014;65(3):243- 3. Brylinsky J.A., Moore J.C.: The identification of built 249 [PMID: 25247805; http://www.ncbi.nlm.nih.gov/ stereotypes in young children. J Res Pers 1994;28:170- pubmed/25247805]. 181 19. Puhl R.M., Andreyeva T., Brownell K.D.: Perceptions 4. Carr D., Friedman M.A.: Is obesity stigmatizing? body of weight discrimination: prevalence and comparison weight, perceived discrimination and psychological Rocz Panstw Zakl Hig 2016;67(2):155-161 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

ORIGINAL ARTICLE

THE LEVEL OF KNOWLEDGE ON NUTRITION AND ITS RELATION TO HEALTH AMONG POLISH YOUNG MEN

Anna Kołłajtis-Dołowy*, Katarzyna Żamojcin

Department of Human Nutrition, Faculty of human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (SGGW), Warsaw, Poland

ABSTRACT Background. Men are less than women interested in nutrition and health. Also low is their nutritional knowledge. More than 25% of men are unwilling to increase their knowledge about food and nutrition. The main sources of men’s knowledge about lifestyle including nutrition consist of Internet, colleagues and family. The low level of knowledge about nutrition and health among men is worrying especially in the context of their incidence of chronic non-communicable diseases like cardiovascular disease, higher than in women. Objective. The aim of the study was to determine the level of knowledge on nutrition and health among young men. Material and Methods. The study included 107 men aged 19-34 years from different places and backgrounds in Poland. Men were selected by the snowball method. The study was conducted using an authors’ validated questionnaire containing six types of closed questions (85 detailed questions in total). For statistical analysis Chi2 test was used (p≤0.05). Results. Almost 42% of men under the study were overweight or obese, and less than ¼ declared high physical activity, most showed (on a 4-point scale) sufficient (45%) or low level (40%) of knowledge of nutrition and health. Younger respondents had higher knowledge than older ones. Very low was the respondent’s awareness of an energy content of products, sources of high quality protein and amount of recommended vegetable and fruit consumption. The well-known were the reasons for civilisation diseases and the effect of dietary fibre. The internet was the main source of nutritional knowledge and health related information followed by: colleagues and family. Conclusions. The majority of men presented sufficient or low knowledge about food, nutrition and their relation to health. Young men should be encouraged to participate in various forms of nutritional and health education. This would increase the chance to avoid civilisation diseases.

Key words: health and nutritional knowledge, sources of knowledge, young men

STRESZCZENIE Wprowadzenie. Mężczyźni mniej niż kobiety interesują się zdrowiem i żywieniem. Mała jest też ich wiedza żywieniowa. Po- nad 25% mężczyzn nie chce zwiększyć swej wiedzy o żywności i żywieniu. Głównymi źródłami wiedzy mężczyzn na temat stylu życia, w tym żywienia, są Internet oraz koledzy i rodzina. Niski poziom wiedzy żywieniowo-zdrowotnej jest niepokojący, szczególnie w kontekście występowania przewlekłych chorób niezakaźnych jak choroby układu krążenia, częściej niż u kobiet. Cel. Określenie poziomu wiedzy żywieniowo-zdrowotnej młodych mężczyzn. Materiał i metody. Badania obejmowały grupę 107 mężczyzn w wieku 19-34 lata, pochodzących z różnych miejsc oraz środowisk w Polsce. Mężczyźni zostali wybrani za pomocą metody „kuli śnieżnej”. Badania przeprowadzono metodą an- kietową przy użyciu kwestionariusza autorskiej, zwalidowanej ankiety zawierającej 6 różnych pytań zamkniętych (w nich łącznie 85 pytań szczegółowych). Do analizy statystycznej użyto testu Chi2 przy poziomie istotności p ≤0.05. Wyniki. Około 42% badanych mężczyzn miało nadwagę lub otyłość, a niej niż 1/4 deklarowała aktywność fizyczną; w 4. stopniowej skali większość wykazała dostateczną (45%) albo małą (40%) wiedzę żywieniowo-zdrowotną. Młodsi respondenci mieli większą wiedzę niż starsi. Respondenci wykazali bardzo małą świadomość na temat wartości energetycznej produk- tów, źródeł wysoko wartościowego białka oraz zalecanych ilości spożywania warzyw i owoców. Dobrze znali przyczyny cho- rób cywilizacyjnych oraz wpływu błonnika pokarmowego na organizm. Głównym źródłem wiedzy żywieniowo-zdrowotnej był internet, a następnie koledzy oraz rodzina. Wnioski. Większość mężczyzn prezentowała dostateczną lub małą wiedzę o żywności i żywieniu oraz ich związkach ze zdrowiem. Młodzi mężczyźni powinni być zachęcani do udziału w różnych formach edukacji żywieniowej i zdrowotnej. Mogłoby to zwiększyć szanse ograniczenia przewlekłych chorób niezakaźnych.

Słowa kluczowe: wiedza żywieniowo-zdrowotna, źródła wiedzy, młodzi mężczyźni

*Corresponding author: Anna Kołłajtis-Dołowy, Department of Human Nutrition, Faculty of human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (SGGW), Nowoursynowska street 159c, 02-776 Warsaw, Poland, phone: +48 22 59 37 116, e-mail: [email protected]

ORIGINAL ARTICLE

THE LEVEL OF KNOWLEDGE ON NUTRITION AND ITS RELATION TO HEALTH AMONG POLISH YOUNG MEN

Anna Kołłajtis-Dołowy*, Katarzyna Żamojcin

Department of Human Nutrition, Faculty of human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (SGGW), Warsaw, Poland

Key words: health and nutritional knowledge, sources of knowledge, young men

Słowa kluczowe: wiedza żywieniowo-zdrowotna, źródła wiedzy, młodzi mężczyźni

© Copyright by the National Institute of Public Health - National Institute of Hygiene 156 A. Kołłajtis-Dołowy, K. Żamojcin No 2 No 2 The level of knowledge on nutrition and its relation to health among Polish young men 157

INTRODUCTION per 100 thousand). The death rate for people from had a proper BMI value (18.5 - 24.9). But 42% were Over 2/3 of respondents had higher education (or other countries such as Switzerland, France, Spain, overweight or obese. Similar proportion was found in incomplete higher education). Slightly more than 1/3 Men are not especially interested in nutrition. The main Netherlands, Norway, Denmark, Portugal, Italy, the study among Greek students [5], in contrast to the of respondents were students, most of them worked source of their knowledge about healthy lifestyle including United Kingdom and Greece are much lower (from Dutch, in which overweight and obesity was present (64.2%), and more than 1/5 of these who work nutrition consists of: internet, colleagues and family [10], 124 to 208 deaths per 100 thousand). Similar death rate in only 20% of men [17]. As many as 88% of men also studied. Almost three-quarters of respondents magazines and newspapers. Many respondents suggested from cardiovascular disease has the Czech Republic suffering from cardiovascular disease are overweight performed mental work (Table 1). The vast majority a TV advertising [3]. Men are less than women interested (424), and much higher: Hungary, Romania, Estonia, or obese [1]. (84%) of respondents did not use any special diets in their looks and health, which may be related to engaging Lithuania, Belarus, Bulgaria, Russia and Ukraine 77% of men in the study lived in cities of over (Table 1). Among those who were on a diet (10 people in more frequent risky behaviours such as eating fatty (from 535 to 980 per 100 thousand). Polish men live 100 thousand inhabitants, and only (10%) in rural out of 17) were on a slimming diet, 6 patients were meats and sausages, fried foods, smoking cigarettes and on average 4.5 years shorter than in the EU [19]. areas (Table 1). 55% of the respondents lived with on a special body builder diet and one man wanted to drinking alcohol [11]. The higher the level of nutritional One way to reduce the occurrence of non- family remaining group lived alone with a partner or gain weight. Our results were similar to the previously knowledge of persons over 20 years of age, the lower the communicable chronic diseases, including colleagues in almost equal proportions. obtained by Łaszek et al. [12] in which 16% of students intake of total fat, saturated fat, cholesterol, sodium and cardiovascular disease, is to educate people that the apply diet - especially low energy diet. sugar, and more dietary fibre [2]. wrong lifestyle, including nutrition, poses a serious Table 1. The characteristics of the study group Among all surveyed young men 3 suffered from Value/size Response rate Men’s knowledge of human health and nutrition threat to their own health. Therefore, the aim of this Features / differentiators cardiovascular disease. Two of them had hypertension is much more limited than the knowledge of women. study was to determine the level of nutritional and (n) (%) and in one of thrombosis and arterial embolism. All The same is true for boy’s knowledge versus their health knowledge in a selected group of young men. BMI respondents with cardiovascular disease have cases of female colleagues [13, 16, 18]. The low level of Mean ± standard deviation 24,4±3,8 hypertension in the family. The cases of cardiovascular < 18.5 (underweight) 1 0.9 nutritional knowledge and lifestyle related diseases are MATERIAL AND METHODS 18.5-24.9 (correct body mass) 61 57.4 disease were rare due to the young age of the respondents represented by lack of knowledge of recommendations 25-29.9 (overweight) 35 32.8 (19 - 34 years). On the other hand, the study Waśkiewicz for vegetable and fruit consumption (21% correct The study included 107 men from the originally 30-34.9 (obesity) 10 8.9 et al. [18] show almost 8 time higher incidence of the answers), fat (35%) and salt intake (15%), alcohol selected by the snowball method 125 men (each person Place of residence hypertension (15.9%) for men aged 20 -34 years. consumption (34%), the need of physical activity randomly selected for the study, recommended several City above 100,000 82 76.6 In families of men under the study hypertension (55%), reduction of smoking (44%) and conduct more people). Respondents were aged 19 - 34 years City below 100,000 14 13.1 was present (59 respondent’s family, 55.1%), diabetes regular lifestyle, including eating meals (35%) [18]. old and were from different places and backgrounds. Village 11 10.3 (30 respondent’s family, 28%), cancer (21 respondent’s Men suffering from cardiovascular diseases have The study was conducted in 2013 using a questionnaire Flat family, 19.6%), cancers (21 respondent’s family, 19.6%), By himself 14 13.1 a greater knowledge of health and human nutrition [2]. consisting of six types of closed questions (containing With family 59 55.1 infarction, stroke (21 respondent’s family, 19.6%), Less than 15% of Italian teenagers did not know that a total of 85 detailed questions), in the form of test With wife/ husband; partner 18 16.8 arteriosclerosis/ hypercholesterolemia (8 respondent’s fat provides the largest amount of energy [16]. of knowledge concerning chronic infectious diseases, With colleagues, friends 16 15.0 family, 7.5%) and NCS (ischemic heart disease) The exception is a group of students enrolled their causes and risk factors, nutrition, nutrient sources Education (2 respondent’s family 1.9%). for the teaching profession [12] and clients of shops in the diet and nutritional recommendations. Basic / vocational 6 5.6 Most men (60%) declared moderate physical selling organic and less processed food [6]. Much Closed-type questions were of true-false type, High school 29 27.1 activity, less than ¼ high, and about 17% - low greater awareness shows respondents in the UK [13]. single or multiple choice, cafeterias (rank products Higher/ university 72 67.3 physical activity (Table 1). Different results were However, the knowledge of men is significantly lower by increasing the energy value), assigning responses. Type of occupation obtained Sochacka et al. [15], according to their study Studies 37 34.6 than women. Contrary to the Polish study in the UK Imprint survey included 13 questions (e.g. age, height Works 45 42.0 almost 58% of respondents had little physical activity men know dietary guidelines (2/3 good response), and weight, place of residence, education, type of Works and studies 23 21.5 and the others had moderate physical activity, none of but also sources of macronutrients (protein, fat, occupation, physical activity, family history, and Unemployed 2 1.9 the respondents declared large physical activity. carbohydrate), fiber, salt and saturated fatty acids. In smoking cigarettes). The questionnaire was revised Job type Approximately 48% of respondents (Table 1) are Poland more than ¼ of men are unwilling to increase after the pilot study. The respondents were assured Physical 10 9.3 smokers. Quarter of smokers did not smoke in the their knowledge about food and nutrition [10]. anonymity. To determine the level of the respondent’s Mental 80 74.8 past and the smaller proportion who is not smoking Men with the BMI greater than 25, and over 40 years knowledge the following criteria were applied: high Mixed mentally-physical 17 15.9 at present smoked in the past. Among 19-25 years old old (respectively 74% and 63%) are more interested in level of expertise - 75% of good answers, sufficient Using diet 42% of people smoke, which is more than the GUS data Yes 17 15.9 the relation between nutrition and health [9]. A similar - between 74.9% and 50%, low - 49.9% to 25% and (31% among 18-24 years old). Even greater difference dependence of the knowledge on the age was found in insufficient less than 25%. There were also simpler Disease in the families between our (52.9%), and GUS data (36%) are for 25 of the respondents Australia, where men above 34 gave significantly more division to insufficient knowledge less than 50% of No 29 27.1 - 36 years old men. The proportion of participants in correct answers than younger respondents. To avoid good answers and sufficient -more than 50% of correct One disease 35 32.7 our study who smoked cigarettes was larger than in false information about nutrition and other lifestyle answers. More than one disease 43 40.2 previous study (40%) [18]. Similar data were obtained factors affecting health, it is recommended to use reliable For statistical analysis the R program was Physical activity of Greek smoking students (37.4%) [5]. Much lower is sources of knowledge, which include scholarly and used (version 3.01 - 64-bit, Chi2 test was used at Low 18 16.8 the proportion of smokers among the Dutch (6%) [17]. popular science books. Meanwhile men get information a significance level of p≤0.05). Moderate 64 59.8 High 25 23.4 about nutrition primarily from the mass media: television, The level of nutritional knowledge of young men radio, popular magazines and more recently the Internet RESULTS AND DISCUSSION Cigarette smoking Yes 51 47.7 [10]. Yes now and in the past 27 25.4 The average percentage of correct true-false answers According to GUS [8]), Poland in terms of the Among the 107 participants 80 (74.8%) were Now yes, no - in the past 24 22.4 to 27 questions (Table 2) was 48.3 ± 18.8%. Assuming number of male deaths from cardiovascular disease 19-25 years old and remaining were 26 to 34 years No now, no in the past 43 40.3 the simplest criteria of knowledge measurement indicate is in 19th place among the EU countries (437 deaths (mean age - 24.5 ± 2.9). 57% of respondents (tab. 1) No now, yes in the past 13 11.9 the insufficient level of nutritional knowledge among 158 A. Kołłajtis-Dołowy, K. Żamojcin No 2 No 2 The level of knowledge on nutrition and its relation to health among Polish young men 159 the subjects. At the same time large standard deviation Very low was the respondents’ awareness of an In their study people living in the city showed vitamin C, but a very small proportion of respondents shows of a wide variation of results. Men studied were energy content of fats and carbohydrates confirmed by a higher awareness of the impact of nutrition on health knew that this vitamin is in peppers and white cabbage aware of the impact of recreation and physical activity (98.1%) incorrect answers. Also were unable to correctly than residents of rural areas. The number of correct (in both cases, 11.9% of respondents) and black currants in the prevention of chronic non-communicable diseases rank by the decreasing energy value 6 products (oil, answers did not depend significantly on education of (only 4,5% right answers). In earlier study [7] results and their causes and also the composition of potatoes butter, rice, potatoes, cottage cheese, and apples). Most the respondents or their places of residence, while it show that only 1/5 of men, less than in our study (1/3), (≥ 75% correct answers). common mistake was treating potatoes as a high-calorie was dependent on age - younger gave more correct knew that pork meat contains a lot of cholesterol, but Quite good knowledge (by sufficient level 50% product, after oil and butter (37.3% wrong answers) or answers than 26-34 years old. The opposite results on showed higher product knowledge providing saturated - <75% of good answers) of respondents concerned more caloric than oil and butter (13.4%). It also worth the dependence of knowledge on place of the residence and unsaturated fatty acids. Statistically significant the milk composition, the relative cholesterol noting the high proportion of “do not know” answers in were reported by Poręba et al. [14]. In their study correlation was found between knowledge about the content in pork and eggs, the effect of fiber on the the true-false questions concerning the recommendation people living in the city showed a higher awareness sources of vitamins E and C and education of the body, comparative biological value of legumes and limiting daily intake of cholesterol (Table 2), the impact of the impact of nutrition on health than residents of respondents. meat protein, and frequency of fruit and vegetables of EFA on the development of the foetus and infant, rural areas. Respondents presented a sufficient level of consumption and the red meat, as well as carotene comparative content of trans fatty acid in French fries, When asked about sources high quality proteins knowledge about the effects of salt (sodium), antioxidant activity and recommendations of salt potato chips and in soft margarines. only 6% of respondents gave complete proper answers cholesterol, and vitamin E on the body and a low level consumption. (among the 16 listed products only 8 were highlighted on the impact of vitamin C (Table 3). properly). The common errors were dismissing poultry Table 2. Distribution as indicated in the test type true-false (in %) and rennet cheese as a protein source (respectively Table 3. Knowledge of the effect of various nutrients in the body Nutrient Good answers (%) Don’t 44.8% and 65.7%), as well as recognition of soybeans The claim T* F* Salt (sodium) know and beans as a source of balanced protein (respectively 59.7 50.7% and 28.3%). Different test results were obtained (increase the chance of hypertension) Civilization diseases are chronic non-infectious diseases that are caused not only by poor nutrition, but also Cholesterol 88.1 3 8.9 in Cadet Officers’ College of the Air Force in Deblin, 74.6 the stress and smoking because nearly 64% of respondents correctly classified (contribution in atherosclerosis) Vitamin E One way to reduce the risk of lifestyle diseases may be reduction of the unsaturated fatty acids intake 32.8 31.3 35.8 as sources high in protein content meat and meat 52.2 (prevents atherosclerotic processes) The same portions of fat and carbohydrates provide the same amount of calories 3.0 74.6 22.4 products, milk and dairy products (46.6%) [7]. Vitamin C Not a single men participating in the study know 46.3 Rest and significant physical activity can prevent lifestyle diseases 91.0 3.0 6.0 (prevents atherosclerotic processes) the sources of dietary fibre and was able to select 6 Grapes contain significant amounts of simple sugars 46.3 10.4 43.3 products which are the source of fibre out of 12. While Using the criteria of the division of knowledge The daily intake of cholesterol should be less than 300 mg 17.9 3 79.1 whole wheat bread was correctly identified by 83.6%, into 4 levels, 44.9% of respondents were classified to and sunflower seeds by 67.2%, but already dried apricots One should not consume more milk because it contains a lot of simple sugars 22.4 46.3 31.3 a group of sufficient level of knowledge (Figure 1). by 50.3% and 47.8% of respondents indicated nuts, kiwi Saturated fatty acids lowers the cholesterol in blood 17.9 37.3 44.8 Low level of knowledge reached 40.3% of respondents, and cucumber respectively 16.4% and 13.4%. Similar Ripe bananas contain mainly complex carbohydrates 43.3 23.9 32.8 10.3% the insufficient level, and the high level only test results received Bronkowska et al. [4] - 31% of 4.5% of respondents. Β-carotene has beneficial antioxidant effect 50.7 8.9 40.3 respondents were unable to identify products that contain EFAs may have an adverse effect on foetal and infant development 13.4 32.8 53.7 fiber. In turn, 62.1% of the surveyed cadets knew that Starch is the main carbohydrate in potatoes 85.1 4.5 10.4 wholemeal bread is a source of fiber, 58.9% indicated as such a source legumes, and only 33% of fruits and Fiber regulates digestion and can reduce blood cholesterol levels 74.6 6 19.4 vegetables [7]. The recommended daily intake of salt for an adult, a healthy person is 15g 11.9 50.7 37.3 Respondents showed limited knowledge of Male 20-35 years old should eat 250-350g of fruits and vegetables / per day 59.7 8.9 31.3 products containing relatively large amounts of’ The average value of the energy required for a man of moderate physical activity is 4000kcal 25.4 46.3 28.3 cholesterol, trans fatty acids, saturated fatty acids and unsaturated (the mean percentage of correct answers French fries and potato chips contain more trans fatty acids than the soft margarine 40.3 4.5 55.2 was 27.5%), as well as the content of vitamins E and Boiled pork contains less trans fatty acids than the roasted one 38.8 11.9 49.2 C (on average 34.3% correct answers). The most men In 100g of sirloin there is more saturated fatty acids than in 100g of sausages 23.8 29.8 46.3 (68.6%) knew that significant quantities of cholesterol Figure 1. The level of nutritional and health knowledge of is present in eggs, 34.3% knew that cholesterol is In the loin (100 g) is more cholesterol than in 2 eggs (100g) 8.9 52.2 38.8 respondents (in number of correct answers) The consumption of cakes and biscuits should be limited, because they contain NKT and trans-fatty acids 25.4 37.3 37.3 present in pork, while only 17.9% of respondents knew of its presence in giblets. Sources of nutritional knowledge of respondents Red meat with a high nutritional value should be eaten 4-5 times a week 25.4 53.7 20.9 Only 34.3% of respondents knew that the fish According to the declarations of the respondents The biological value of soy and beans protein is the same as meat protein 19.4 52.2 28.3 contain unsaturated fatty acids, and even somewhat the most common source of nutritional knowledge According to the recommendations the vegetables and fruits should be eaten 1-2 times a day 22.4 65.7 11.9 less (31.3%), that they are present in fish oil. Subjects was the internet (Table 4) following by colleagues confuse products in which there are saturated fatty The recommended frequency of fish consumption is once per week 56.7 32.8 10.4 and friends and the family. To the least frequently acids with those containing unsaturated fatty acids, Milk contains certain amount of cholesterol and is the source of wit. B2 and calcium 71.6 8.9 19.4 used knowledge source was advertisement which, was and vice versa. 61.2% and 59.7% respectively knew classified as “other sources” by 10% of respondents. Vitamin C is in legumes, vegetables and fruit 82.1 8.9 8.9 that vitamin E is in substantial quantities in sunflower *T-true, F-false oil and salmon. Almost half (49.7%) of respondents properly identified that vegetable sprouts are rich in 158 A. Kołłajtis-Dołowy, K. Żamojcin No 2 No 2 The level of knowledge on nutrition and its relation to health among Polish young men 159 the subjects. At the same time large standard deviation Very low was the respondents’ awareness of an In their study people living in the city showed vitamin C, but a very small proportion of respondents shows of a wide variation of results. Men studied were energy content of fats and carbohydrates confirmed by a higher awareness of the impact of nutrition on health knew that this vitamin is in peppers and white cabbage aware of the impact of recreation and physical activity (98.1%) incorrect answers. Also were unable to correctly than residents of rural areas. The number of correct (in both cases, 11.9% of respondents) and black currants in the prevention of chronic non-communicable diseases rank by the decreasing energy value 6 products (oil, answers did not depend significantly on education of (only 4,5% right answers). In earlier study [7] results and their causes and also the composition of potatoes butter, rice, potatoes, cottage cheese, and apples). Most the respondents or their places of residence, while it show that only 1/5 of men, less than in our study (1/3), (≥ 75% correct answers). common mistake was treating potatoes as a high-calorie was dependent on age - younger gave more correct knew that pork meat contains a lot of cholesterol, but Quite good knowledge (by sufficient level 50% product, after oil and butter (37.3% wrong answers) or answers than 26-34 years old. The opposite results on showed higher product knowledge providing saturated - <75% of good answers) of respondents concerned more caloric than oil and butter (13.4%). It also worth the dependence of knowledge on place of the residence and unsaturated fatty acids. Statistically significant the milk composition, the relative cholesterol noting the high proportion of “do not know” answers in were reported by Poręba et al. [14]. In their study correlation was found between knowledge about the content in pork and eggs, the effect of fiber on the the true-false questions concerning the recommendation people living in the city showed a higher awareness sources of vitamins E and C and education of the body, comparative biological value of legumes and limiting daily intake of cholesterol (Table 2), the impact of the impact of nutrition on health than residents of respondents. meat protein, and frequency of fruit and vegetables of EFA on the development of the foetus and infant, rural areas. Respondents presented a sufficient level of consumption and the red meat, as well as carotene comparative content of trans fatty acid in French fries, When asked about sources high quality proteins knowledge about the effects of salt (sodium), antioxidant activity and recommendations of salt potato chips and in soft margarines. only 6% of respondents gave complete proper answers cholesterol, and vitamin E on the body and a low level consumption. (among the 16 listed products only 8 were highlighted on the impact of vitamin C (Table 3). properly). The common errors were dismissing poultry Table 2. Distribution as indicated in the test type true-false (in %) and rennet cheese as a protein source (respectively Table 3. Knowledge of the effect of various nutrients in the body Nutrient Good answers (%) Don’t 44.8% and 65.7%), as well as recognition of soybeans The claim T* F* Salt (sodium) know and beans as a source of balanced protein (respectively 59.7 50.7% and 28.3%). Different test results were obtained (increase the chance of hypertension) Civilization diseases are chronic non-infectious diseases that are caused not only by poor nutrition, but also Cholesterol 88.1 3 8.9 in Cadet Officers’ College of the Air Force in Deblin, 74.6 the stress and smoking because nearly 64% of respondents correctly classified (contribution in atherosclerosis) Vitamin E One way to reduce the risk of lifestyle diseases may be reduction of the unsaturated fatty acids intake 32.8 31.3 35.8 as sources high in protein content meat and meat 52.2 (prevents atherosclerotic processes) The same portions of fat and carbohydrates provide the same amount of calories 3.0 74.6 22.4 products, milk and dairy products (46.6%) [7]. Vitamin C Not a single men participating in the study know 46.3 Rest and significant physical activity can prevent lifestyle diseases 91.0 3.0 6.0 (prevents atherosclerotic processes) the sources of dietary fibre and was able to select 6 Grapes contain significant amounts of simple sugars 46.3 10.4 43.3 products which are the source of fibre out of 12. While Using the criteria of the division of knowledge The daily intake of cholesterol should be less than 300 mg 17.9 3 79.1 whole wheat bread was correctly identified by 83.6%, into 4 levels, 44.9% of respondents were classified to and sunflower seeds by 67.2%, but already dried apricots One should not consume more milk because it contains a lot of simple sugars 22.4 46.3 31.3 a group of sufficient level of knowledge (Figure 1). by 50.3% and 47.8% of respondents indicated nuts, kiwi Saturated fatty acids lowers the cholesterol in blood 17.9 37.3 44.8 Low level of knowledge reached 40.3% of respondents, and cucumber respectively 16.4% and 13.4%. Similar Ripe bananas contain mainly complex carbohydrates 43.3 23.9 32.8 10.3% the insufficient level, and the high level only test results received Bronkowska et al. [4] - 31% of 4.5% of respondents. Β-carotene has beneficial antioxidant effect 50.7 8.9 40.3 respondents were unable to identify products that contain EFAs may have an adverse effect on foetal and infant development 13.4 32.8 53.7 fiber. In turn, 62.1% of the surveyed cadets knew that Starch is the main carbohydrate in potatoes 85.1 4.5 10.4 wholemeal bread is a source of fiber, 58.9% indicated as such a source legumes, and only 33% of fruits and Fiber regulates digestion and can reduce blood cholesterol levels 74.6 6 19.4 vegetables [7]. The recommended daily intake of salt for an adult, a healthy person is 15g 11.9 50.7 37.3 Respondents showed limited knowledge of Male 20-35 years old should eat 250-350g of fruits and vegetables / per day 59.7 8.9 31.3 products containing relatively large amounts of’ The average value of the energy required for a man of moderate physical activity is 4000kcal 25.4 46.3 28.3 cholesterol, trans fatty acids, saturated fatty acids and unsaturated (the mean percentage of correct answers French fries and potato chips contain more trans fatty acids than the soft margarine 40.3 4.5 55.2 was 27.5%), as well as the content of vitamins E and Boiled pork contains less trans fatty acids than the roasted one 38.8 11.9 49.2 C (on average 34.3% correct answers). The most men In 100g of sirloin there is more saturated fatty acids than in 100g of sausages 23.8 29.8 46.3 (68.6%) knew that significant quantities of cholesterol Figure 1. The level of nutritional and health knowledge of is present in eggs, 34.3% knew that cholesterol is In the loin (100 g) is more cholesterol than in 2 eggs (100g) 8.9 52.2 38.8 respondents (in number of correct answers) The consumption of cakes and biscuits should be limited, because they contain NKT and trans-fatty acids 25.4 37.3 37.3 present in pork, while only 17.9% of respondents knew of its presence in giblets. Sources of nutritional knowledge of respondents Red meat with a high nutritional value should be eaten 4-5 times a week 25.4 53.7 20.9 Only 34.3% of respondents knew that the fish According to the declarations of the respondents The biological value of soy and beans protein is the same as meat protein 19.4 52.2 28.3 contain unsaturated fatty acids, and even somewhat the most common source of nutritional knowledge According to the recommendations the vegetables and fruits should be eaten 1-2 times a day 22.4 65.7 11.9 less (31.3%), that they are present in fish oil. Subjects was the internet (Table 4) following by colleagues confuse products in which there are saturated fatty The recommended frequency of fish consumption is once per week 56.7 32.8 10.4 and friends and the family. To the least frequently acids with those containing unsaturated fatty acids, Milk contains certain amount of cholesterol and is the source of wit. B2 and calcium 71.6 8.9 19.4 used knowledge source was advertisement which, was and vice versa. 61.2% and 59.7% respectively knew classified as “other sources” by 10% of respondents. Vitamin C is in legumes, vegetables and fruit 82.1 8.9 8.9 that vitamin E is in substantial quantities in sunflower *T-true, F-false oil and salmon. Almost half (49.7%) of respondents properly identified that vegetable sprouts are rich in 160 A. Kołłajtis-Dołowy, K. Żamojcin No 2 No 2 The level of knowledge on nutrition and its relation to health among Polish young men 161

Table 4. Sources of nutritional knowledge among respondents* CONCLUSIONS 7. Gaździńska A., Baran P., Wyleżoł M., Jagielski P., 15. Sochacka-Tatara E., Pac A., Majewska R.: Assesment of Answers Skibniewski F. W.: Assessment of the level of nutritional nutrition through nutritional interview on the Internet. Source (%) 1. The majority of men presented sufficient or knowledge of cadets Officers’ College of Air Force in Probl Hig Epidemiol 2010;91(1):77-82 (in Polish). Deblin - preliminary study. Probl Hig Epidemiol 2013; 16. Turconi G., Guarcello M., Maccarini L., Cignoli F., Setti Internet 67.2 low knowledge about food, nutrition, lifestyle, and their relation to health. This is particularly 94(2):368-370 (in Polish). S., Bazzano R, Roggi C.: Eating habits and behaviors, Colleagues, friends 64.2 8. GUS: Demographic Yearbook of Poland. Warsaw, physical activity, nutritional and food safety, knowledge worrying due to relationship between lifestyle, Family 61.2 Statistical Publishing Establishment. 2012. and beliefs in an adolescent Italian population. J Am especially diet, and the occurrence of hypertension 9. Hendrige G. A., Coveney J., Cox D.: Exploring nutrition Coll Nutr 2008;1(27):31-43. TV 40.3 and other cardiovascular diseases, type 2 diabetes knowledge and demographic variation in knowledge 17. Van der Veer T., Frings-Dresen M. H. W., Sluiter J. K.: School 23.9 and certain types of cancer in young men and in in an Australian community sample. Public Health Health behaviors, care needs and attitudes towards self- Popular science magazines, books 22.4 men of older age. Nutrition 2008;11(12):1365-1371. prescription: a cross-sectional survey among Dutch 2. The internet was the main source of nutritional 10. Heropolitańska-Janik J., Jeżewska-Zychowicz M.: medical students. PLOS ONE 2011;11(6):1-6. Doctor / dietician 19.4 knowledge and health related information followed Analysis of the needs of men in the area of nutrition 18. Waśkiewicz A.: The quality of nutrition and health Radio 16.4 by: colleagues, friends and family. education. Żyw Człow Metab 2002;3(29):134-143 (in knowledge level among young adult Poles - study Popular magazines 14.9 3. Young men should be encouraged to participate in Polish). WOBASZ. Prob Hig Epidem 2010;91(2):233-237 (in Another 10.4 various forms of nutritional and health education. 11. Królikowska S.: The role of gender stereotypes in Polish). shaping attitudes of men and women to health. Nowiny 19. Wojtyniak B., Stokwiszewski J., Goryński P., Poznańska *the sum is higher than 100% because more than one answer could This would increase the chance for improving their Lekarskie 2011;80(5):387-393 (in Polish). A.: The health situation of the Polish population. In: be picked by the respondents lifestyle, including nutrition, and thus health now 12. Łaszek M., Nowacka E., Gawron-Skarbek A., Szatko Wojtyniak B, Goryński P. (eds). Warszawa, Narodowy and in the future. F.: Negative patterns of health behaviors of students. Instytut Zdrowia Publicznego – Państwowy Zakład It is worth noting that the advertisement was Part II. Physical activity and eating habits. Probl Hig Higieny, 2008 (in Polish). not selected as the sources of knowledge to choose Conflict of interest Epidemiol 2011;92(3):461-465 (in Polish). 20. Wójtowicz-Chomicz K., Kowal M., Wójtowicz M., from. There is therefore a high probability that if The authors declare no conflict of interest. 13. Parmenter K., Waller J., Wardle J.: Demographic Borzęcki A.: Attempt to assess the unhealthy behaviors advertisement would be given it would be chosen by variation in nutrition knowledge in England. Health of students of the Medical University of Lublin. Probl a much larger part of respondents. As relatively less REFERENCES Education Research 2000;2(15):163-174. Hig Epidemiol 2007;88(1):108-111(in Polish). popular sources of information respondents mentioned 14. Poręba R., Gać P., Zawadzki M., Poręba M., Derkacz colour magazines, radio and physicians/ nutritionist’s 1. Anyżewska A., Wawrzyniak A., Woźniak A., Krotki M., A., Pawlas K., Pilecki W., Andrzejak R.: Lifestyle and Received: 10.10.2015 advice. Although the nutrition information on the Górnicka M.: Nutritional assessment in Polish men risk factors of cardiovascular disease among Wroclaw Accepted: 18.02.2016 product were not mentioned in the questionnaire with cardiovascular diseases. Rocz Panstw Zakl Hig college students. Polskie Archiwum Medycyny almost 1/3 (32.8%) of respondents drew attention to 2013,64(3):211-215 [PMID: 24325088; http://www. Wewnętrznej 2008;118(3),1-9 (in Polish). the information on food packaging and read them. ncbi.nlm.nih.gov/pubmed/24325088]. 2. Beydoun M.A., Powell L.M., Wang Y.: Reduced away- Respondents with higher or incomplete higher from-home food expenditure and better nutrition education significantly more than people with lower knowledge and belief can improve quality of dietary education payed attention and read the nutrition intake among US adults. Public Health Nutrition information. Over 11% of men never been interested 2008;12(3):369-381. in nutrition information. Also in earlier studies the 3. Bronkowska M., Gołecki M., Słomian J., Mikołajczak internet has been determined as the main source of J., Kosacka M., Porębska I., Jankowska R., Biernat J., nutrition information by over 70% of the Polish Air Piesiak P.: Wiedza żywieniowa oraz wybrane element Force Academy cadets. At the same time doctors/ stylu życia otyłych osób z rozpoznanym obturacyjnym nutritionists counselling was determined to be not bezdechem w czasie snu [Nutritional knowledge and very popular source of information for cadets [7]. The lifestyle of obese persons with diagnosed obturative reason may be that doctors do not always communicate sleep apnea] Rocz Panstw Zakl Hig 2010,61(3):317- nutritional knowledge to patients or do it incorrectly. 322 (in Polish) [PMID: 21365869; http://www.ncbi. nlm.nih.gov/pubmed/21365869]. It is even worse but patients with hypertension instead 4. Bronkowska M., Martynowicz H., Żmich K., Szuba A., of listening to the doctors read articles in glossy Biernat J.: Selected elements of lifestyle and nutrition magazines [4]. knowledge obese patients with arterial hypertension. Our study confirm previously obtained results, Arterial Hypertentions 2009;4(13):266-274 (in Polish). which showed that for men the family is the main 5. Chourdakis M., Tzellos T., Papazisis G., Toulis K., source of information about nutrition (58.1%). The Kouvelas D.: Eating habits, health attitudes and obesity family is the main sources especially for young 20-29 indicas among medical students in northern Greece. years old of which 75% use the information obtained Appetite 2010;55(7):722-725. from the family [10]. Men also benefit from the advice 6. Drobnica L., Cebulak T., Pieczonka W.: Żywienie of extended family members (47.3%), colleagues, a chroniczne choroby niezakaźne w opinii konsumentów and friends (36.6% of responses), as well as the żywności niekonwencjonalnej. [Nutrition and information in the package labelling on food products chronic no communcable diseases inunconventional food consumer reviews]. Zywn Nauk Technol Ja (35.5%). Although such information was not identified 2007;6(55):315-326 (in Polish). as a source of the knowledge by the respondents. 160 A. Kołłajtis-Dołowy, K. Żamojcin No 2 No 2 The level of knowledge on nutrition and its relation to health among Polish young men 161

Table 4. Sources of nutritional knowledge among respondents* CONCLUSIONS 7. Gaździńska A., Baran P., Wyleżoł M., Jagielski P., 15. Sochacka-Tatara E., Pac A., Majewska R.: Assesment of Answers Skibniewski F. W.: Assessment of the level of nutritional nutrition through nutritional interview on the Internet. Source (%) 1. The majority of men presented sufficient or knowledge of cadets Officers’ College of Air Force in Probl Hig Epidemiol 2010;91(1):77-82 (in Polish). Deblin - preliminary study. Probl Hig Epidemiol 2013; 16. Turconi G., Guarcello M., Maccarini L., Cignoli F., Setti Internet 67.2 low knowledge about food, nutrition, lifestyle, and their relation to health. This is particularly 94(2):368-370 (in Polish). S., Bazzano R, Roggi C.: Eating habits and behaviors, Colleagues, friends 64.2 8. GUS: Demographic Yearbook of Poland. Warsaw, physical activity, nutritional and food safety, knowledge worrying due to relationship between lifestyle, Family 61.2 Statistical Publishing Establishment. 2012. and beliefs in an adolescent Italian population. J Am especially diet, and the occurrence of hypertension 9. Hendrige G. A., Coveney J., Cox D.: Exploring nutrition Coll Nutr 2008;1(27):31-43. TV 40.3 and other cardiovascular diseases, type 2 diabetes knowledge and demographic variation in knowledge 17. Van der Veer T., Frings-Dresen M. H. W., Sluiter J. K.: School 23.9 and certain types of cancer in young men and in in an Australian community sample. Public Health Health behaviors, care needs and attitudes towards self- Popular science magazines, books 22.4 men of older age. Nutrition 2008;11(12):1365-1371. prescription: a cross-sectional survey among Dutch 2. The internet was the main source of nutritional 10. Heropolitańska-Janik J., Jeżewska-Zychowicz M.: medical students. PLOS ONE 2011;11(6):1-6. Doctor / dietician 19.4 knowledge and health related information followed Analysis of the needs of men in the area of nutrition 18. Waśkiewicz A.: The quality of nutrition and health Radio 16.4 by: colleagues, friends and family. education. Żyw Człow Metab 2002;3(29):134-143 (in knowledge level among young adult Poles - study Popular magazines 14.9 3. Young men should be encouraged to participate in Polish). WOBASZ. Prob Hig Epidem 2010;91(2):233-237 (in Another 10.4 various forms of nutritional and health education. 11. Królikowska S.: The role of gender stereotypes in Polish). shaping attitudes of men and women to health. Nowiny 19. Wojtyniak B., Stokwiszewski J., Goryński P., Poznańska *the sum is higher than 100% because more than one answer could This would increase the chance for improving their Lekarskie 2011;80(5):387-393 (in Polish). A.: The health situation of the Polish population. In: be picked by the respondents lifestyle, including nutrition, and thus health now 12. Łaszek M., Nowacka E., Gawron-Skarbek A., Szatko Wojtyniak B, Goryński P. (eds). Warszawa, Narodowy and in the future. F.: Negative patterns of health behaviors of students. Instytut Zdrowia Publicznego – Państwowy Zakład It is worth noting that the advertisement was Part II. Physical activity and eating habits. Probl Hig Higieny, 2008 (in Polish). not selected as the sources of knowledge to choose Conflict of interest Epidemiol 2011;92(3):461-465 (in Polish). 20. Wójtowicz-Chomicz K., Kowal M., Wójtowicz M., from. There is therefore a high probability that if The authors declare no conflict of interest. 13. Parmenter K., Waller J., Wardle J.: Demographic Borzęcki A.: Attempt to assess the unhealthy behaviors advertisement would be given it would be chosen by variation in nutrition knowledge in England. Health of students of the Medical University of Lublin. Probl a much larger part of respondents. As relatively less REFERENCES Education Research 2000;2(15):163-174. Hig Epidemiol 2007;88(1):108-111(in Polish). popular sources of information respondents mentioned 14. Poręba R., Gać P., Zawadzki M., Poręba M., Derkacz colour magazines, radio and physicians/ nutritionist’s 1. Anyżewska A., Wawrzyniak A., Woźniak A., Krotki M., A., Pawlas K., Pilecki W., Andrzejak R.: Lifestyle and Received: 10.10.2015 advice. Although the nutrition information on the Górnicka M.: Nutritional assessment in Polish men risk factors of cardiovascular disease among Wroclaw Accepted: 18.02.2016 product were not mentioned in the questionnaire with cardiovascular diseases. Rocz Panstw Zakl Hig college students. Polskie Archiwum Medycyny almost 1/3 (32.8%) of respondents drew attention to 2013,64(3):211-215 [PMID: 24325088; http://www. Wewnętrznej 2008;118(3),1-9 (in Polish). the information on food packaging and read them. ncbi.nlm.nih.gov/pubmed/24325088]. 2. Beydoun M.A., Powell L.M., Wang Y.: Reduced away- Respondents with higher or incomplete higher from-home food expenditure and better nutrition education significantly more than people with lower knowledge and belief can improve quality of dietary education payed attention and read the nutrition intake among US adults. Public Health Nutrition information. Over 11% of men never been interested 2008;12(3):369-381. in nutrition information. Also in earlier studies the 3. Bronkowska M., Gołecki M., Słomian J., Mikołajczak internet has been determined as the main source of J., Kosacka M., Porębska I., Jankowska R., Biernat J., nutrition information by over 70% of the Polish Air Piesiak P.: Wiedza żywieniowa oraz wybrane element Force Academy cadets. At the same time doctors/ stylu życia otyłych osób z rozpoznanym obturacyjnym nutritionists counselling was determined to be not bezdechem w czasie snu [Nutritional knowledge and very popular source of information for cadets [7]. The lifestyle of obese persons with diagnosed obturative reason may be that doctors do not always communicate sleep apnea] Rocz Panstw Zakl Hig 2010,61(3):317- nutritional knowledge to patients or do it incorrectly. 322 (in Polish) [PMID: 21365869; http://www.ncbi. nlm.nih.gov/pubmed/21365869]. It is even worse but patients with hypertension instead 4. Bronkowska M., Martynowicz H., Żmich K., Szuba A., of listening to the doctors read articles in glossy Biernat J.: Selected elements of lifestyle and nutrition magazines [4]. knowledge obese patients with arterial hypertension. Our study confirm previously obtained results, Arterial Hypertentions 2009;4(13):266-274 (in Polish). which showed that for men the family is the main 5. Chourdakis M., Tzellos T., Papazisis G., Toulis K., source of information about nutrition (58.1%). The Kouvelas D.: Eating habits, health attitudes and obesity family is the main sources especially for young 20-29 indicas among medical students in northern Greece. years old of which 75% use the information obtained Appetite 2010;55(7):722-725. from the family [10]. Men also benefit from the advice 6. Drobnica L., Cebulak T., Pieczonka W.: Żywienie of extended family members (47.3%), colleagues, a chroniczne choroby niezakaźne w opinii konsumentów and friends (36.6% of responses), as well as the żywności niekonwencjonalnej. [Nutrition and information in the package labelling on food products chronic no communcable diseases inunconventional food consumer reviews]. Zywn Nauk Technol Ja (35.5%). Although such information was not identified 2007;6(55):315-326 (in Polish). as a source of the knowledge by the respondents. Rocz Panstw Zakl Hig 2016;67(2):163-167 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

ORIGINAL ARTICLE

THE NUTRITIONAL AWARENESS OF FUNCTIONAL FOOD AMONG UNIVERSITY STUDENTS IN POLAND

Anna Morawska*, Ilona Górna, Izabela Bolesławska, Juliusz Przysławski

Poznań University of Medical Sciences, Faculty of Pharmacy, Chair and Department of Bromatology, Poznań, Poland

ABSTRACT Background. A lack of knowledge or a fear of unknown products are common reasons why new foods are not accepted. A good example of such foods are those containing pro-health ingredients. These are termed functional foods. Objective. The aim of the study was to determine the level of knowledge that university students have on functional foods. Material and Methods. Subjects surveyed were 266 students from the Poznan University of Medical Sciences, majoring in Dietetics and Pharmacy. A short original questionnaire was put to the students comprising 7 closed (force-choice) questions in order to test their knowledge on definition, function, form or examples of functional foods. Results. Compared to Pharmacy students, Dietetic students had significantly greater nutritional awareness about the characteristics, forms and examples of functional foods, as well as they consumed a wider range of functional products. They also evaluated their knowledge more highly than Pharmacy students on such issues. This greater nutritional knowledge in Dietetic students, seems likely to have arisen from the very nature of their studies. Conclusions. There is a need to promote functional foods in medical schools and universities, that not only include those studying nutrition subjects but also in other health-related areas.

Key words: functional food, level of knowledge, students, food neophobia

STRESZCZENIE Wprowadzenie. Zdarza się, że brak akceptacji nowego produktu spożywczego wynika z braku wiedzy na jego temat oraz obawy przed nieznanymi produktami, czyli tak zwanej neofobii żywnościowej. Przykładem takim jest tak zwana żywność funkcjonalna, czyli żywność zawierająca składniki prozdrowotne. Cel badań. Celem przeprowadzonych badań było określenie poziomu wiedzy studentów na temat żywności funkcjonalnej Materiał i metody. W badaniu uczestniczyło 266 respondentów, studiujących na Uniwersytecie Medycznym w Poznaniu, na dwóch kierunkach Dietetyka i Farmacja. Badanych konsumentów poproszono o wypełnienie krótkiego, autorskiego kwestionariusza ankiety zawierającego 7 pytań zamkniętych. Pytania sprawdzały wiedzę ankietowanych w zakresie znajo- mości definicji, funkcji, postaci oraz przykładów żywności funkcjonalnej. Wyniki. Studenci dietetyki, w stosunku do studentów farmacji, charakteryzowali się istotnie większą wiedzą na temat cech, postaci oraz przykładów żywności funkcjonalnej, jak również korzystali z szerszej gamy produktów funkcjonalnych. Ponadto studenci Dietetyki wyżej oceniali swój poziom wiedzy w zakresie żywności funkcjonalnej. Uzyskane wyniki wskazują na prawdopodobny wyższy poziom wiedzy żywieniowej wśród studentów dietetyki, co może mieć związek z wybranym kierunkiem studiów. Wnioski. Istnieje potrzeba popularyzacji produktów zaliczanych do żywności funkcjonalnej na uczelniach medycznych, nie tylko wśród studentów, których kierunek studiów ma związek z żywieniem, ale również wśród studentów innych kie- runków związanych ze zdrowiem.

Słowa kluczowe: żywność funkcjonalna, poziom wiedzy, studenci, neofobia żywnościowa

INTRODUCTION 7, 16]. Food containing such pro-health ingredients is called functional food [15]. The concept is rooted in There is an increasing number of scientific writing the Eastern culture which does not set a clear boundary tackling the issue of the correlation between nutrition between a cure or medicine and food. Functional food and the occurrence of the chronic diseases of modern was first mentioned in Japan in the mid 80’s. In the civilisation [1, 5, 9]. Many authors underline the next couple of years, the interest in this type of food beneficial influence of bioactive food ingredients, spread to the USA and Europe [3]. According to the which help to maintain physical and psychological working definition elaborated in the 1999 FUFOSE wellbeing as well as improve the general health [1, 5, (Functional Food Science in Europe) document,

ORIGINAL ARTICLE

THE NUTRITIONAL AWARENESS OF FUNCTIONAL FOOD AMONG UNIVERSITY STUDENTS IN POLAND

Anna Morawska*, Ilona Górna, Izabela Bolesławska, Juliusz Przysławski

Poznań University of Medical Sciences, Faculty of Pharmacy, Chair and Department of Bromatology, Poznań, Poland

Key words: functional food, level of knowledge, students, food neophobia

Słowa kluczowe: żywność funkcjonalna, poziom wiedzy, studenci, neofobia żywnościowa

*Corresponding author: Anna Morawska, Chair and Department of Bromatology, Faculty of Pharmacy, Poznan University of Medical Sciences, Marcelińska 42, 60-354 Poznań, Poland; phone +48 61 854 71 96, fax: +48 61 854 71 98, e-mail: [email protected] © Copyright by the National Institute of Public Health - National Institute of Hygiene 164 A. Morawska, I. Górna, I. Bolesławska et al. No 2 No 2 The nutritional awareness of functional food among university students in Poland 165 functional foods are those foods which “beneficially MATERIAL AND METHODS The analysis of the questions probing the respondents, regardless the field of studies, associated affect one or more target functions in the body beyond knowledge of functional foods characteristics among the functional foods with their other name - pro-health adequate nutritional effects in a way that is relevant to The surveyed group comprised 266 young young consumers is shown in Table 2. It provided very foods, however, the Dietetics Studies students did this either an improved state of health and well-being and/ consumers ranging from aged 18 to 27. They were interesting results. more often. A similar trend can be observed when it or reduction of risk of disease” [9, 11]. Additionally, students of Nutrition and Pharmacy at the Poznan There were significant differences in the level comes to providing examples of functional foods. those foods are intended to be consumed as part of the University of Medical Sciences in Poland. Two of knowledge depending on the interviewees’ field More Dietetics students were able to provide examples normal diet and do not come in form of a pill, a capsule interviewees’ subgroups were created according to of study. The Dietetics students were much more of functional foods as: high fibre, low in calories fruit or any form of dietary supplement [3, 9, 11]. Their the studies the young people were enrolled in (161 knowledgeable in terms of the specific features juices with extra vitamins, probiotic yoghurts and beneficial effect on at least one or more human body and 105 for the Dietetics and the Pharmacy Studies of functional foods and they were able to indicate other fermented dairy products, cold pressed oils and functions needs to be scientifically proven (besides the respectively). The consumers were asked to fill that these types of foods are consumed as a part omega-3 enriched eggs. nutritional value they have). These foods may enhance in an original, short questionnaire comprising 7 of a normal food pattern. More than a half of health or wellbeing as well as have prophylactic closed (forced-choice) questions. The knowledge of properties [3, 5, 9, 11, 15, 18]. We may distinguish definition, function, form or examples of functional Table 2. The level of Dietetic and Pharmacy students’ nutritional knowledge of the functional food a few kinds of functional foods: naturally rich in foods was tested with these questions. Number of answers Possibile Significance of differences between D and P pro-health ingredients food, foods with enhanced Checking knowledge questions Dietetics (D) Pharmacy (P) answers (Chi2 test) absorption of pro-health ingredients, purified foods The results were statistically analysed by the n % n % (from which some non-beneficial ingredients have StatSoft, Inc. (2011) STATISTICA (Data Analysis correct 96 60 42 40 been extracted) and enriched foods [9, 18]. Software System) version 10 software. For the initial Incorrect characteristic of incorrect 51 31 19 18 <0.0001 Their common market availability may constitute analysis, a basic descriptive statistics was employed: functional food „I do not know” 14 9 44 42 an opportunity to reduce the risk of many diseases of average (X), standard deviation (SD), variance (V (%)), correct 124 77 60 57 modern civilisation [11]. For the functional foods to be median (Me), minimum variable (Min), maximum Examples of functional food incorrect 26 16 7 7 <0.0001 often consumed and popular, there needs to be broader variable (Max). For quantitative variables to verify the do not know” 11 7 38 36 awareness and acceptance of them, especially among normal dispersion, the Shapiro-Wilk test was applied. young consumers [16, 18]. As pointed out by Cha et al. To find the statistically significant differences between correct 140 87 61 58 [7], consumers’ acceptance of functional food depends the two analysed variables, with the lack of the normal Another name of functional food incorrect 7 4 3 3 <0.0001 on several factors, which include: demographic factors dispersion, the Mann-Whitney test was applied. In the “do not know” 14 9 41 39 (gender, age, education), product factors (price, taste) and case of the variables in categorical scale the Chi2 of correct 129 80 46 44 psychological factors (confidence and/or concerns about independence test was applied, whereas in the case of incorrect 20 13 20 19 <0.0001 The form of functional food these foods). According to Steinka [19], technological small quantities in specific categories, the correction „do not know” 12 7 39 37 advancements as well as unconventional or unknown of the Chi2 - the Fisher’s exact test was used. For all products are often not well received by consumers who the analysed variables the statistical significance of The practical aspect linked to the conducted research oat products. In terms of other functional foods also are rather used to their usual foods and eating habits. P-value = 0.05 was applied. was included in the question on functional foods in commonly consumed by the respondents (such as high It is common that new foods are not accepted due to a normal food pattern (Table 3). Table 3 indicates that fibre grain products, fruit and vegetable juices with lack of knowledge, some fear of unknown products or RESULTS the Pharmacy students consume far less functional added vitamins, green tea), there was no correlation risk perception associated with their consumption [1, 7, foods of any kind. The respondents’ field of study had between their popularity and the field of study. 18]. This phenomenon is referred to as food neophobia The study results reveal that significantly more a significant influence on the consumption of functional The results of the subjective knowledge level of [3, 19]. Basing on these premises, we conducted studies Dietetics students than Pharmacy students have already foods such as: cold pressed oils, fermented diary and the students are shown in the Table 4. which aimed at uncovering functional food awareness come across the term - functional foods (Table 1). levels among university students. Table 3. The most popular functional products among university students Table 1. The sources of information of functional food among university students in Poland Number of answers [%]b Significance of differences between D and P The most popular functional products b Dietetics (D) Pharmacy (P) (Fisher’s exact test) Number of answers [%] Significance of differences between D and P The sources of information Fermented dairy products 58 20 p<0.0001 Dietetics (D) Pharmacy (P) (Fisher’s exact test) Cold-pressed plant oils 47 27 p=0.0008 Family and friends 9 1 p=0.0036 Eggs fortified in omega-3 acids 7 3 p=0.1727a Product packaging 23 3 p<0.0001 Low salt products 20 13 p=0.1874a a TV program, radio 17 10 p=0.0765 Energy drinks 14 17 p=0.4844a Scientific press 38 5 p<0.0001 Soy products 19 10 p=0.0832a a Newspapers 8 2 p=0.0534 Juices with vitamins 35 28 p=0.2296a a Doctors 1 0 p=0.5204 Green tea 65 52 p=0.0552a Internet 37 11 p<0.0001 Cereal products rich in fibre 47 35 p=0.0580a Other source 37 9 p<0.0001 Oat product 57 34 p=0.0004 I do not know 17 69 p<0.0001 Low energy foods 11 10 p=1.0000a a no statistically significant differences; Other functional products 6 1 p=0.0943 b values do not add up to 100 because respondents could choose more than one answer I do not use 8 38 p<0.0001 a no statistically significant differences; b values do not add up to 100 because respondents could choose more than one answer 164 A. Morawska, I. Górna, I. Bolesławska et al. No 2 No 2 The nutritional awareness of functional food among university students in Poland 165 functional foods are those foods which “beneficially MATERIAL AND METHODS The analysis of the questions probing the respondents, regardless the field of studies, associated affect one or more target functions in the body beyond knowledge of functional foods characteristics among the functional foods with their other name - pro-health adequate nutritional effects in a way that is relevant to The surveyed group comprised 266 young young consumers is shown in Table 2. It provided very foods, however, the Dietetics Studies students did this either an improved state of health and well-being and/ consumers ranging from aged 18 to 27. They were interesting results. more often. A similar trend can be observed when it or reduction of risk of disease” [9, 11]. Additionally, students of Nutrition and Pharmacy at the Poznan There were significant differences in the level comes to providing examples of functional foods. those foods are intended to be consumed as part of the University of Medical Sciences in Poland. Two of knowledge depending on the interviewees’ field More Dietetics students were able to provide examples normal diet and do not come in form of a pill, a capsule interviewees’ subgroups were created according to of study. The Dietetics students were much more of functional foods as: high fibre, low in calories fruit or any form of dietary supplement [3, 9, 11]. Their the studies the young people were enrolled in (161 knowledgeable in terms of the specific features juices with extra vitamins, probiotic yoghurts and beneficial effect on at least one or more human body and 105 for the Dietetics and the Pharmacy Studies of functional foods and they were able to indicate other fermented dairy products, cold pressed oils and functions needs to be scientifically proven (besides the respectively). The consumers were asked to fill that these types of foods are consumed as a part omega-3 enriched eggs. nutritional value they have). These foods may enhance in an original, short questionnaire comprising 7 of a normal food pattern. More than a half of health or wellbeing as well as have prophylactic closed (forced-choice) questions. The knowledge of properties [3, 5, 9, 11, 15, 18]. We may distinguish definition, function, form or examples of functional Table 2. The level of Dietetic and Pharmacy students’ nutritional knowledge of the functional food a few kinds of functional foods: naturally rich in foods was tested with these questions. Number of answers Possibile Significance of differences between D and P pro-health ingredients food, foods with enhanced Checking knowledge questions Dietetics (D) Pharmacy (P) answers (Chi2 test) absorption of pro-health ingredients, purified foods The results were statistically analysed by the n % n % (from which some non-beneficial ingredients have StatSoft, Inc. (2011) STATISTICA (Data Analysis correct 96 60 42 40 been extracted) and enriched foods [9, 18]. Software System) version 10 software. For the initial Incorrect characteristic of incorrect 51 31 19 18 <0.0001 Their common market availability may constitute analysis, a basic descriptive statistics was employed: functional food „I do not know” 14 9 44 42 an opportunity to reduce the risk of many diseases of average (X), standard deviation (SD), variance (V (%)), correct 124 77 60 57 modern civilisation [11]. For the functional foods to be median (Me), minimum variable (Min), maximum Examples of functional food incorrect 26 16 7 7 <0.0001 often consumed and popular, there needs to be broader variable (Max). For quantitative variables to verify the do not know” 11 7 38 36 awareness and acceptance of them, especially among normal dispersion, the Shapiro-Wilk test was applied. young consumers [16, 18]. As pointed out by Cha et al. To find the statistically significant differences between correct 140 87 61 58 [7], consumers’ acceptance of functional food depends the two analysed variables, with the lack of the normal Another name of functional food incorrect 7 4 3 3 <0.0001 on several factors, which include: demographic factors dispersion, the Mann-Whitney test was applied. In the “do not know” 14 9 41 39 (gender, age, education), product factors (price, taste) and case of the variables in categorical scale the Chi2 of correct 129 80 46 44 psychological factors (confidence and/or concerns about independence test was applied, whereas in the case of incorrect 20 13 20 19 <0.0001 The form of functional food these foods). According to Steinka [19], technological small quantities in specific categories, the correction „do not know” 12 7 39 37 advancements as well as unconventional or unknown of the Chi2 - the Fisher’s exact test was used. For all products are often not well received by consumers who the analysed variables the statistical significance of The practical aspect linked to the conducted research oat products. In terms of other functional foods also are rather used to their usual foods and eating habits. P-value = 0.05 was applied. was included in the question on functional foods in commonly consumed by the respondents (such as high It is common that new foods are not accepted due to a normal food pattern (Table 3). Table 3 indicates that fibre grain products, fruit and vegetable juices with lack of knowledge, some fear of unknown products or RESULTS the Pharmacy students consume far less functional added vitamins, green tea), there was no correlation risk perception associated with their consumption [1, 7, foods of any kind. The respondents’ field of study had between their popularity and the field of study. 18]. This phenomenon is referred to as food neophobia The study results reveal that significantly more a significant influence on the consumption of functional The results of the subjective knowledge level of [3, 19]. Basing on these premises, we conducted studies Dietetics students than Pharmacy students have already foods such as: cold pressed oils, fermented diary and the students are shown in the Table 4. which aimed at uncovering functional food awareness come across the term - functional foods (Table 1). levels among university students. Table 3. The most popular functional products among university students Table 1. The sources of information of functional food among university students in Poland Number of answers [%]b Significance of differences between D and P The most popular functional products b Dietetics (D) Pharmacy (P) (Fisher’s exact test) Number of answers [%] Significance of differences between D and P The sources of information Fermented dairy products 58 20 p<0.0001 Dietetics (D) Pharmacy (P) (Fisher’s exact test) Cold-pressed plant oils 47 27 p=0.0008 Family and friends 9 1 p=0.0036 Eggs fortified in omega-3 acids 7 3 p=0.1727a Product packaging 23 3 p<0.0001 Low salt products 20 13 p=0.1874a a TV program, radio 17 10 p=0.0765 Energy drinks 14 17 p=0.4844a Scientific press 38 5 p<0.0001 Soy products 19 10 p=0.0832a a Newspapers 8 2 p=0.0534 Juices with vitamins 35 28 p=0.2296a a Doctors 1 0 p=0.5204 Green tea 65 52 p=0.0552a Internet 37 11 p<0.0001 Cereal products rich in fibre 47 35 p=0.0580a Other source 37 9 p<0.0001 Oat product 57 34 p=0.0004 I do not know 17 69 p<0.0001 Low energy foods 11 10 p=1.0000a a no statistically significant differences; Other functional products 6 1 p=0.0943 b values do not add up to 100 because respondents could choose more than one answer I do not use 8 38 p<0.0001 a no statistically significant differences; b values do not add up to 100 because respondents could choose more than one answer 166 A. Morawska, I. Górna, I. Bolesławska et al. No 2 No 2 The nutritional awareness of functional food among university students in Poland 167

Table 4. Subjective assessment of the level of students’ knowledge of the functional food Conflict of interest 10. Górnicka M., Pierzynowska J., Kaniewska E., Kossa- kowska K., Woźniak A.: School pupils and university Number of answers The authors declare no conflict of interest. Significance of differences between students surveyed for drinking beverages containing Subjective assessment of the level of D and P (Chi2 test) caffeine. Rocz Panstw Zakl Hig 2014;65(2):113-117 students’ knowledge Dietetics (D) Pharmacy (P) REFERENCES [PMID: 25272577; http://www.ncbi.nlm.nih.gov/pub- n % n % 1. Al-Nabulsi A.A., Obiedat B., Ali R., Osaili T.M., Bawadi med/25272577]. very low 17 11 59 56 H., Abushelaibi A., Shaker R.R., Holley R.A.: Knowl- 11. Kolarzyk E., Pach D.: Different aspects of food low 31 19 26 25 edge of probiotics and factors affecting their consump- consumed by contemporary people. Przegl Lek 2012;69(8):492-497 (in Polish) medium 74 46 18 17 < 0.0001 tion by Jordanian college students. Int J Probiotics and Prebiotics 2014;9(3):77-86. 12. Kopacz A., Wawrzyniak A., Hamułka J., Górnicka high 33 20 1 1 2. Asemi A.: Information Searching Habits of Internet M.: Badania uwarunkowań spożywania napojów very high 6 4 1 1 Users: A Case Study on the Medical Sciences Univer- energetyzujących przez studentów [Studies on the de- sity of Isfahan, Iran. Webology 2005;2(1), Available terminants of energy drinks intake by students]. Rocz Most of the Pharmacy students declared their among the group of students. These findings disagree from: http://www.webology.org/2005/v2n1/a10.html Panstw Zakl Hig 2012;63(4):491-497 (in Polish) knowledge level to be low or very low, whereas almost with studies by Bulut et al. [4], Buxton and Hagan [6], (2.01.2016). [PMID: 23631272; http://www.ncbi.nlm.nih.gov/pub- a half of Dietetics students indicated their knowledge Górnicka et al. [11] and Kopacz et al. [12, 13], where 3. Bilgiç S., Yüksel A.: University students’ perception and med/23631272]. level to be medium. Significantly more Dietetics more than a half of studied university students drank attitudes towards functional foods in Istanbul. Proceed- 13. Kopacz A., Wawrzyniak A., Hamułka J., Górnicka students, than those studying Pharmacy, described energy drinks to stay awake and improve their mental ings of the 2012 International Conference on Industrial M.: Evaluation of energy drink intake in selected stu- their level of knowledge on functional foods as high performance. Students most often drank energy drinks Engineering and Operations Management Istanbul, dent groups. Rocz Panstw Zakl Hig 2013;64(1):49-53 [PMID: 23789313; http://www.ncbi.nlm.nih.gov/pub- or very high. during the examination session. Turkey, July 3-6, 2012, Available from: http://iieom. org/ieom2012/pdfs/279.pdf (20.12.2015). med/23789313]. Green tea was a very popular functional product 14. Kramkowska M., Grzelak T., Czyżewska K.: Customers’ DISCUSSION among respondents in the present study. 65% of Dietetics 4. Bulut B., Beyhun N.E., Topbaş M., Çan G.: Energy Drink Use in University Students and Associated Fac- attitudes towards genetically modified food. Bromatol students and 52% of Pharmacy students declared choosing tors. J Community Health 2014;39(5):1004-1011, DOI Chem Toksykol 2012;XLV(2):206-211 (in Polish) Nowadays the Internet is considered to be the best this functional product. These results are similar to results 10.1007/s10900-014-9849-3. 15. Lovik M.: Impact of a New European regulations on and the fastest source of knowledge on various topics obtained in the study by Drywień et al. [8]. 5. Butnariu M., Caunii A.: Design management of func- functional food market – an overview. Clinical and [2, 14]. Also in our study, the most common source of Generally, Dietetics students assessed their level tional foods for quality of life improvement. Ann Agric Translational Allergy 2011;1(1):55 DOI:10.1186/2045- information on the functional foods for both groups of knowledge about functional foods more highly than Environ Med 2013;20(4):736-741. 7022-1-S1-S55 was the Internet. The Dietetics students have also often Pharmacy students. Their higher score may be related to 6. Buxton Ch., Hagan J.E.: A survey of energy drinks con- 16. Schnettler B., Miranda H., Lobos G., Sepulveda J., indicated other sources of information on functional the knowledge they are exposed to during the academic sumption practices among student -athletes in Ghana: Orellana L., Mora M., Grunert K.: Willingness to foods such as: scientific journals, product packaging education and to their areas of interest which is linked lessons for developing health education intervention pro- purchase functional foods according to their benefits. British Food Journal 2015;177(5):1453-1473 DOI: or other including university lectures, while the to their field of studies. It may suggest that the field of grammes. Journal of the International Society of Sports 10.1108/BFJ-07-2014-0273 Pharmacy students pointed to TV or radio broadcasts study and the knowledge derived from it regarding Nutrition 2012 9:9. DOI 10.1186/1550-2783-9-9. 7. Cha M.H., Lee J., Song M.J.: Dieticians’ intentions to 17. Sicińska E., Bojarska K.: Intakes of folic acid from die- as sources of information on the topic. Similar sources the functional foods have an indirect influence on the tary supplements and fortified products in students. Rocz of information were indicated by Asemi [2] and acceptance level and shape positively functional foods recommend functional foods: The mediating role of consumption frequency of functional foods. Nutr Res Panstw Zakl Hig 2013;64(1):55-59 [PMID: 23789314; Kramkowska et al. [14], as the nutritional awareness eating behaviours. Similar conclusions were drawn Pract 2010;4(1):75-81, DOI: 10.4162/nrp.2010.4.1.75. http://www.ncbi.nlm.nih.gov/pubmed/23789314]. among students is mainly shaped by the Internet, by other authors who stated that the more educated the 8. Drywień M., Podkowska J., Frąckiewicz J., Górnicka M.: 18. Stein A.J., Rodriguez-Cerezo E.: Functional food in the Eu- books and scientific journals. person is and the more food awareness they have, the Consumption of black and green teas as a dietary source of ropean Union. JRC Scientific and Technological Reports, Our survey results showed that a large group of students more positive eating behaviours they present [1, 3, 14, 16, polyphenols in Polish inhabitants of the Mazovian region. Luxemburg, European Communities 2008, Available from: of both faculties did not have sufficient knowledge about 18]. On the other hand, studies demonstrated that the lack Rocz Panstw Zakl Hig 2015;66(1):35-38 [PMID: 25813071; http://ftp.jrc.es/EURdoc/JRC43851.pdf (18.12.2015) functional foods and some of them even did not know that of knowledge about some product made the consumers http://www.ncbi.nlm.nih.gov/pubmed/25813071]. 19. Steinka I.: Acceptance of unconventional food for they ate functional foods. The results coincide with the decide against buying and eating this product [3]. 9. European Commission report on functional foods. Eu- young consumers. Żywność, Nauka. Technologia. results of other authors [1, 3, 17]. According to Sicińska ropean Union 2010. Available from: http://www.euro- Jakość 2009;5(65):218-226 (in Polish). and Bojarska [17], 89% of students who participated in CONCLUSIONS sfaire.prd.fr/7pc/documents/1276590504_functional_ Received: 24.11.2015 their research, consumed products fortified with folic acid, foods_en_publi_ce.pdf (18.12.2015) Accepted: 19.02.2016 however a quarter of them were not aware of the usage of 1. The results indicate that there is a need to such functional products. promote functional foods at medical schools and When we compare our results on the most popular universities, not only among students directly functional products with those obtained by other linked with nutrition, but also among the other European authors, we may observe that such products students of health related degrees. in Poland are juices and drinks enriched with minerals, 2. In order to promote functional foods available on vitamins, fibre or inulin, probiotic yoghurts, energy the market among various groups of consumers, and isotonic drinks, breakfast cereals and margarine it is highly important to implement a widespread with stanols [11]. At the same time in Europe, the advertising campaign together with education on most commonly consumed functional foods are dairy the topic. These actions may diminish the risks of (fermented and unfermented with probiotics) and grain diet-related diseases. products with extra fibre [3, 11, 18]. The presented study demonstrates a low consumption of energy drinks 166 A. Morawska, I. Górna, I. Bolesławska et al. No 2 No 2 The nutritional awareness of functional food among university students in Poland 167

Table 4. Subjective assessment of the level of students’ knowledge of the functional food Conflict of interest 10. Górnicka M., Pierzynowska J., Kaniewska E., Kossa- kowska K., Woźniak A.: School pupils and university Number of answers The authors declare no conflict of interest. Significance of differences between students surveyed for drinking beverages containing Subjective assessment of the level of D and P (Chi2 test) caffeine. Rocz Panstw Zakl Hig 2014;65(2):113-117 students’ knowledge Dietetics (D) Pharmacy (P) REFERENCES [PMID: 25272577; http://www.ncbi.nlm.nih.gov/pub- n % n % 1. Al-Nabulsi A.A., Obiedat B., Ali R., Osaili T.M., Bawadi med/25272577]. very low 17 11 59 56 H., Abushelaibi A., Shaker R.R., Holley R.A.: Knowl- 11. Kolarzyk E., Pach D.: Different aspects of food low 31 19 26 25 edge of probiotics and factors affecting their consump- consumed by contemporary people. Przegl Lek 2012;69(8):492-497 (in Polish) medium 74 46 18 17 < 0.0001 tion by Jordanian college students. Int J Probiotics and Prebiotics 2014;9(3):77-86. 12. Kopacz A., Wawrzyniak A., Hamułka J., Górnicka high 33 20 1 1 2. Asemi A.: Information Searching Habits of Internet M.: Badania uwarunkowań spożywania napojów very high 6 4 1 1 Users: A Case Study on the Medical Sciences Univer- energetyzujących przez studentów [Studies on the de- sity of Isfahan, Iran. Webology 2005;2(1), Available terminants of energy drinks intake by students]. Rocz Most of the Pharmacy students declared their among the group of students. These findings disagree from: http://www.webology.org/2005/v2n1/a10.html Panstw Zakl Hig 2012;63(4):491-497 (in Polish) knowledge level to be low or very low, whereas almost with studies by Bulut et al. [4], Buxton and Hagan [6], (2.01.2016). [PMID: 23631272; http://www.ncbi.nlm.nih.gov/pub- a half of Dietetics students indicated their knowledge Górnicka et al. [11] and Kopacz et al. [12, 13], where 3. Bilgiç S., Yüksel A.: University students’ perception and med/23631272]. level to be medium. Significantly more Dietetics more than a half of studied university students drank attitudes towards functional foods in Istanbul. Proceed- 13. Kopacz A., Wawrzyniak A., Hamułka J., Górnicka students, than those studying Pharmacy, described energy drinks to stay awake and improve their mental ings of the 2012 International Conference on Industrial M.: Evaluation of energy drink intake in selected stu- their level of knowledge on functional foods as high performance. Students most often drank energy drinks Engineering and Operations Management Istanbul, dent groups. Rocz Panstw Zakl Hig 2013;64(1):49-53 [PMID: 23789313; http://www.ncbi.nlm.nih.gov/pub- or very high. during the examination session. Turkey, July 3-6, 2012, Available from: http://iieom. org/ieom2012/pdfs/279.pdf (20.12.2015). med/23789313]. Green tea was a very popular functional product 14. Kramkowska M., Grzelak T., Czyżewska K.: Customers’ DISCUSSION among respondents in the present study. 65% of Dietetics 4. Bulut B., Beyhun N.E., Topbaş M., Çan G.: Energy Drink Use in University Students and Associated Fac- attitudes towards genetically modified food. Bromatol students and 52% of Pharmacy students declared choosing tors. J Community Health 2014;39(5):1004-1011, DOI Chem Toksykol 2012;XLV(2):206-211 (in Polish) Nowadays the Internet is considered to be the best this functional product. These results are similar to results 10.1007/s10900-014-9849-3. 15. Lovik M.: Impact of a New European regulations on and the fastest source of knowledge on various topics obtained in the study by Drywień et al. [8]. 5. Butnariu M., Caunii A.: Design management of func- functional food market – an overview. Clinical and [2, 14]. Also in our study, the most common source of Generally, Dietetics students assessed their level tional foods for quality of life improvement. Ann Agric Translational Allergy 2011;1(1):55 DOI:10.1186/2045- information on the functional foods for both groups of knowledge about functional foods more highly than Environ Med 2013;20(4):736-741. 7022-1-S1-S55 was the Internet. The Dietetics students have also often Pharmacy students. Their higher score may be related to 6. Buxton Ch., Hagan J.E.: A survey of energy drinks con- 16. Schnettler B., Miranda H., Lobos G., Sepulveda J., indicated other sources of information on functional the knowledge they are exposed to during the academic sumption practices among student -athletes in Ghana: Orellana L., Mora M., Grunert K.: Willingness to foods such as: scientific journals, product packaging education and to their areas of interest which is linked lessons for developing health education intervention pro- purchase functional foods according to their benefits. British Food Journal 2015;177(5):1453-1473 DOI: or other including university lectures, while the to their field of studies. It may suggest that the field of grammes. Journal of the International Society of Sports 10.1108/BFJ-07-2014-0273 Pharmacy students pointed to TV or radio broadcasts study and the knowledge derived from it regarding Nutrition 2012 9:9. DOI 10.1186/1550-2783-9-9. 7. Cha M.H., Lee J., Song M.J.: Dieticians’ intentions to 17. Sicińska E., Bojarska K.: Intakes of folic acid from die- as sources of information on the topic. Similar sources the functional foods have an indirect influence on the tary supplements and fortified products in students. Rocz of information were indicated by Asemi [2] and acceptance level and shape positively functional foods recommend functional foods: The mediating role of consumption frequency of functional foods. Nutr Res Panstw Zakl Hig 2013;64(1):55-59 [PMID: 23789314; Kramkowska et al. [14], as the nutritional awareness eating behaviours. Similar conclusions were drawn Pract 2010;4(1):75-81, DOI: 10.4162/nrp.2010.4.1.75. http://www.ncbi.nlm.nih.gov/pubmed/23789314]. among students is mainly shaped by the Internet, by other authors who stated that the more educated the 8. Drywień M., Podkowska J., Frąckiewicz J., Górnicka M.: 18. Stein A.J., Rodriguez-Cerezo E.: Functional food in the Eu- books and scientific journals. person is and the more food awareness they have, the Consumption of black and green teas as a dietary source of ropean Union. JRC Scientific and Technological Reports, Our survey results showed that a large group of students more positive eating behaviours they present [1, 3, 14, 16, polyphenols in Polish inhabitants of the Mazovian region. Luxemburg, European Communities 2008, Available from: of both faculties did not have sufficient knowledge about 18]. On the other hand, studies demonstrated that the lack Rocz Panstw Zakl Hig 2015;66(1):35-38 [PMID: 25813071; http://ftp.jrc.es/EURdoc/JRC43851.pdf (18.12.2015) functional foods and some of them even did not know that of knowledge about some product made the consumers http://www.ncbi.nlm.nih.gov/pubmed/25813071]. 19. Steinka I.: Acceptance of unconventional food for they ate functional foods. The results coincide with the decide against buying and eating this product [3]. 9. European Commission report on functional foods. Eu- young consumers. Żywność, Nauka. Technologia. results of other authors [1, 3, 17]. According to Sicińska ropean Union 2010. Available from: http://www.euro- Jakość 2009;5(65):218-226 (in Polish). and Bojarska [17], 89% of students who participated in CONCLUSIONS sfaire.prd.fr/7pc/documents/1276590504_functional_ Received: 24.11.2015 their research, consumed products fortified with folic acid, foods_en_publi_ce.pdf (18.12.2015) Accepted: 19.02.2016 however a quarter of them were not aware of the usage of 1. The results indicate that there is a need to such functional products. promote functional foods at medical schools and When we compare our results on the most popular universities, not only among students directly functional products with those obtained by other linked with nutrition, but also among the other European authors, we may observe that such products students of health related degrees. in Poland are juices and drinks enriched with minerals, 2. In order to promote functional foods available on vitamins, fibre or inulin, probiotic yoghurts, energy the market among various groups of consumers, and isotonic drinks, breakfast cereals and margarine it is highly important to implement a widespread with stanols [11]. At the same time in Europe, the advertising campaign together with education on most commonly consumed functional foods are dairy the topic. These actions may diminish the risks of (fermented and unfermented with probiotics) and grain diet-related diseases. products with extra fibre [3, 11, 18]. The presented study demonstrates a low consumption of energy drinks Rocz Panstw Zakl Hig 2016;67(2):169-177 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

ORIGINAL ARTICLE

ASSESSMENT OF THE NUTRITIONAL VALUE OF DAILY FOOD RATIONS OF CHILDREN AGED 1-4 YEARS

Katarzyna Marcinek1, Rafał Wojciech Wójciak2, Zbigniew Krejpcio1

1Poznań University of Life Sciences, Department of Human Nutrition and Hygiene, Poznań, Poland 2Poznań University of Medical Sciences, Clinical Psychology Unit, Poznań, Poland

ABSTRACT Background. An adequately balanced daily food rations (DFR) providing the organism with a sufficient amount of energy and nutrients, including minerals, is particularly important in infanthood and early childhood due to the child’s intensive physical, intellectual and motoric development. Objective. The aim of this study was to evaluation the supply of energy, nutrients and vitamins in daily food rations of children fed at home and in nursery schools. Material and Methods. 75 children aged 1-4 years were the research subjects. They were divided into three age subgroups: 12-24-month-olds, 25-36-month-olds and 37-48-month-olds. The daily consumption of energy and vitamins was assessed by means of a 7-day 24-hour nutritional interview made with current note taking and by means of a computer database (Dietetyk 2). Significant differences in the content of energy, nutrients and vitamins in the DFR were investigated using the two-way analysis of variance (Statistica 10.0) at significance level p≤0.05. Results. Neither the children’s sex nor age had influence on the intake of energy and macronutrients. Apart from the amount of energy (68-101.8% RDA) and proteins (183-288% RDA) these values were generally normal, but they had influence on the content of vitamins in the DFR. The DFR was characterised by generally excessive content of vitamins A, B2, B6 and B12. However, in comparison with the RDA the intake was significantly higher in the DFR of the youngest children (12-24 months old). In the group aged 37-48 months there were significantly higher values in the intake of vitamins 2B (317% vs 137% RDA) and B6 (334% vs 147% RDA). On the other hand, in comparison with the RDA, the DFR provided too small amounts of vitamins D, E, folates and vitamin C. The DFR of the youngest children (12-24 months old) contained significantly greater amounts of vitamins: D (41.3% vs 16.2% RDA), E (83.6% vs 63.5% RDA) and C (102.0% vs 48.6% RDA), as compared with the children aged 37-48 months. Only the content of vitamins B1 and PP in the children’s DFR was similar or slightly greater than the RDA. Conclusions. The intake of energy in the DFR of the children aged 1-4 years was generally comparable, but in the children aged 37-48 months it did not satisfy the daily demand. In all the age groups under study the supply of macronutrients satisfied about 100% of the demand, whereas the supply of protein and sucrose was excessive. The children aged 12-24 months consumed more vitamins D, E, B2, PP, B6, B12, C than the children aged 37-48 months. The supply of vitamins D,

E, C and folates was too low, whereas the consumption of vitamins: B2, B6 and B12 exceeded the recommended daily intake.

Key words: nutrition, children, vitamins, intake

STRESZCZENIE Wprowadzenie. Odpowiednio zbilansowana całodzienna racja pokarmowa (CRP), dostarczająca organizmowi odpowied- niej ilości energii i składników odżywczych, w tym składników mineralnych jest niezwykle ważna w okresie niemowlę- cym i wczesnodziecięcym, ze względu na intensywny rozwój fizyczny, umysłowy i motoryczny dziecka. Cel. Celem niniejszej pracy była ocena podaży energii, składników odżywczych i witamin w całodziennych racjach pokarmowych dzieci żywionych w warunkach domowych i przedszkolnych. Materiał i metody. Badaniem objęto 75 dzieci w wielu 1-4 lata, które podzielono na trzy podgrupy wiekowe: 12-24 m-ce, 25-36 m-cy oraz 37-48 m-cy. Ocenę dziennego spożycia energii i witamin przeprowadzono za pomocą 7-dniowego 24 go- dzinnego wywiadu żywieniowego sporządzanego metodą bieżącego notowania oraz komputerowej bazy danych (Dietetyk 2). Różnice istotne statystycznie w zawartości energii, składników odżywczych oraz witamin w CRP zbadano za pomocą dwuczynnikowej analizy wariancji (Statistica 10.0) na poziomie istotności p≤0.05.

*Corresponding author: Katarzyna Marcinek, Department of Human Nutrition and Hygiene, Poznań University of Life Sciences, Wojska Polskiego street 31, 60-624 Poznań, Poland, tel. +48 61 8487306; e-mail: [email protected]

ORIGINAL ARTICLE

ASSESSMENT OF THE NUTRITIONAL VALUE OF DAILY FOOD RATIONS OF CHILDREN AGED 1-4 YEARS

Katarzyna Marcinek1, Rafał Wojciech Wójciak2, Zbigniew Krejpcio1

1Poznań University of Life Sciences, Department of Human Nutrition and Hygiene, Poznań, Poland 2Poznań University of Medical Sciences, Clinical Psychology Unit, Poznań, Poland

E, C and folates was too low, whereas the consumption of vitamins: B2, B6 and B12 exceeded the recommended daily intake.

Key words: nutrition, children, vitamins, intake

© Copyright by the National Institute of Public Health - National Institute of Hygiene 170 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 171

Wyniki Zarówno płeć jak i wiek dzieci nie miały wpływu na wielkość pobrania energii i makroskładników, która z wyjąt- (body weight). The anthropometric data gathered in the energy, nutrients and vitamins in the DFR, where the kiem energii (68% - 101,8 % RDA) i białka (183 – 288% RDA) była ogólnie prawidłowa ale miały wpływ na zawartość research were used to calculate the body mass index significance level was p ≤ 0.05. Pearson’s test was witamin w CRP. CRP charakteryzowało się ogólnie zbyt wysoką zawartością witaminy A, B2, B6 i B12, przy czym istotnie (BMI) values (kg/m2) . Then they were standardised used to calculate the correlation coefficients for the wyższe pobranie w stosunku do RDA zanotowano w CRP dzieci najmłodszych (12- 24 mce), w stosunku do grupy w wieku with reference to the WHO growth charts. For each dependences between the body weight, body height 37-48 mcy w przypadku witaminy B (317% vs. 137% RDA) i B (334% vs. 147% RDA). Z kolei CRP dostarczyły zbyt 2 6 child a standardised body mass index z-score and and individual components of the DFR. Microsoft małe w stosunku do RDA ilości witamin D, E, folianów oraz witaminy C. Stwierdzono, że CRP dzieci najmłodszych (12- percentile values of the body weight, body height and Excel ver 2007 and Statistica 10.0 Pl programs were 24 mce) zawierały znacząco wyższe ilości witamin: D (41,3% vs.16,2% RDA), E (83,6% vs. 63,5% RDA) i C (102,0% vs. 48,6% RDA) w stosunku do dzieci w wieku (37- 48 mcy). Zbliżone lub nieco wyższe w stosunku do RDA zawartości body mass index were calculated. used for statistical analysis, where the significance level was p ≤ 0.05. witamin w CRP dzieci zanotowano tylko dla witaminy B1 i PP. Wnioski. Ilość pobranej energii w CRP dzieci w wieku 1-4 lat była ogólnie porównywalna, przy czym u dzieci w wieku Assessment of energy intake and consumption of 37-48 mcy nie pokryła dziennego zapotrzebowania. Podaż makroskładników odżywczych we wszystkich badanych gru- nutrients RESULTS pach pokrywała zapotrzebowanie w około 100%, a w przypadku białka i sacharozy w nadmiarze. Dzieci w wieku 12-24 The assessment of the children’s nutrition was mcy spożywały więcej witamin D, E, B2, PP, B6, B12, C w porównaniu z dziećmi w wieku 37-48 mcy. Podaż witamin D, E, based on 24h - records of the 75 children’s menus, Table 1 shows the characteristics of the group of C i folianów była zbyt niska w stosunku do norm, a spożycie witamin: B2, B6 i B12 pokrywało zalecane dzienne spożycie which their guardians made by means of current children under study. Each child’s state of nutrition w nadmiarze. note taking for seven consecutive days. The data on was assessed by means of sex-and-age-independent the amount of consumed portions were obtained by body mass index z-score. 57.3% of the children were Słowa kluczowe: żywienie, dzieci, witaminy, spożycie weighing ready meals and leavings. The data gathered in a normal state of nutrition and their BMI z-score in this way were used to estimate the daily food ration ranged from -1.0 to +1.0. Low body weight (BMI INTRODUCTION and parents in developing feeding habits the aim of (DFR) and its energetic and nutritional value was z-score between -2.0 and-1.0) was observed in 17.3% this study was an assessment of the supply of energy, calculated by means of the ‘Dietetyk 2’ nutritional of the children, whereas very low body weight (BMI The first three years in a child’s life is a period macronutrients and vitamins in DFRs of children aged computer program. The calculations allowed for z-score <-2.0) was observed in 4.0% of the children. of particularly intensive physical, intellectual and 1-4 years fed at home and in nursery schools. The culinary and technological losses. An equal loss Overweight and obesity was observed in 20.0% and motoric development. During this period the manner aim of the study was to determine the influence of of 10% was assumed for the energetic value, total 1.3% of the children, respectively. The children aged of children’s nutrition changes from the one that is sex and age on the intake of energy, macronutrients protein, fats, carbohydrates and vitamins B6, B12 and 37-48 months were characterised by much lower typical of infanthood to the manner of nutrition which and vitamins in the daily food rations of children aged D. Due to the diversified sensitivity of other vitamins WA (weight-for-age) and LA (length/height-for-age) is typical of adults although a three-year-old child 1-4 years with reference to the recommended daily to factors observed in the culinary processing of than the younger children. Tables 2 and 3 show the has different demand for nutrients than an adult [10]. allowance (RDA) for a particular age group. food the content of vitamin A was reduced by 20%, results. The energy intake was comparable in all the An inadequate amount of nutrients may permanently riboflavin and niacin – by 25%, vitamin E – by 30%, age groups, but in the group of 37-48-month-olds change metabolism and the course of physiological Population under study folates – by 40%, vitamin C – by 55% [16]. The values it was about 30% lower than the RDA. In all the processes and in consequence, it may increase the The Bioethical Commission, Medical University of consumption which differed by ± 10% from the groups under investigation the consumption of fat and child’s predisposition to obesity at a later period in of Poznań gave the permission for the study (No. standard values were regarded as adequate. carbohydrates in the DFR was similar and covered life. Apart from basic nutrients, such as proteins, fats 871/10). The study was conducted in 75 children aged about 100% of the demand. Neither the children’s age and carbohydrates, it is also vitamins and minerals that 1-4 years living in Poznan and the surrounding area. Statistical analysis nor sex (independent of each other) had significant are particularly important for the child’s development The population was divided into three age subgroups: This study assumed a 15% standard error in the influence on the intake of energy and macronutrients. [11, 20, 29]. The demand for individual components 12-24-month-olds (27 children), 25-36-month-olds estimation of the values of the nutritional indexes As was observed, both the boys’ and girls’ DFR changes depending on one’s age, growth rate, body (19 children) and 37-48-month-olds (29 children). The under investigation and the minimum size of the was characterised by an excessive supply of protein build and physical activity. It is very important to first two subgroups consisted of children staying at population subgroup calculated for the error was – at least 83% more than the RDA. The analysis of maintain adequate proportions between nutrients, to home with their parents or legal guardians. Children 16 people. The results were analysed statistically. variance did not reveal an interaction between the consume products from all groups, to diversify meals attending to several nursery schools in Poznan were The arithmetic mean and standard deviation were investigated factors in their effect on the consumption and to serve products free from microorganisms and recruited to the subgroup aged 37-48 months. The calculated. The two-way analysis of variance was used of macronutrients. contaminations regularly, at specific times of the day. children’s age was the criterion for inclusion into to investigate significant differences in the content of Apart from parents and legal guardians, public day- the group under study (12-48 months), whereas the care centres for children play an important role in exclusion criterion was the children’s illnesses, which Table 1. The characteristics of the children group under study developing adequate feeding habits. In Poland about caused the need to apply a different nutrition than oral 12-24 months 25-36 months 37-48 months 70% of children aged 3-6 years attend nursery schools nutrition. The study was conducted in April 2014. Total girls boys total girls boys total girls boys [22]. Appropriate nutrition is an important aspect of n 27 9 18 19 12 7 29 18 11 children’s stay in nursery schools, because they spend MATERIAL AND METHODS * a b c most of the day there and the meals they receive are body weight [kg] 12.1±2.0 11.2±1.4 12.5±2.1 14.0±1.8 14.3±1.5 13.5±2.3 15.2±2.2 14.8±2.3 15.9±2.0 * a b c the basis of all-day nutrition. Therefore, it is important Anthropometric test height [cm] 85.6±3.9 84.6±4.5 86.2±3.5 94.4±4.0 94.4±3.2 94.5±5.4 98.7±4.3 98.9±3.2 98.3±5.3 that meals served both at home and in nursery schools Anthropometric measurements were made LA 1.3±1.2b 1.6±1.4 1.1±1.0 1.3±1.0a 1.3±0.9 1.3±1.2 0.0±0.8a 0.1±0.8 -0.1±0.9 provide the amounts of energy and nutrients which are according to the generally accepted methodology, in WA * 0.9±0.8b 1.0±0.7 0.9±0.9 1.0±1.0b 1.2±0.8 0.6±0.9 0.1±1.0a -0.1±1.0 0.4±0.9 adequate to children’s age [7]. the morning, without outerwear and shoes. The height BMI 16.4±2.6 15.7±2.0 16.8±2.8 15.6±1.2 15.8±1.3 15.3±0.9 15.6±1.8 15.1±2.0 15.1±2.0 Data on the nutritional value of daily food rations and body weight were measured on medical scales (DFR) of children aged 1-4 years are incomplete [5]. with an accuracy of 0.10 cm (body height) and 0.10 kg BMI z-score* 0.1±1.6 -0.3±1,7 0.3±1.6 0.0±1.1 0.3±1.1 -0.6±0.9 0.0±1.4 -0.3±1.6 0.7±0.9 In view of the important role of public institutions *(a,b,c)statistically significant differences between age groups (p < 0.01) BMI z-score* - body mass index-for-age; LA- length/height-for-age; WA - weight-for-age 170 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 171

Wyniki Zarówno płeć jak i wiek dzieci nie miały wpływu na wielkość pobrania energii i makroskładników, która z wyjąt- (body weight). The anthropometric data gathered in the energy, nutrients and vitamins in the DFR, where the kiem energii (68% - 101,8 % RDA) i białka (183 – 288% RDA) była ogólnie prawidłowa ale miały wpływ na zawartość research were used to calculate the body mass index significance level was p ≤ 0.05. Pearson’s test was witamin w CRP. CRP charakteryzowało się ogólnie zbyt wysoką zawartością witaminy A, B2, B6 i B12, przy czym istotnie (BMI) values (kg/m2) . Then they were standardised used to calculate the correlation coefficients for the wyższe pobranie w stosunku do RDA zanotowano w CRP dzieci najmłodszych (12- 24 mce), w stosunku do grupy w wieku with reference to the WHO growth charts. For each dependences between the body weight, body height 37-48 mcy w przypadku witaminy B (317% vs. 137% RDA) i B (334% vs. 147% RDA). Z kolei CRP dostarczyły zbyt 2 6 child a standardised body mass index z-score and and individual components of the DFR. Microsoft małe w stosunku do RDA ilości witamin D, E, folianów oraz witaminy C. Stwierdzono, że CRP dzieci najmłodszych (12- percentile values of the body weight, body height and Excel ver 2007 and Statistica 10.0 Pl programs were 24 mce) zawierały znacząco wyższe ilości witamin: D (41,3% vs.16,2% RDA), E (83,6% vs. 63,5% RDA) i C (102,0% vs. 48,6% RDA) w stosunku do dzieci w wieku (37- 48 mcy). Zbliżone lub nieco wyższe w stosunku do RDA zawartości body mass index were calculated. used for statistical analysis, where the significance level was p ≤ 0.05. witamin w CRP dzieci zanotowano tylko dla witaminy B1 i PP. Wnioski. Ilość pobranej energii w CRP dzieci w wieku 1-4 lat była ogólnie porównywalna, przy czym u dzieci w wieku Assessment of energy intake and consumption of 37-48 mcy nie pokryła dziennego zapotrzebowania. Podaż makroskładników odżywczych we wszystkich badanych gru- nutrients RESULTS pach pokrywała zapotrzebowanie w około 100%, a w przypadku białka i sacharozy w nadmiarze. Dzieci w wieku 12-24 The assessment of the children’s nutrition was mcy spożywały więcej witamin D, E, B2, PP, B6, B12, C w porównaniu z dziećmi w wieku 37-48 mcy. Podaż witamin D, E, based on 24h - records of the 75 children’s menus, Table 1 shows the characteristics of the group of C i folianów była zbyt niska w stosunku do norm, a spożycie witamin: B2, B6 i B12 pokrywało zalecane dzienne spożycie which their guardians made by means of current children under study. Each child’s state of nutrition w nadmiarze. note taking for seven consecutive days. The data on was assessed by means of sex-and-age-independent the amount of consumed portions were obtained by body mass index z-score. 57.3% of the children were Słowa kluczowe: żywienie, dzieci, witaminy, spożycie weighing ready meals and leavings. The data gathered in a normal state of nutrition and their BMI z-score in this way were used to estimate the daily food ration ranged from -1.0 to +1.0. Low body weight (BMI INTRODUCTION and parents in developing feeding habits the aim of (DFR) and its energetic and nutritional value was z-score between -2.0 and-1.0) was observed in 17.3% this study was an assessment of the supply of energy, calculated by means of the ‘Dietetyk 2’ nutritional of the children, whereas very low body weight (BMI The first three years in a child’s life is a period macronutrients and vitamins in DFRs of children aged computer program. The calculations allowed for z-score <-2.0) was observed in 4.0% of the children. of particularly intensive physical, intellectual and 1-4 years fed at home and in nursery schools. The culinary and technological losses. An equal loss Overweight and obesity was observed in 20.0% and motoric development. During this period the manner aim of the study was to determine the influence of of 10% was assumed for the energetic value, total 1.3% of the children, respectively. The children aged of children’s nutrition changes from the one that is sex and age on the intake of energy, macronutrients protein, fats, carbohydrates and vitamins B6, B12 and 37-48 months were characterised by much lower typical of infanthood to the manner of nutrition which and vitamins in the daily food rations of children aged D. Due to the diversified sensitivity of other vitamins WA (weight-for-age) and LA (length/height-for-age) is typical of adults although a three-year-old child 1-4 years with reference to the recommended daily to factors observed in the culinary processing of than the younger children. Tables 2 and 3 show the has different demand for nutrients than an adult [10]. allowance (RDA) for a particular age group. food the content of vitamin A was reduced by 20%, results. The energy intake was comparable in all the An inadequate amount of nutrients may permanently riboflavin and niacin – by 25%, vitamin E – by 30%, age groups, but in the group of 37-48-month-olds change metabolism and the course of physiological Population under study folates – by 40%, vitamin C – by 55% [16]. The values it was about 30% lower than the RDA. In all the processes and in consequence, it may increase the The Bioethical Commission, Medical University of consumption which differed by ± 10% from the groups under investigation the consumption of fat and child’s predisposition to obesity at a later period in of Poznań gave the permission for the study (No. standard values were regarded as adequate. carbohydrates in the DFR was similar and covered life. Apart from basic nutrients, such as proteins, fats 871/10). The study was conducted in 75 children aged about 100% of the demand. Neither the children’s age and carbohydrates, it is also vitamins and minerals that 1-4 years living in Poznan and the surrounding area. Statistical analysis nor sex (independent of each other) had significant are particularly important for the child’s development The population was divided into three age subgroups: This study assumed a 15% standard error in the influence on the intake of energy and macronutrients. [11, 20, 29]. The demand for individual components 12-24-month-olds (27 children), 25-36-month-olds estimation of the values of the nutritional indexes As was observed, both the boys’ and girls’ DFR changes depending on one’s age, growth rate, body (19 children) and 37-48-month-olds (29 children). The under investigation and the minimum size of the was characterised by an excessive supply of protein build and physical activity. It is very important to first two subgroups consisted of children staying at population subgroup calculated for the error was – at least 83% more than the RDA. The analysis of maintain adequate proportions between nutrients, to home with their parents or legal guardians. Children 16 people. The results were analysed statistically. variance did not reveal an interaction between the consume products from all groups, to diversify meals attending to several nursery schools in Poznan were The arithmetic mean and standard deviation were investigated factors in their effect on the consumption and to serve products free from microorganisms and recruited to the subgroup aged 37-48 months. The calculated. The two-way analysis of variance was used of macronutrients. contaminations regularly, at specific times of the day. children’s age was the criterion for inclusion into to investigate significant differences in the content of Apart from parents and legal guardians, public day- the group under study (12-48 months), whereas the care centres for children play an important role in exclusion criterion was the children’s illnesses, which Table 1. The characteristics of the children group under study developing adequate feeding habits. In Poland about caused the need to apply a different nutrition than oral 12-24 months 25-36 months 37-48 months 70% of children aged 3-6 years attend nursery schools nutrition. The study was conducted in April 2014. Total girls boys total girls boys total girls boys [22]. Appropriate nutrition is an important aspect of n 27 9 18 19 12 7 29 18 11 children’s stay in nursery schools, because they spend MATERIAL AND METHODS * a b c most of the day there and the meals they receive are body weight [kg] 12.1±2.0 11.2±1.4 12.5±2.1 14.0±1.8 14.3±1.5 13.5±2.3 15.2±2.2 14.8±2.3 15.9±2.0 * a b c the basis of all-day nutrition. Therefore, it is important Anthropometric test height [cm] 85.6±3.9 84.6±4.5 86.2±3.5 94.4±4.0 94.4±3.2 94.5±5.4 98.7±4.3 98.9±3.2 98.3±5.3 that meals served both at home and in nursery schools Anthropometric measurements were made LA 1.3±1.2b 1.6±1.4 1.1±1.0 1.3±1.0a 1.3±0.9 1.3±1.2 0.0±0.8a 0.1±0.8 -0.1±0.9 provide the amounts of energy and nutrients which are according to the generally accepted methodology, in WA * 0.9±0.8b 1.0±0.7 0.9±0.9 1.0±1.0b 1.2±0.8 0.6±0.9 0.1±1.0a -0.1±1.0 0.4±0.9 adequate to children’s age [7]. the morning, without outerwear and shoes. The height BMI 16.4±2.6 15.7±2.0 16.8±2.8 15.6±1.2 15.8±1.3 15.3±0.9 15.6±1.8 15.1±2.0 15.1±2.0 Data on the nutritional value of daily food rations and body weight were measured on medical scales (DFR) of children aged 1-4 years are incomplete [5]. with an accuracy of 0.10 cm (body height) and 0.10 kg BMI z-score* 0.1±1.6 -0.3±1,7 0.3±1.6 0.0±1.1 0.3±1.1 -0.6±0.9 0.0±1.4 -0.3±1.6 0.7±0.9 In view of the important role of public institutions *(a,b,c)statistically significant differences between age groups (p < 0.01) BMI z-score* - body mass index-for-age; LA- length/height-for-age; WA - weight-for-age 172 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 173 a a a a b b

Table 2. The influence of investigated factors on the intake of energy and selected nutrients in the daily food rations of ab ab ab 58.8 92.6 children aged 1-4 years 74.7 48.6 89.5 42.1 94.3 44.9 53.7 102.0 130.0

Energy Protein Fat Cholesterol Carbohy- Sucrose (mg) 16.85±7.92

Experimental factor C Vitamin 27.91±16.07 34.03±20.41 22.45±10.10 26.84±10.96 24.30 ± 10.41 52.22±28.26 (kcal) (g) (g) (mg) drates (g) (g) 40.80 ± 22.33 35.81±18.01 37.72±19.07 29.89 ± 18.65 a b ab 12 414 346 301 614 158 192 Sex (A) 393 496 172 291.1 348.1

mean ±SD 1008.78±236.09 41.68±13.42 39.57±12.88 170.97±98.03 130.09±27.47 25.64±10.10 (µg) 2.94±2.02 3.31±4.69 3.75±2.51 3.12±1.70 2.72±1.00 5.53±8.43 1.90±0.95 2.30±0.90 2.07 ± 0.93 Boys A 3.54 ± 2.27 1 % RDA 90.4 269 101.8 - 100.1 - 4.47 ± 6.71 Vitamin B Vitamin mean ±SD 967.90±242.10 37.62±10.86 164.36±58.67 131.50±34.03 27.91±13.52 a a a b

Girls A 36.45±11.4993.8 ab ab 2 % RDA 87.7 229 - 101.2 - 45.6 62.5 67.2 60.0 35.5 61.7 79.7 39.6 72.2 35.4 35.6 Age (B) (µg) Folates 79.20±30.08 93.10±43.14 mean ±SD 1017.74±219.42 40.37±11.40 38.34±11.32 178.23±109.06 137.21±26.31 26.01±8.67 89.97 ± 47.91 70.93 ± 21.47 59.35±12.81 70.69±24.87 71.25±17.36 100.73 ± 40.26 92.48±32.63 12-24 months B1 119.57±51.84 % RDA 101.8 288 86.3 - 105.6 - 108.34±52.29 a a a b b mean ±SD 1009.87±213.72 40.23±10.48 38.55±13.25 162.41±4±9.44 135.12±30.49 30.85±11.62 ab ab ab ab 25-36 months B 6 2 % RDA 101.0 287 86,7 - 103.9 - 334 253 147 335 330 243 259 142 155 239.8 248.0 mean ±SD 951.74±266.89 38.62±14.02 37.34±12.66 161.96±66.28 123.37±33.56 25.21±14.06 (mg) 1.32±0.80 1.20±0.65 0.85±0.29 0.93±0.15 0.88 ± 0.24 1.68±0.94 37-48 months B3 1.67 ± 0.94 1.65±1.03 1.22±0.64 1.30±0.59 % RDA 67.9 183 112.1 - 94.9 - 1.27 ± 0.59 Vitamin B Vitamin a Interaction of factors (AxB) b ab 70.0 82.7 75.4 115.3 151.0 121.0 124.5 100.5 101.5 mean ±SD 1061.85±206.71 43.89±11.35 40.60±10.51 186.79±121.33 139.81±26.69 27.29±8.16 143.3 109.5 A B 1 1 % RDA 106.2 313 91.4 - 107.5 - 6.61±1.20 9.10±4.38 7.26±2.15 7.47±4.53 6.03±1.47 5.60±3.01 7.64±4.19 6.63±2.48 6.03 ± 2.42 8.60±3.94 (mg eq.) 6.57 ± 2.94 mean ±SD 916.91±229.49 32.32±6.77 33.19±12.23 158.67±78.49 131.27±26.43 23.08±9.75 PP Vitamin A2B1 a % RDA 91.7 230 90.5 - 101.0 - b ab 142 352 238 235 279 133 317 263 137 240.2 mean ±SD 967.83±265.73 44.98±14.38 39.35±18.93 152.89±48.25 115.46±16.91 26.30±13.04 219.5 A1B2 2 % RDA 96.8 321 74.9 - 88.8 - B (mg) 1.76±1.69 1.19±0.54 1.18±0.57 1.40±0.74 0.80±0.37 0.85±0.25 1.34±1.27 1.08±0.57 0.82 ± 0.32 Vitamin 1.59 ± 1.45 mean ±SD 1035.09±187.12 37.38±6.65 38.07±9.64 168.12±51.81 146.92±31.27 33.58±10.41 1.32 ± 0.67 A B 2 2 % RDA 103.5 267 85.7 - 113.0 - 77 78 79 119 142 132 134 126 133 Sex mean ±SD 953.90±264.86 36.68±15.42 38.20±13.51 157.83±81.96 123.92±29.70 22.87±11.32 Age 118.1 109.3

A B 1 1 3 % RDA 68.1 175 114.6 - 95.3 - B (mg) 0.60±0.25 0.71±0.28 0.66±0.66 0.67±0.36 0.46±0.16 0.47±0.14 0.56±0.33 0.59±0.28 0.63 ± 0.26 0.67 ± 0.47 0.47 ± 0.15 mean ±SD 950.42±275.77 39.81±13.41 36.81±12.48 164.48±57.16 123.02±36.55 26.64±15.63 Vitamin A B 2 3 % RDA 67.9 190 110.4 - 94.6 - a b ab SFA - saturated fatty acids; MFA - monounsaturated fatty acids, PFA - polyunsaturated fatty acids; - no data available in reference publications; Interaction of factors (AxB) 83.9 83.1 41.6 83.6 63.6 63.5 69.4 70.9 83.6 67.9 63.5 for energy EER (estimated energy requirement) is given; for fat RI (reference intake) is given (mg) 5.03±1.79 4.99±0.57 2.49±0.45 5.02±3.88 3.81±0.98 3.81±1.82 4.16±1.66 4.25±2.39 3.81 ± 1.35 5.02 ± 1.51 4.07 ± 3.27 The consumption of vitamins in the children’s DFR 48 months. In comparison with the RDA, the children’s E Vitamin a a a a was diversified, depending on the vitamin type, child’s DFR provided similar or slightly greater amounts of b b b ab ab 41.3 20.9 16.2 39.4 45.8 12.6 25.8 12.5 21.4 25.5 age and sex. It was adequate, too high or too low in only vitamins B1 (79.0-133%) and PP (75.4-143.3%). 24.0 comparison with the recommended amounts. In general The analysis of variance revealed the occurrence (µg) 3.83±3.29 3.59±2.82 2.43 ± 2.15 1.89±1.19 1.87±1.90 3.21±2.36 6.20 ± 2.95 5.90±3.36 6.87±1.69 3.13 ± 2.41 the DFR was characterised by too high content of vitamin of interactions between the investigated factors in 3.88±2.69 Vitamin D Vitamin

A (134-181% RDA), B2 (137-317% RDA), B6 (147- their effect on the children’s consumption of vitamins 334% RDA) and B (172-496% RDA). In comparison D, B and C and folates. As was observed, both the 181 168 134 175 12 6 196 121 196 134 136 143.3 with the RDA the intake was significantly greater in the boys and girls in the youngest group consumed much 176.1

DFR of the youngest children (12-24-month-olds). As more vitamin D than the boys aged 25-36 months and A (µg) Vitamin Vitamin

far as the children aged 37-48 months are concerned, the boys and girls aged 37-48 months. The youngest 686.5±482.79 786.5±629.93 727.88±383.25 674.21 ± 519.59 606.87 ± 366.38 630.99±344.27 703.31±395.71 784.03±376.58 486.97±168.32 604.34±329.57 610.34±435.88 the intake of vitamins B2 (317% vs 137% RDA) and boys’ DFR was characterised by a higher content of

B6 (334% vs 147% RDA) was too high. On the other vitamin B6 than the oldest boys’ and girls’ DFR. The hand, in comparison with the RDA, the DFR provided content was about 98% and 81% greater, respectively. too small amounts of vitamins D (16.2-41.3%), E The analysis of interactions between the sex and age (63.5-83,6%), folates (35.5-67.2%) and vitamin C revealed that the consumption of folates and vitamin C mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA mean ±SD % RDA

(48.6-102.0%). The youngest children’s (12-24-month- by the 12-24-month-old girls was significantly greater 1 1 2 2 3 3 1 2 3 1 2 B B B B B B 1 olds) DFRs were found to contain significantly greater than the consumption by 25-36-month-old boys and 2 1 2 1 2 A A A A A A amounts of vitamins D (41.3% vs 16.2% RDA), E 37-48-month-old children. The difference was about (83.6% vs 63.5% AI) and C (102.0% vs 48.6% RDA), 101% and 68%, respectively; for folates - 209% and as compared with the DFRs of the children aged 37- 170%, respectively. Experimental factor Girls A Girls 12-24 months B 25-36 months B 37-48 months B Boys A Boys Table 3. The influence of investistigated factors on the intake vitamins in daily food rations children aged 1-4 years 3. Table AI (adequate intake) is given p<0.05 for vitamin E % 172 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 173 a a a a b b

Energy Protein Fat Cholesterol Carbohy- Sucrose (mg) 16.85±7.92

Girls A 36.45±11.4993.8 ab ab 2 % RDA 87.7 229 - 101.2 - 45.6 62.5 67.2 60.0 35.5 61.7 79.7 39.6 72.2 35.4 35.6 Age (B) (µg) Folates 79.20±30.08 93.10±43.14 mean ±SD 1017.74±219.42 40.37±11.40 38.34±11.32 178.23±109.06 137.21±26.31 26.01±8.67 89.97 ± 47.91 70.93 ± 21.47 59.35±12.81 70.69±24.87 71.25±17.36 100.73 ± 40.26 92.48±32.63 12-24 months B1 119.57±51.84 % RDA 101.8 288 86.3 - 105.6 - 108.34±52.29 a a a b b mean ±SD 1009.87±213.72 40.23±10.48 38.55±13.25 162.41±4±9.44 135.12±30.49 30.85±11.62 ab ab ab ab 25-36 months B 6 2 % RDA 101.0 287 86,7 - 103.9 - 334 253 147 335 330 243 259 142 155 239.8 248.0 mean ±SD 951.74±266.89 38.62±14.02 37.34±12.66 161.96±66.28 123.37±33.56 25.21±14.06 (mg) 1.32±0.80 1.20±0.65 0.85±0.29 0.88 ± 0.24 0.93±0.15 1.68±0.94 37-48 months B3 1.67 ± 0.94 1.65±1.03 1.22±0.64 1.30±0.59 % RDA 67.9 183 112.1 - 94.9 - 1.27 ± 0.59 Vitamin B Vitamin a Interaction of factors (AxB) b ab 70.0 75.4 82.7 115.3 151.0 121.0 124.5 100.5 101.5 mean ±SD 1061.85±206.71 43.89±11.35 40.60±10.51 186.79±121.33 139.81±26.69 27.29±8.16 143.3 109.5 A B 1 1 % RDA 106.2 313 91.4 - 107.5 - 9.10±4.38 7.26±2.15 7.47±4.53 6.03±1.47 5.60±3.01 6.61±1.20 7.64±4.19 6.63±2.48 6.03 ± 2.42 8.60±3.94 (mg eq.) 6.57 ± 2.94 mean ±SD 916.91±229.49 32.32±6.77 33.19±12.23 158.67±78.49 131.27±26.43 23.08±9.75 PP Vitamin A2B1 a % RDA 91.7 230 90.5 - 101.0 - b ab 352 238 235 279 133 142 317 263 137 240.2 mean ±SD 967.83±265.73 44.98±14.38 39.35±18.93 152.89±48.25 115.46±16.91 26.30±13.04 219.5 A1B2 2 % RDA 96.8 321 74.9 - 88.8 - B (mg) 1.76±1.69 1.19±0.54 1.18±0.57 1.40±0.74 0.80±0.37 0.85±0.25 1.34±1.27 1.08±0.57 0.82 ± 0.32 Vitamin 1.59 ± 1.45 mean ±SD 1035.09±187.12 37.38±6.65 38.07±9.64 168.12±51.81 146.92±31.27 33.58±10.41 1.32 ± 0.67 A B 2 2 % RDA 103.5 267 85.7 - 113.0 - 77 78 79 119 142 132 134 126 133 Sex mean ±SD 953.90±264.86 36.68±15.42 38.20±13.51 157.83±81.96 123.92±29.70 22.87±11.32 Age 118.1 109.3

DFR of the youngest children (12-24-month-olds). As more vitamin D than the boys aged 25-36 months and A (µg) Vitamin Vitamin far as the children aged 37-48 months are concerned, the boys and girls aged 37-48 months. The youngest 686.5±482.79 786.5±629.93 727.88±383.25 674.21 ± 519.59 606.87 ± 366.38 630.99±344.27 703.31±395.71 784.03±376.58 486.97±168.32 604.34±329.57 610.34±435.88 the intake of vitamins B2 (317% vs 137% RDA) and boys’ DFR was characterised by a higher content of

(48.6-102.0%). The youngest children’s (12-24-month- by the 12-24-month-old girls was significantly greater 1 1 2 2 3 3 1 2 3 1 2 B B B B B B 1 olds) DFRs were found to contain significantly greater than the consumption by 25-36-month-old boys and 2 1 2 1 2 A A A A A A amounts of vitamins D (41.3% vs 16.2% RDA), E 37-48-month-old children. The difference was about (83.6% vs 63.5% AI) and C (102.0% vs 48.6% RDA), 101% and 68%, respectively; for folates - 209% and as compared with the DFRs of the children aged 37- 170%, respectively. Experimental factor Girls A Girls 12-24 months B 25-36 months B 37-48 months B Boys A Boys Table 3. The influence of investistigated factors on the intake vitamins in daily food rations children aged 1-4 years 3. Table AI (adequate intake) is given p<0.05 for vitamin E % 174 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 175

DISCUSSION DFRs was generally adequate and it ranged from Vitamin D is one of more significant factors increases the absorption of calcium and iron, which about 33.9% to 35.3% of the energy intake. Trafalska which are necessary for normal absorption of calcium is necessary for the production of red blood cells. Energy is necessary to regulate biochemical et al. [23] observed that the content of fat in the food from the alimentary tract. The absorption of calcium In this research the demand for vitamin C was fully processes in the organism, sustain physiological rations of children aged 13-36 months was 30 g per ranges from 10% to 80%, depending on the supply satisfied only in the youngest group of children. There functions, the organism structure, growth and all day and it amounted to about 31.1% of total energy. of vitamin D in the organism. Disruption of calcium was a low supply of the vitamin observed in the physical activity [10]. The daily demand for energy is In the study by Smorczewska-Czupryńska et al. [27] homeostasis caused by deficient vitamin D may cause other children’s DFRs, i.e. about 60% of the RDA. 1000 kcal in children aged 1-3 years and 1400 kcal 92% of the demand for fat was satisfied. The highest disorders of calcium and phosphate metabolism and in Insufficient consumption of this vitamin was also in children aged 4 years. This study proved that the coverage of the allowance, i.e. 180% in the food consequence, it may cause bone diseases [11, 14, 19]. noted in the studies by Orkusz and Włodarczyk [21]. energy intake in the DFR was generally adequate in rations in nursery schools was proved by Dymkowska- The supply of vitamin D in the DFRs of the children Sadowska and Krzymuska [25] observed that the low the children aged 1-3 years, but it was lower in the Malesa and Szparaga [3]. aged 1-4 years was too low and it amounted only to consumption of vitamin C was caused by the fact that children aged 4 years. It was caused by the fact that the Carbohydrates should provide 55-60% of energy 1-41% of the RDA. In the studies by Dymkowska- children were reluctant to eat vegetables. Leszczyńska pre-school children ate only a portion servings. This in a child’s DFR. They are necessary elements of Malesa and Szparaga [3] and Sochacka-Tatara et al. et al. [18] reported that the content of vitamin C in food can be explained by other dietary preferences or the a child’s DFR, because they are the basic energetic [28] the content of vitamin D in food rations was also rations in nursery schools depended on the season of stress of separation from their parents. The study by material in the human organism. Too small supply of low (11.2% RDA). the year. In spring 50% of the demand for vitamin C Weker et al. [35] revealed that the energetic value of carbohydrates has negative influence on metabolic A DFR with a low content of vitamin E is was satisfied, in autumn and winter – 44%, whereas the DFR consumed by children in Warsaw crèches was processes in the system and causes disorders in fat particularly unfavourable to the development of it was the lowest in summer – 35%. Trafalska et al. 20% greater than the recommended value. Trafalska and protein metabolism. This study proved that the children, especially neonates, because it may cause [23] analysed the nutritional value of crèche children’s et al. [23] observed that the energy content differed in total share of carbohydrates in the DFR was adequate. anaemia, visual disorders (retinopathy, fibroplasia), food rations and they proved that nearly 100% of the individual decades and it ranged from 442.8 kcal per However, their structure was inadequate due to the bronchopulmonary dysplasia and sudden death [4]. demand for vitamin C was satisfied. On the contrary, day to 1507.0 kcal per day. Smorczewska-Czupryńska high share of sucrose, i.e. about 20% of total energy. The deficiency of vitamins E and C in the organism Dymkowska-Malesa and Szparaga [3] proved et al. [27] assessed nutrition in crèches in Białystok Similarly, Hamułka et al. [8, 9] observed that there causes reduced immunity to infections, which can a relatively high content of vitamin C, i.e. 120.6 mg and they found that the energy intake was about 100 was too high supply of sucrose in the DFR of children be observed in impaired phagocyte activity [13]. per day. In the study by Sochacka-Tatara et al. [28] the kcal greater than the recommended value. On the aged 1-6 years. Trafalska et al. [23] observed that the The consumption of vitamin E by the population of consumption of vitamin C exceeded the recommended other hand, Sadowska and Krzymuska [25] proved supply of carbohydrates was slightly lower than the children aged 1-4 years under study did not satisfy the allowance twice. The demand was satisfied in a slightly that the energetic value of the meals consumed in recommended allowance (i.e. 130 g) and it amounted recommended demand of 6 mg per day. The studies lower degree (177% RDA) in the study by Grajeta nursery schools in Szczecin was 10% greater than to 120.8 g. On the other hand, Weker et al. [35] proved by Sadowska et al. [26] and Grajeta et al. [7] revealed et al. [7]. Weker et al. [30, 31] analysed the manner the allowance. In the study by Czerwonogrodzka- that crèche children’s food rations provided 142.4 g of that the supply of this vitamin was adequate or even of nutrition of 400 children aged 13-36 months and Senczyna et al. [2] the researchers observed that the carbohydrates. slightly higher and it amounted to 125% and 120% of they observed that both the supply of vitamin C and average supply of energy in the DFR of children aged This study proved that neither the children’s the AI, respectively. B vitamins exceeded the recommended allowance. 1-3 years with simple obesity was high and amounted sex nor age had influence on the consumption of B vitamins are necessary for optimal functioning of The authors suggested that it was caused by the high to 156% of the allowance. macronutrients in the DFR, but they influenced the the central nervous system, because they have accessory share of enriched food in the children’s DFR (60% Adequate consumption of protein according to consumption of vitamins. The children aged 12-24 functions in the production of neurotransmitters. The of the children), including food products for special the demand is of primary importance to human health. months were observed to take much more vitamins in analysis of the DFR of the children aged 1-4 years nutritional purposes for infants and small children. Proteins are necessary for the growth of young organisms, their total DFR than the children aged 37-48 months. revealed that the content of B vitamins, especially but their excess in the DFR burdens the kidneys and liver It was caused by the fact that the younger children’s vitamins B2, B6, B12, considerably exceeded the CONCLUSIONS and it may cause metabolic disorders and atherosclerotic menu included products for special nutritional recommended daily allowance of food, except folates processes in adulthood [28]. Excessive supply of protein purposes, such as modified milk or cereals enriched (vitamin B9). Dymkowska-Malesa and Szparaga [3], 1. The intake of energy in the DFRs of the children is commonly observed in children. The average daily with some vitamins. The share of these products in the Sadowska et al. [26] and Kucharska et al. [15] obtained aged 1-4 years was generally comparable, but it content of protein in the DFR of the children aged 1-4 children’s DFR decreased as they grew older in favour similar results in their analyses of food rations in did not satisfy the daily demand in the children years in this study was 39 g. It was much greater than of the products typical of adults’ food rations. nursery schools. In our research only the consumption aged 37-48 months. the recommended allowance (RDA), i.e. 14 g per day Both the excess and deficit of vitamin A contributes of vitamin B1 in the group of three-year-olds was similar 2. In all the age groups under study the supply and 21 g per day for children aged 1-3 years and 4 years, to many irregularities: liver function disorders, loss of to the recommended value and it amounted to about of macronutrients satisfied about 100% of the respectively. Similarly, Trafalska et al. [25] analysed the appetite, growth restriction or visual problems. The 93.2%. Sochacka-Tatara et al. [28] also observed that demand, whereas the supply of protein and sucrose nutritional value of the DFR of crèche children and they DFRs of the children aged 1-4 years were generally on average the supply of vitamin B1 satisfied 91% of was excessive. observed that the content of protein in the DFR was too characterised by excessive supply of vitamin A (134- the demand and simultaneously, there was excessive 3. The DFRs of the children aged 12-24 months 181% RDA). Dymkowska-Malesa and Szparaga [3] supply of vitamin B . Leszczyńska et al. [18] found high (32.8 g per day) and it concerned 65% of DFRs in 12 contained more vitamins D, E, B2, PP, B6, B12, C the crèches under study. analysed the supply of vitamins in a nursery school that meals in nursery schools sufficiently satisfied the than the DFRs of the children aged 37-48 months. The amount of energy from fat in the DFR of in Koszalin and they also found that the intake of demand for thiamine and riboflavin. Górnicka et al. [6] The supply of vitamins D, E, C and folates in the children aged 1-3 years assumed to be 40% and 30% vitamin A exceeded the recommended allowance by found in their study that the consumption of folates, DFRs was too low, whereas the supply of vitamins 76% on average. Excessive consumption of vitamin which are responsible for normal development of the for 4-year-olds [10]. Children’s and young people’s B2, B6 and B12 was too high in comparison with excessive consumption of energetic nutrients, A in nursery school children’s food rations was also nervous system and haematopoietic processes, was too recommended allowances. especially animal fats and refined carbohydrates observed in the studies by Orkusz and Włodarczyk low. The authors proved that only 2 out of 5 nursery 4. About 42.7% of the children under study were increases the total caloricity of food and contributes to [21], Sadowska et al. [26] and Grajeta et al. [7]. Like schools satisfied the daily demand for folates. characterised by an abnormal state of nutrition. overweight and obesity by increasing the number of fat in this study, Trafalska [24] proved that the supply of Vitamin C participates in the production of 5. An inadequately balanced DFR needs to be cells which are metabolically active during the whole vitamin A considerably exceeded the recommended immunoglobulins and increases immunity to some corrected by educating parents or guardians in human life [10]. The amount of fat in the children’s values in 30 crèches in Łódź. viral and bacterial diseases [17]. Apart from that, it appropriate nutrition. 174 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 175

DISCUSSION DFRs was generally adequate and it ranged from Vitamin D is one of more significant factors increases the absorption of calcium and iron, which about 33.9% to 35.3% of the energy intake. Trafalska which are necessary for normal absorption of calcium is necessary for the production of red blood cells. Energy is necessary to regulate biochemical et al. [23] observed that the content of fat in the food from the alimentary tract. The absorption of calcium In this research the demand for vitamin C was fully processes in the organism, sustain physiological rations of children aged 13-36 months was 30 g per ranges from 10% to 80%, depending on the supply satisfied only in the youngest group of children. There functions, the organism structure, growth and all day and it amounted to about 31.1% of total energy. of vitamin D in the organism. Disruption of calcium was a low supply of the vitamin observed in the physical activity [10]. The daily demand for energy is In the study by Smorczewska-Czupryńska et al. [27] homeostasis caused by deficient vitamin D may cause other children’s DFRs, i.e. about 60% of the RDA. 1000 kcal in children aged 1-3 years and 1400 kcal 92% of the demand for fat was satisfied. The highest disorders of calcium and phosphate metabolism and in Insufficient consumption of this vitamin was also in children aged 4 years. This study proved that the coverage of the allowance, i.e. 180% in the food consequence, it may cause bone diseases [11, 14, 19]. noted in the studies by Orkusz and Włodarczyk [21]. energy intake in the DFR was generally adequate in rations in nursery schools was proved by Dymkowska- The supply of vitamin D in the DFRs of the children Sadowska and Krzymuska [25] observed that the low the children aged 1-3 years, but it was lower in the Malesa and Szparaga [3]. aged 1-4 years was too low and it amounted only to consumption of vitamin C was caused by the fact that children aged 4 years. It was caused by the fact that the Carbohydrates should provide 55-60% of energy 1-41% of the RDA. In the studies by Dymkowska- children were reluctant to eat vegetables. Leszczyńska pre-school children ate only a portion servings. This in a child’s DFR. They are necessary elements of Malesa and Szparaga [3] and Sochacka-Tatara et al. et al. [18] reported that the content of vitamin C in food can be explained by other dietary preferences or the a child’s DFR, because they are the basic energetic [28] the content of vitamin D in food rations was also rations in nursery schools depended on the season of stress of separation from their parents. The study by material in the human organism. Too small supply of low (11.2% RDA). the year. In spring 50% of the demand for vitamin C Weker et al. [35] revealed that the energetic value of carbohydrates has negative influence on metabolic A DFR with a low content of vitamin E is was satisfied, in autumn and winter – 44%, whereas the DFR consumed by children in Warsaw crèches was processes in the system and causes disorders in fat particularly unfavourable to the development of it was the lowest in summer – 35%. Trafalska et al. 20% greater than the recommended value. Trafalska and protein metabolism. This study proved that the children, especially neonates, because it may cause [23] analysed the nutritional value of crèche children’s et al. [23] observed that the energy content differed in total share of carbohydrates in the DFR was adequate. anaemia, visual disorders (retinopathy, fibroplasia), food rations and they proved that nearly 100% of the individual decades and it ranged from 442.8 kcal per However, their structure was inadequate due to the bronchopulmonary dysplasia and sudden death [4]. demand for vitamin C was satisfied. On the contrary, day to 1507.0 kcal per day. Smorczewska-Czupryńska high share of sucrose, i.e. about 20% of total energy. The deficiency of vitamins E and C in the organism Dymkowska-Malesa and Szparaga [3] proved et al. [27] assessed nutrition in crèches in Białystok Similarly, Hamułka et al. [8, 9] observed that there causes reduced immunity to infections, which can a relatively high content of vitamin C, i.e. 120.6 mg and they found that the energy intake was about 100 was too high supply of sucrose in the DFR of children be observed in impaired phagocyte activity [13]. per day. In the study by Sochacka-Tatara et al. [28] the kcal greater than the recommended value. On the aged 1-6 years. Trafalska et al. [23] observed that the The consumption of vitamin E by the population of consumption of vitamin C exceeded the recommended other hand, Sadowska and Krzymuska [25] proved supply of carbohydrates was slightly lower than the children aged 1-4 years under study did not satisfy the allowance twice. The demand was satisfied in a slightly that the energetic value of the meals consumed in recommended allowance (i.e. 130 g) and it amounted recommended demand of 6 mg per day. The studies lower degree (177% RDA) in the study by Grajeta nursery schools in Szczecin was 10% greater than to 120.8 g. On the other hand, Weker et al. [35] proved by Sadowska et al. [26] and Grajeta et al. [7] revealed et al. [7]. Weker et al. [30, 31] analysed the manner the allowance. In the study by Czerwonogrodzka- that crèche children’s food rations provided 142.4 g of that the supply of this vitamin was adequate or even of nutrition of 400 children aged 13-36 months and Senczyna et al. [2] the researchers observed that the carbohydrates. slightly higher and it amounted to 125% and 120% of they observed that both the supply of vitamin C and average supply of energy in the DFR of children aged This study proved that neither the children’s the AI, respectively. B vitamins exceeded the recommended allowance. 1-3 years with simple obesity was high and amounted sex nor age had influence on the consumption of B vitamins are necessary for optimal functioning of The authors suggested that it was caused by the high to 156% of the allowance. macronutrients in the DFR, but they influenced the the central nervous system, because they have accessory share of enriched food in the children’s DFR (60% Adequate consumption of protein according to consumption of vitamins. The children aged 12-24 functions in the production of neurotransmitters. The of the children), including food products for special the demand is of primary importance to human health. months were observed to take much more vitamins in analysis of the DFR of the children aged 1-4 years nutritional purposes for infants and small children. Proteins are necessary for the growth of young organisms, their total DFR than the children aged 37-48 months. revealed that the content of B vitamins, especially but their excess in the DFR burdens the kidneys and liver It was caused by the fact that the younger children’s vitamins B2, B6, B12, considerably exceeded the CONCLUSIONS and it may cause metabolic disorders and atherosclerotic menu included products for special nutritional recommended daily allowance of food, except folates processes in adulthood [28]. Excessive supply of protein purposes, such as modified milk or cereals enriched (vitamin B9). Dymkowska-Malesa and Szparaga [3], 1. The intake of energy in the DFRs of the children is commonly observed in children. The average daily with some vitamins. The share of these products in the Sadowska et al. [26] and Kucharska et al. [15] obtained aged 1-4 years was generally comparable, but it content of protein in the DFR of the children aged 1-4 children’s DFR decreased as they grew older in favour similar results in their analyses of food rations in did not satisfy the daily demand in the children years in this study was 39 g. It was much greater than of the products typical of adults’ food rations. nursery schools. In our research only the consumption aged 37-48 months. the recommended allowance (RDA), i.e. 14 g per day Both the excess and deficit of vitamin A contributes of vitamin B1 in the group of three-year-olds was similar 2. In all the age groups under study the supply and 21 g per day for children aged 1-3 years and 4 years, to many irregularities: liver function disorders, loss of to the recommended value and it amounted to about of macronutrients satisfied about 100% of the respectively. Similarly, Trafalska et al. [25] analysed the appetite, growth restriction or visual problems. The 93.2%. Sochacka-Tatara et al. [28] also observed that demand, whereas the supply of protein and sucrose nutritional value of the DFR of crèche children and they DFRs of the children aged 1-4 years were generally on average the supply of vitamin B1 satisfied 91% of was excessive. observed that the content of protein in the DFR was too characterised by excessive supply of vitamin A (134- the demand and simultaneously, there was excessive 3. The DFRs of the children aged 12-24 months 181% RDA). Dymkowska-Malesa and Szparaga [3] supply of vitamin B . Leszczyńska et al. [18] found high (32.8 g per day) and it concerned 65% of DFRs in 12 contained more vitamins D, E, B2, PP, B6, B12, C the crèches under study. analysed the supply of vitamins in a nursery school that meals in nursery schools sufficiently satisfied the than the DFRs of the children aged 37-48 months. The amount of energy from fat in the DFR of in Koszalin and they also found that the intake of demand for thiamine and riboflavin. Górnicka et al. [6] The supply of vitamins D, E, C and folates in the children aged 1-3 years assumed to be 40% and 30% vitamin A exceeded the recommended allowance by found in their study that the consumption of folates, DFRs was too low, whereas the supply of vitamins 76% on average. Excessive consumption of vitamin which are responsible for normal development of the for 4-year-olds [10]. Children’s and young people’s B2, B6 and B12 was too high in comparison with excessive consumption of energetic nutrients, A in nursery school children’s food rations was also nervous system and haematopoietic processes, was too recommended allowances. especially animal fats and refined carbohydrates observed in the studies by Orkusz and Włodarczyk low. The authors proved that only 2 out of 5 nursery 4. About 42.7% of the children under study were increases the total caloricity of food and contributes to [21], Sadowska et al. [26] and Grajeta et al. [7]. Like schools satisfied the daily demand for folates. characterised by an abnormal state of nutrition. overweight and obesity by increasing the number of fat in this study, Trafalska [24] proved that the supply of Vitamin C participates in the production of 5. An inadequately balanced DFR needs to be cells which are metabolically active during the whole vitamin A considerably exceeded the recommended immunoglobulins and increases immunity to some corrected by educating parents or guardians in human life [10]. The amount of fat in the children’s values in 30 crèches in Łódź. viral and bacterial diseases [17]. Apart from that, it appropriate nutrition. 176 K. Marcinek, R. Wojciech Wójciak, Z. Krejpcio No 2 No 2 Assessment of the nutritional value of daily food rations of children aged 1-4 years 177

Conflict of interest Hepatol Żywienie Dziecka 2006;7(3):246. 28. Sochacka-Tatara E., Jacek R., Sowa A., Musiał A.: Ocena W.: Źródła składników odżywczych w dietach dzieci The authors declare no conflict of interest. 13. Krzysik M., Biernat J., Grajeta H.: Wpływ sposobu żywienia dzieci w wieku przedszkolnym. Probl w wieku 13-36 miesięcy – badanie ogólnopolskie. wybranych składników odżywczych pożywienia na Hig Epidemiol 2008;89 (3):389-394. Bromat Chem Toksykol 2011;44(3):233-239. REFERENCES funkcjonowanie układu odpornościowego Cz. II. 29. Socha J., Socha P., Weker H., Neuhoff-Murawska 31. Weker H., Hamułka J., Więch M., Głowacka K.: Analysis Immunomodulacyjne działanie witamin i pierwiastków J.: Żywienie dzieci a zdrowie wczoraj, dziś i jutro. of nutrition of children in Warsaw day nurseries in 1. Charzewska J., Chwojnowska Z.: Rola witamin śladowych na organizm człowieka. Adv Clin Exp Med Pediatria Współ Gastroenterol, Hepatol Żywienie view of current recommendations. 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Kunachowicz H., Nadolna I., Przygoda B., Iwanow K.: 3. Dymkowska-Malesa M., Szparaga A.: Ocena spożycia Tabele składu i wartości odżywczej żywności. PZWL, wybranych witamin i składników mineralnych Warszawa, 13. 2005 w przedszkolnych racjach pokarmowych dzieci z terenu 17. Lebiedzińska A., Czaja J., Petrykowska K., Szefer P.: Koszalina. Nowa Ped 2013;3:106-110. Soki i nektary owocowe źródłem witaminy C. Bromat 4. Eitenmiller R.R., Ye L., Landen W.O.: Vitamin analysis Chem Toksykol 2012;3:390-396. for the health and food sciences. Second Edition. Taylor 18. Leszczyńska T., Sikora E., Kręcina K., Pysz K.: Udział & Francis Group. 2008 posiłków przedszkolnych w całkowitym pokryciu 5. Gawęcki J., Galiński G., Konieczka M., Kufel M.: zapotrzebowania na energię i składniki odżywcze na Ilościowa i jakościowa ocena spożycia tłuszczów przykładzie wybranej stołówki. Żywność. Nauka. i węglowodanów przez dzieci przedszkolne z różnych Technologia. Jakość 2007 6 (55):327-334 środowisk i regionów. 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Conflict of interest Hepatol Żywienie Dziecka 2006;7(3):246. 28. Sochacka-Tatara E., Jacek R., Sowa A., Musiał A.: Ocena W.: Źródła składników odżywczych w dietach dzieci The authors declare no conflict of interest. 13. Krzysik M., Biernat J., Grajeta H.: Wpływ sposobu żywienia dzieci w wieku przedszkolnym. Probl w wieku 13-36 miesięcy – badanie ogólnopolskie. wybranych składników odżywczych pożywienia na Hig Epidemiol 2008;89 (3):389-394. Bromat Chem Toksykol 2011;44(3):233-239. REFERENCES funkcjonowanie układu odpornościowego Cz. II. 29. Socha J., Socha P., Weker H., Neuhoff-Murawska 31. Weker H., Hamułka J., Więch M., Głowacka K.: Analysis Immunomodulacyjne działanie witamin i pierwiastków J.: Żywienie dzieci a zdrowie wczoraj, dziś i jutro. of nutrition of children in Warsaw day nurseries in 1. Charzewska J., Chwojnowska Z.: Rola witamin śladowych na organizm człowieka. Adv Clin Exp Med Pediatria Współ Gastroenterol, Hepatol Żywienie view of current recommendations. J Pre-Clin Res i składników mineralnych w żywieniu dzieci 2007;16(1):123–133. Dziecka 2010;12(1):34-37. 2010;4(1):63-67. i młodzieży. [W:] Jarosz M: Zasady prawidłowego 14. Książyk J.: Witamina D, osteopenia, krzywica 30. Weker H., Barańska M., Riahi A., Więch M., Strucińska żywienia dzieci i młodzieży oraz wskazówki dotyczące i osteoporoza. Nowa Ped 2004;1:41-44. M., Kurpińska P., Dyląg H., Rowicka G., Klemarczyk Received: 29.12.2015 zdrowego stylu życia. IŻŻ, Warszawa, 53-77, 2008 15. Kucharska A., Sińska B., Dobrowolska E.: Ocena Accepted: 08.04.2016 2. Czerwonogrodzka-Senczyna A., Kryńska P., Majcher jakości żywienia i stanu odżywienia dzieci w wybranym A., Rumińska M., Jeznach-Steinhagen A., Pyrżak B.: przedszkolu miejskim i wiejskim. Fizjologiczne Wpływ czynników środowiskowych na występowanie uwarunkowania postępowania dietetycznego. SGGW, otyłości u dzieci do 7 roku życia. Endo Pediatr Warszawa 2004;2:599-602. 2014;13,2(47):17-24. 16. Kunachowicz H., Nadolna I., Przygoda B., Iwanow K.: 3. Dymkowska-Malesa M., Szparaga A.: Ocena spożycia Tabele składu i wartości odżywczej żywności. PZWL, wybranych witamin i składników mineralnych Warszawa, 13. 2005 w przedszkolnych racjach pokarmowych dzieci z terenu 17. Lebiedzińska A., Czaja J., Petrykowska K., Szefer P.: Koszalina. Nowa Ped 2013;3:106-110. Soki i nektary owocowe źródłem witaminy C. Bromat 4. Eitenmiller R.R., Ye L., Landen W.O.: Vitamin analysis Chem Toksykol 2012;3:390-396. for the health and food sciences. Second Edition. Taylor 18. Leszczyńska T., Sikora E., Kręcina K., Pysz K.: Udział & Francis Group. 2008 posiłków przedszkolnych w całkowitym pokryciu 5. Gawęcki J., Galiński G., Konieczka M., Kufel M.: zapotrzebowania na energię i składniki odżywcze na Ilościowa i jakościowa ocena spożycia tłuszczów przykładzie wybranej stołówki. Żywność. Nauka. i węglowodanów przez dzieci przedszkolne z różnych Technologia. Jakość 2007 6 (55):327-334 środowisk i regionów. Nowiny Lek 2005;74(4):393- 19. Morris H.A., Turner A.G., Anderson P.H.: Vitamin 395. D regulation of bone mineralisation and remodeling 6. Górnicka M., Frąckiewicz J., Trela I.: Zawartość during growth. Front Biosci 2012;1(4):677-689. wybranych witamin w racjach pokarmowych 20. Nicklas T.A., Hayes D.: American Dietetic Association: przedszkoli na terenie Warszawy i okolic [Selected Position of the American Dietetic Association: nutrition vitamins content in pre-school children diet in Warsaw guidance for healthy children ages 2 to 11 years. J Am and regions]. Rocz Panstw Zakl Hig 2011;62(2):205- Diet Assoc 2008;108(6):1038-1044, 1046-1047. 208 (in Polish) [PMID: 21980868; http://www.ncbi. 21. Orkusz A, Włodarczyk A.: Ocena żywienia dzieci nlm.nih.gov/pubmed/21980868]. w przedszkolu na podstawie dekadowych jadłospisów. 7. Grajeta H., Ilow R., Prescha A., Regulska-Ilow B., Biernat Nauki Inż Technol 2014;1(12):72-81. J.: Ocena wartości energetycznej i odżywczej posiłków 22. Rocznik Statystyczny, GUS, Warszawa. 2001 przedszkolnych [Evaluation of energy and nutritive value 23. Trafalska E., Szczepanik A., Kolmaga A.: Wartość of meals for nursery school children]. Rocz Panstw Zakl energetyczna i odżywcza racji pokarmowych dzieci Hig 2003;54(4):417–425 (in Polish) [PMID: 15052740; uczęszczających do żłobka. Probl Hig Epidemiol http://www.ncbi.nlm.nih.gov/pubmed/15052740]. 2014;95(2):477-480. 8. Hamułka J., Wawrzyniak A.: Ocena wartości odżywczej 24. Trafalska E.: Assessing diets for energy and nutrients jadłospisów dekadowych dzieci w wieku 1-6 lat. content in nursery school children from Lodz, Bromat Chem Toksykol 2003:36(1);7-11. Poland. Rocz Panstw Zakl Hig 2014;65(1):27-33 9. Hamułka J., Wawrzyniak A., Uznańska N.: Analiza [PMID: 24964576; http://www.ncbi.nlm.nih.gov/ porównawcza zawartości witaminy C oraz ocena pubmed/24964576]. wartości energetycznej całodziennych racji 25. Sadowska J., Krzymuska A.: Ocena uzupełniania pokarmowych małych dzieci [Comparative assessment przedszkolnej racji pokarmowej przez rodziców of vitamin C content and evaluation of energy intake u dzieci w wieku przedszkolnym. Bromat Chem in children daily food rations]. Rocz Panstw Zakl Hig Toksykol 2010;52(2):203-211. 2003;54(3):287-293 (in Polish) [PMID: 14755856; 26. Sadowska J., Radziszewska M., Krzymuska A.: http://www.ncbi.nlm.nih.gov/pubmed/14755856]. Evaluation of nutrition manner and nutritional status 10. Jarosz M: Normy żywienia dla populacji polskiej- of pre-school children. Acta Sc Pol, Technol Aliment nowelizacja. IŻŻ, Warszawa. 2012 2010;9(1):105-115. 11. Karalus J., Chlebna-Sokół D.: Optymalne stężenie 27. Smorczewska-Czupryńska B., Ustymowicz- witaminy D jako ważny czynnik rozwoju i utrzymania Farbiszewska J., Rygorczuk B., Maksymowicz- prawidłowej masy kostnej dzieci i młodzieży. Endo. 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ORIGINAL ARTICLE

THE NEED FOR MODIFYING ENERGY INTAKE IN PRESCHOOL CHILDREN FROM PIŁA, POLAND1

Sylwia Merkiel*, Wojciech Chalcarz

Eugeniusz Piasecki University School of Physical Education in Poznan, Food and Nutrition Department, Poznan, Poland

ABSTRACT Background. Monitoring energy intake in preschool children is the basis for planning intervention programmes. The published articles in which energy intake in Polish preschool children was reported are still very few. Objective. The objective was to assess energy intake in preschool children from Piła, including energy intake and intake of energy from macronutrients. Material and Methods. Energy intake was assessed from weighed food records kept over seven consecutive days by preschool staff and parents of 122 children, 61 girls and 61 boys, aged 4 to 6 years. Energy intake was calculated using Dieta 4.0 and Microsoft Excel computer programmes. Weight and height were measured and BMI was calculated. Statistical analysis was carried out using the IBM SPSS Statistics 21 computer programme. Results. Energy intake was the lowest in underweight children, 1286 kcal, and the highest in obese children, 1636 kcal. Energy intake (kcal, kJ, kcal/kg body weight, kJ/kg body weight) and intake of energy from sucrose (%) were statistically significantly higher in boys compared to girls, 1546 vs 1428 kcal, 6477 vs 5985 kJ, 77 vs 71 kcal/kg body weight, 322 vs 298 kJ/kg body weight, and 21.2 vs 19.7%, respectively. Intake of energy from starch was statistically significantly higher in girls compared to boys, 24.8 vs 23.4%. It is noteworthy that energy intakes from fat and saturated fatty acids were above the recommendations in 71.3% and 98.4% of the studied preschool children, respectively. Energy intakes from polyunsaturated fatty acids and available carbohydrates were below the recommendations in 98.4% and 57.4% of the studied preschool children, respectively. Conclusions. Energy intakes from macronutrients in the studied preschool children need urgent modification to prevent the risk of future diet-related diseases. Preschoolers’ parents and preschool staff should be educated about nutrition recommendations for children, especially about dietary risks of diseases and impaired neurodevelopment.

Key words: preschool children, dietary intake, energy, macronutrients, nutrition, gender

STRESZCZENIE Wprowadzenie. Monitorowanie spożycia energii przez dzieci w wieku przedszkolnym jest podstawą planowania progra- mów interwencyjnych. Do tej pory opublikowano niewiele prac poświęconych ocenie spożycia energii przez polskie dzieci w wieku przedszkolnym. Cel. Celem badań była ocena spożycia energii przez dzieci w wieku przedszkolnym z Piły, z uwzględnieniem spożycia energii i spożycia energii z makroskładników. Materiał i metody. Spożycie energii oceniono na podstawie bieżącego notowania spożywanych produktów, potraw i na- pojów przez siedem kolejnych dni przez personel przedszkolny i rodziców 122 dzieci, 61 dziewczynek i 61 chłopców, w wieku 4 do 6 lat. Spożycie energii obliczono przy użyciu programów komputerowych Dieta 4.0 oraz Microsoft Excel. Zmierzono masę ciała i wysokość ciała oraz obliczono BMI. Statystyczną analizę wyników przeprowadzono przy pomocy programu komputerowego IBM SPSS Statistics, wersja 21. Wyniki. Spożycie energii było najniższe u dzieci z niedowagą, 1286 kcal, a najwyższe u dzieci otyłych, 1636 kcal. Spoży- cie energii (kcal, kJ, kcal/kg masy ciała, kJ/kg masy ciała) oraz spożycie energii z sacharozy (%) były statystycznie istotnie wyższe u chłopców niż u dziewczynek, odpowiednio, 1546 vs 1428 kcal, 6477 vs 5985 kJ, 77 vs 71 kcal/kg masy ciała, 322 vs 298 kJ/kg masy ciała, i 21,2 vs 19,7%. Spożycie energii ze skrobi było statystycznie istotnie wyższe u dziewczynek niż u chłopców, 24,8 vs 23,4%. Warto zwrócić uwagę, że spożycie energii z tłuszczu i nasyconych kwasów tłuszczowych było wyższe niż zalecane u, odpowiednio, 71,3% i 98,4% badanych dzieci. Spożycie energii z wielonienasyconych kwasów tłuszczowych i węglowodanów przyswajalnych było niższe niż zalecane u, odpowiednio, 98,4% i 57,4% badanych dzieci.

1 This study was financed by the National Science Centre from the resources for financing research in the years 2010-2014 as a research project N N404 140437 titled: ‘Modifying dietary intake and physical activity in preschool children and its influence on nutrition status and physical fitness’.

*Corresponding author: Sylwia Merkiel, Food and Nutrition Department, Eugeniusz Piasecki University School of Physical Education in Poznan, Królowej Jadwigi 27/39 street, 61-871 Poznan, Poland, Tel.: +48 61 835 52 87, Fax: +48 61 851 73 84, e-mail: sylwiamerkiel@ awf.poznan.pl

ORIGINAL ARTICLE

THE NEED FOR MODIFYING ENERGY INTAKE IN PRESCHOOL CHILDREN FROM PIŁA, POLAND1

Sylwia Merkiel*, Wojciech Chalcarz

Eugeniusz Piasecki University School of Physical Education in Poznan, Food and Nutrition Department, Poznan, Poland

Key words: preschool children, dietary intake, energy, macronutrients, nutrition, gender

© Copyright by the National Institute of Public Health - National Institute of Hygiene 180 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 181

Wnioski. Spożycie energii z makroskładników przez badane dzieci wymaga pilnej modyfikacji, aby zapobiec wystąpieniu was calculated using gender- and age-dependent Oxford (Armonk, NY: IBM Corp.). Energy intake (kcal, kJ) chorób dietozależnych w przyszłości. Rodzice badanych dzieci oraz personel przedszkolny powinni być objęci edukacją predictive equations [12]. Records with EI:BMR ratios and intakes of energy from macronutrients (%) were z zakresu zaleceń żywieniowych dla dzieci, a zwłaszcza z zakresu żywieniowych czynników ryzyka chorób oraz zaburzo- up to 0.97 for children aged 4 to 5 years, up to 1.01 for analysed according to gender. Energy intake (kcal) was nego rozwoju układu nerwowego. 6-year-old girls and up to 1.04 for 6-year-old boys were also analysed according to the percentile categories for considered as not plausible measurements of the actual BMI. Means, standard deviations (SD), medians and Słowa kluczowe: dzieci przedszkolne, sposób żywienia, energia, makroskładniki, żywienie, płeć energy intake [35]. In the studied population, one 4-year- standard errors (SE) were calculated. The percentages old girl and one 6-year-old boy with EI:BMR ratio below of children with energy intakes from macronutrients INTRODUCTION at the beginning of the study, that is before introducing the the abovementioned cut-off values were identified and below or above the recommendations were calculated. intervention. The study was approved by the Bioethics were excluded from further analysis. Statistical analysis was performed as previously Nowadays, we are facing the increasing prevalence Committee of the Poznan University of Medical Sciences. [22]. Qualitative variables were presented in contingency of diet-related diseases, therefore preventing them in Comparison with nutritional guidelines tables. Statistical significance was determined using the society becomes of crucial importance. Excessive Subjects To assess if energy intake was adequate, body Pearson’s chi-square test with the level of significance energy intake is the cause of obesity, while inadequate The target population for this study were 234 mass index (BMI) was calculated and assessed as at P≤0.05. The normality of quantitative variables was or excessive intakes of energy from macronutrients may children who attended two randomly selected preschools described in the section Anthropometric measures tested using the Shapiro-Wilk statistisc. The level of lead to the increased risk of atherosclerosis, diabetes or in Piła. Parents of 154 children provided written consent and energy intake was presented according to the significance was set atP ≤0.05. To investigate statistically cancer. The prevention of diet-related diseases should to take part in the study. However, parents withdrew 19 percentile categories for BMI. Intakes of energy from significant differences, the unpaired Student’s t test for start as early as possible, preferably in women who plan children at the beginning of the study, only five children macronutrients were compared to those recommended normally distributed variables and the non-parametric pregnancy. Therefore, preschool age is the time when were 3 years old and therefore were not included in in the prevention of diet-related diseases [39], similarly Mann-Whitney U test for skewed variables were used. this prevention should start at the latest. the analysis, food records of two girls were also not to the previous articles [22, 27]. The level of significance was also set at P≤0.05. Monitoring energy intake in preschool children is included because they had problems with adapting the basis for planning intervention programmes aimed themselves to the new environment and they ate hardly Anthropometric measures RESULTS at improving children’s diets and forming healthy food anything at preschool, parents of three children did not To calculate BMI, weight and height were behaviour which would be tracked into prepubertal age, provide food records and parents of one child did not measured. Similarly to our previous articles [22, 25], Table 1 shows energy intake in the studied children adolescence and adulthood, as well as nutrition education keep food records over the weekend. Moreover, we BMI was classified to the percentile ranges using according to the percentile categories for BMI. Energy programmes addressed to preschool staff, parents and also identified two underreporters as described in the section the tables provided by Kuczmarski et al. [17]. The intake was the lowest in underweight children, 1286 the preschoolers. Unfortunately, the published articles Underreporting of energy intake. Thus, we present the percentile ranges were called using the terminology kcal, and the highest in obese children, 1636 kcal. in which energy intake in Polish preschool children was results of the assessment of food records collected from recommended by the International Obesity Task Force Table 2 presents energy intake in the studied children reported are still very few. These include: a study on 122 children, 61 girls and 61 boys, aged 4 to 6 years. (IOTF) [2]: below the 5th percentile – underweight; according to gender. Energy intake (kcal, kJ, kcal/kg a representative group of Polish preschoolers published by from the 5th to the 84th percentile – healthy weight; body weight, kJ/kg body weight) and intake of energy Szponar et al. in 2003 [38], a study on randomly selected Energy and macronutrient intakes from the 85th to the 94th percentile – overweight; the from sucrose (%) were statistically significantly higher 4-year-olds from all over Poland published by Rogalska- Data collection 95th percentile or above – obesity. in boys compared to girls, 1546 vs 1428 kcal, 6477 vs Niedźwiedź et al. in 2008 [31], a study on 6-year-olds Energy intake was estimated from weighed food There were two reasons for using the IOTF 5985 kJ, 77 vs 71 kcal/kg body weight, 322 vs 298 kJ/kg from Nowy Sącz and the vicinity published by Merkiel in records kept over seven consecutive days as described in classification and terminology. The first reason is that body weight, and 21.2 vs 19.7%, respectively. Intake of 2014 [22] and a study on 4-6-year-old children from Turek details in the previous article [4]. In brief, food records were presenting results according to this classification makes energy from starch was statistically significantly higher published by Merkiel et al. in 2014 [27]. Also, Sadowska et kept by parents and preschool staff who were instructed it possible to compare the results with the results of in girls compared to boys, 24.8 vs 23.4%. al. [32] published in 2010 a study on 4-6-year-old children how to do it. Although the menu is the same for all children children from various countries. The second reason was Table 3 shows the percentages of the studied from Szczecin in whom total energy intake was reported within one preschool, usually some children refuse to eat that there are only four percentile ranges according to the children in the reference ranges for energy intake from but not energy from macronutrients which were analysed all the meals served or all the meal components. Moreover, IOTF classification and as many as seven according to macronutrients according to gender. No statistically only as expressed in grams. children eat various portion sizes. Therefore, preschool the Polish percentile ranges for BMI. When we classified significant differences were observed. It is noteworthy The objective of our study was to assess energy staff weighed all foods, all components of the dishes, as the results according to the Polish percentiles, as many as that energy intakes from fat and saturated fatty acids intake in preschool children from Piła, including energy well as beverages and water individually for each child. three percentile ranges were represented by only one child were above the recommendations in 71.3% and 98.4% intake and intake of energy from macronutrients. These Supplements, if taken by the children, were also recorded. or two children which is not good for statistical analysis. of the studied preschool children, respectively. Energy results are the part of a wide-range study described in intakes from polyunsaturated fatty acids and available details in the other article [4]. Dietary assessment Statistical analysis carbohydrates were below the recommendations in Energy intake (kcal, kJ) was calculated in Dieta Statistical analysis was carried out using the IBM 98.4% and 57.4% of the studied preschool children, MATERIAL AND METHODS 4.0 computer programme and modified as described in SPSS Statistics computer programme, version 21.0 respectively. our previous article [23] to receive as accurate data as General information possible. Intakes of energy from macronutrients (%) Table 1. Energy intake in the studied children according to the percentile categories for BMI The results presented in this article are the part of the were calculated using the Microsoft Excel programme Energy intake (kcal) Population results of an intervention study on Polish preschoolers as also described in the previous articles [4, 23]. Percentile categories for BMI which aim was to modify diet and physical activity in Mean SD Median SE % N preschool children in order to improve their nutritional Underreporting of energy intake Below the 5th percentile (underweight) 1286 202 1298 90 4.1 5 status and physical fitness. The outline of this study [23] Underreporters were identified using the same 5th – 84th percentile (healthy weight) 1481 231 1462 25 73.0 89 and the detailed description of the methodology [4] were methods as in our previous article [22]. In brief, the 85th – 94th percentile (overweight) 1521 330 1458 69 18.8 23 presented in our previous articles. We present the results ratio of energy intake to predicted basal metabolic rate 95th percentile and above (obesity) 1636 299 1689 134 4.1 5 of dietary intake assessment from food records collected (EI:BMR) was calculated [35]. Basal metabolic rate 180 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 181

Wnioski. Spożycie energii z makroskładników przez badane dzieci wymaga pilnej modyfikacji, aby zapobiec wystąpieniu was calculated using gender- and age-dependent Oxford (Armonk, NY: IBM Corp.). Energy intake (kcal, kJ) chorób dietozależnych w przyszłości. Rodzice badanych dzieci oraz personel przedszkolny powinni być objęci edukacją predictive equations [12]. Records with EI:BMR ratios and intakes of energy from macronutrients (%) were z zakresu zaleceń żywieniowych dla dzieci, a zwłaszcza z zakresu żywieniowych czynników ryzyka chorób oraz zaburzo- up to 0.97 for children aged 4 to 5 years, up to 1.01 for analysed according to gender. Energy intake (kcal) was nego rozwoju układu nerwowego. 6-year-old girls and up to 1.04 for 6-year-old boys were also analysed according to the percentile categories for considered as not plausible measurements of the actual BMI. Means, standard deviations (SD), medians and Słowa kluczowe: dzieci przedszkolne, sposób żywienia, energia, makroskładniki, żywienie, płeć energy intake [35]. In the studied population, one 4-year- standard errors (SE) were calculated. The percentages old girl and one 6-year-old boy with EI:BMR ratio below of children with energy intakes from macronutrients INTRODUCTION at the beginning of the study, that is before introducing the the abovementioned cut-off values were identified and below or above the recommendations were calculated. intervention. The study was approved by the Bioethics were excluded from further analysis. Statistical analysis was performed as previously Nowadays, we are facing the increasing prevalence Committee of the Poznan University of Medical Sciences. [22]. Qualitative variables were presented in contingency of diet-related diseases, therefore preventing them in Comparison with nutritional guidelines tables. Statistical significance was determined using the society becomes of crucial importance. Excessive Subjects To assess if energy intake was adequate, body Pearson’s chi-square test with the level of significance energy intake is the cause of obesity, while inadequate The target population for this study were 234 mass index (BMI) was calculated and assessed as at P≤0.05. The normality of quantitative variables was or excessive intakes of energy from macronutrients may children who attended two randomly selected preschools described in the section Anthropometric measures tested using the Shapiro-Wilk statistisc. The level of lead to the increased risk of atherosclerosis, diabetes or in Piła. Parents of 154 children provided written consent and energy intake was presented according to the significance was set atP ≤0.05. To investigate statistically cancer. The prevention of diet-related diseases should to take part in the study. However, parents withdrew 19 percentile categories for BMI. Intakes of energy from significant differences, the unpaired Student’s t test for start as early as possible, preferably in women who plan children at the beginning of the study, only five children macronutrients were compared to those recommended normally distributed variables and the non-parametric pregnancy. Therefore, preschool age is the time when were 3 years old and therefore were not included in in the prevention of diet-related diseases [39], similarly Mann-Whitney U test for skewed variables were used. this prevention should start at the latest. the analysis, food records of two girls were also not to the previous articles [22, 27]. The level of significance was also set at P≤0.05. Monitoring energy intake in preschool children is included because they had problems with adapting the basis for planning intervention programmes aimed themselves to the new environment and they ate hardly Anthropometric measures RESULTS at improving children’s diets and forming healthy food anything at preschool, parents of three children did not To calculate BMI, weight and height were behaviour which would be tracked into prepubertal age, provide food records and parents of one child did not measured. Similarly to our previous articles [22, 25], Table 1 shows energy intake in the studied children adolescence and adulthood, as well as nutrition education keep food records over the weekend. Moreover, we BMI was classified to the percentile ranges using according to the percentile categories for BMI. Energy programmes addressed to preschool staff, parents and also identified two underreporters as described in the section the tables provided by Kuczmarski et al. [17]. The intake was the lowest in underweight children, 1286 the preschoolers. Unfortunately, the published articles Underreporting of energy intake. Thus, we present the percentile ranges were called using the terminology kcal, and the highest in obese children, 1636 kcal. in which energy intake in Polish preschool children was results of the assessment of food records collected from recommended by the International Obesity Task Force Table 2 presents energy intake in the studied children reported are still very few. These include: a study on 122 children, 61 girls and 61 boys, aged 4 to 6 years. (IOTF) [2]: below the 5th percentile – underweight; according to gender. Energy intake (kcal, kJ, kcal/kg a representative group of Polish preschoolers published by from the 5th to the 84th percentile – healthy weight; body weight, kJ/kg body weight) and intake of energy Szponar et al. in 2003 [38], a study on randomly selected Energy and macronutrient intakes from the 85th to the 94th percentile – overweight; the from sucrose (%) were statistically significantly higher 4-year-olds from all over Poland published by Rogalska- Data collection 95th percentile or above – obesity. in boys compared to girls, 1546 vs 1428 kcal, 6477 vs Niedźwiedź et al. in 2008 [31], a study on 6-year-olds Energy intake was estimated from weighed food There were two reasons for using the IOTF 5985 kJ, 77 vs 71 kcal/kg body weight, 322 vs 298 kJ/kg from Nowy Sącz and the vicinity published by Merkiel in records kept over seven consecutive days as described in classification and terminology. The first reason is that body weight, and 21.2 vs 19.7%, respectively. Intake of 2014 [22] and a study on 4-6-year-old children from Turek details in the previous article [4]. In brief, food records were presenting results according to this classification makes energy from starch was statistically significantly higher published by Merkiel et al. in 2014 [27]. Also, Sadowska et kept by parents and preschool staff who were instructed it possible to compare the results with the results of in girls compared to boys, 24.8 vs 23.4%. al. [32] published in 2010 a study on 4-6-year-old children how to do it. Although the menu is the same for all children children from various countries. The second reason was Table 3 shows the percentages of the studied from Szczecin in whom total energy intake was reported within one preschool, usually some children refuse to eat that there are only four percentile ranges according to the children in the reference ranges for energy intake from but not energy from macronutrients which were analysed all the meals served or all the meal components. Moreover, IOTF classification and as many as seven according to macronutrients according to gender. No statistically only as expressed in grams. children eat various portion sizes. Therefore, preschool the Polish percentile ranges for BMI. When we classified significant differences were observed. It is noteworthy The objective of our study was to assess energy staff weighed all foods, all components of the dishes, as the results according to the Polish percentiles, as many as that energy intakes from fat and saturated fatty acids intake in preschool children from Piła, including energy well as beverages and water individually for each child. three percentile ranges were represented by only one child were above the recommendations in 71.3% and 98.4% intake and intake of energy from macronutrients. These Supplements, if taken by the children, were also recorded. or two children which is not good for statistical analysis. of the studied preschool children, respectively. Energy results are the part of a wide-range study described in intakes from polyunsaturated fatty acids and available details in the other article [4]. Dietary assessment Statistical analysis carbohydrates were below the recommendations in Energy intake (kcal, kJ) was calculated in Dieta Statistical analysis was carried out using the IBM 98.4% and 57.4% of the studied preschool children, MATERIAL AND METHODS 4.0 computer programme and modified as described in SPSS Statistics computer programme, version 21.0 respectively. our previous article [23] to receive as accurate data as General information possible. Intakes of energy from macronutrients (%) Table 1. Energy intake in the studied children according to the percentile categories for BMI The results presented in this article are the part of the were calculated using the Microsoft Excel programme Energy intake (kcal) Population results of an intervention study on Polish preschoolers as also described in the previous articles [4, 23]. Percentile categories for BMI which aim was to modify diet and physical activity in Mean SD Median SE % N preschool children in order to improve their nutritional Underreporting of energy intake Below the 5th percentile (underweight) 1286 202 1298 90 4.1 5 status and physical fitness. The outline of this study [23] Underreporters were identified using the same 5th – 84th percentile (healthy weight) 1481 231 1462 25 73.0 89 and the detailed description of the methodology [4] were methods as in our previous article [22]. In brief, the 85th – 94th percentile (overweight) 1521 330 1458 69 18.8 23 presented in our previous articles. We present the results ratio of energy intake to predicted basal metabolic rate 95th percentile and above (obesity) 1636 299 1689 134 4.1 5 of dietary intake assessment from food records collected (EI:BMR) was calculated [35]. Basal metabolic rate 182 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 183

Table 3. The percentages of the studied children in the reference ranges for energy intake from macronutrients 1 5 23 97 SE 0.2 0.4 0.2 0.4 0.4 0.1 0.4 0.2 0.1 Girls Boys All children P Nutrient (N = 61) (N = 61) (N = 122) ( N = 122) 75 % % % 3.5 3.6 313 11.9 12.8 53.8 20.4 23.8 33.2 14.3 All children 6116 1459

Median Energy from protein (%) below the recommendations 3.3 6.6 4.9 within the recommendations 95.1 86.9 91.0 NS 2 7 33 SE 0.3 0.6 0.2 0.6 0.5 0.2 0.5 0.3 0.1 138 above the recommendations 1.6 6.6 4.1 Energy from fat (%) within the recommendations 26.2 31.1 28.7 Boys NS ( N = 61) above the recommendations 73.8 68.9 71.3 77 3.7 3.5 324 12.8 53.7 20.9 22.9 12.1 33.7 14.4 1519 6374

Median Energy from saturated fatty acids (%) within the recommendations 3.3 0.0 1.6 NS above the recommendations 96.7 100.0 98.4 2 7 31 SE 0.3 0.6 0.3 0.5 0.6 0.2 0.6 0.3 0.1

130 Energy from polyunsaturated fatty acids (%) below the recommendations 96.7 100.0 98.4 NS within the recommendations 3.3 0.0 1.6 Girls

( N = 61) Energy from monounsaturated fatty acids (%) 72 3.3 3.7 302 11.8 12.8 53.9 19.2 24.9 32.9 14.2 1425 5970 below the recommendations 9.8 13.1 11.5 Median NS within the recommendations 90.2 86.9 88.5 Energy from available carbohydrates (%) below the recommendations 57.4 57.4 57.4 P NS NS NS NS NS NS NS NS 0.011 0.011 0.047 0.010 0.017 0.017 within the recommendations 42.6 42.6 42.6 P – significance; NS – not significantP ( >0.05). 14 57 2.2 4.9 2.1 4.2 4.3 1.6 4.5 2.3 0.9 SD 256 1073 DISCUSSION and boys from Portugal [28]. Only among 4-6-year- old girls and boys from Turek [27] and 4.6-year-old ( N = 122) 74 All children 4.0 3.8 310

13.0 54.1 20.5 24.1 girls and boys from urban regions [31], energy intake 12.0 14.3 33.4 Gender as a factor influencing energy intake 1487 6231 Mean Higher intake of energy in boys compared to girls was not statistically significantly different. is natural and results from mean higher body weight We expected to find more statistically significant 14 57 2.0 4.9 1.9 4.6 4.2 1.8 2.1 4.1 0.8 SD 258 1078 of males compared to their female peers. Moreover, differences in energy intake from macronutrients in

Boys boys are usually more physically active than girls the studied preschoolers from Piła. Among 6-year- ( N = 61) 77 4.1 3.7 322 12.8 54.3 21.2 23.4 12.1 14.5 33.2 irrespective of age [15], however, not always as was old girls and boys from Nowy Sącz and the vicinity 1546 6477 Mean observed among preschool children from Poznań [7]. [22] and among 7-year-old girls and boys from Great In the previously studied Polish preschoolers, energy Britain [10], statistically significant differences were 13 54 2.4 5.0 2.3 3.7 4.4 1.5 2.4 4.9 1.0 SD 243 1019 intake was also higher in boys compared to girls: in found in energy intake from four macronutrients, while

Girls 4-6-year-old girls and boys from all over Poland [38], among 4-6.5-year-old girls and boys from Belgium ( N = 61) 71 3.9 3.9 298

13.3 54.0 19.7 24.8 [13] – from as many as six macronutrients. However, 12.0 14.2 33.7 in 4-6-year-old girls and boys from Turek [27], as well 1428 5985 Mean as in 4.6-year-old girls and boys from both urban and among 7-9-year-old girls and boys from Portugal

2 rural regions [31]. The same tendency may be found in [28], statistically significant difference was found 1 P >0.05). preschool children from other countries, for example in energy intake from only one macronutrient and NA NA NA NA NA <10% values 6-10% >10% in 4-6-year-old girls and boys from Great Britain [11] among 4-6-year-old girls and boys from Turek [27] no 10-15% 20-30% 55-70% Reference dependent body weight or in 4-6.5-year-old girls and boys from Belgium [13]. statistically significant differences were observed. Moreover, as in the studied preschool girls and boys from Piła, statistically significant differences in Assessment of energy intake energy intake between girls and boys were also found Energy intake in the studied preschool children in children of the same or similar age from Poland or from Piła increased through the percentile categories other countries. Gender was reported to be statistically for BMI. Although such result is logical and should significant factor of energy intake among 4.6-year-old be expected, it is not usually observed due to girls and boys from rural regions [31], among girls underreporting of energy intake by overweight and

Median Energy from saturated fatty acids (%) within the recommendations 3.3 0.0 1.6 NS above the recommendations 96.7 100.0 98.4 2 7 31 SE 0.3 0.6 0.3 0.5 0.6 0.2 0.6 0.3 0.1

130 Energy from polyunsaturated fatty acids (%) below the recommendations 96.7 100.0 98.4 NS within the recommendations 3.3 0.0 1.6 Girls

Girls 4-6-year-old girls and boys from all over Poland [38], among 4-6.5-year-old girls and boys from Belgium ( N = 61) 71 3.9 3.9 298

Energy and boys aged 49-60 months from Greece [21], among obese subjects. However, underreporting has been little 4-6.5-year-old girls and boys from Belgium [13], explored in preschool children. Energy underreporting among 6-year-old girls and boys from Nowy Sącz in children with the highest body weight and/or the and the vicinity [22], among 7-year-old girls and boys highest BMI was found in 4-11-year-old children from Great Britain [10], among 5-11-year-old girls and from the United States [9], 2-18-year-old children boys from France [20] and among 7-9-year-old girls and adolescents from Germany [1] and 3-17-year-old Energy (kcal) Energy Energy from available carbohydrates (%) Energy from lactose (%) Energy from sucrose (%) Energy from starch (%) Energy Energy (kJ) Energy Energy (kcal/kg body weight) Energy (kJ/kg body weight) Energy from protein (%) Energy Energy from fat (%) Energy Energy from saturated fatty acids (%) Energy from polyunsaturated fatty acids (%) Energy Energy from monounsaturated fatty acids (%) Energy Calculated by difference as: energy from fat – (energy from saturated fatty acids + energy from polyunsaturated fatty acids). acids + energy from saturated fatty from fat – (energy as: energy Calculated by difference from fat. from protein – energy – energy as: the percentage of total energy Calculated by difference Table 2. Energy intake in the studied children according to gender 2. Energy Table 1 2 – significance; NA – not available; NS significant ( P – significance; NA 184 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 185 children from France [19]. It is worth noting that in girls from Piła was exactly the same as in 4-6-year-old 5-11-year-olds [20] and Portuguese 7-9-year-olds only for cooking but also for spreading on bread or the latter study, the rate of underreporters was very girls from all over Poland [38], while in the studied [28]. The highest energy intake from fat, above 40%, pouring on salads and cooked vegetables. To make the low in younger children, aged 3 to 10 years, and much boys it was lower than in 4-6-year-old boys from all was observed in Cretan 5.7-7.6-year-olds [37] and taste of rapeseed oil better when spreading on bread higher in older children, aged 11 to 17 years [19]. In over Poland [38] but still within the recommendations. Spanish 6-7-year-olds [30]. In all of the mentioned or adding to vegetables, the good idea is to mix it with the studied group of preschool children from Piła, only Higher energy intake from protein, compared to the groups of children from various countries [3, 10, herbs, red pepper, garlic or ginger. Such mixture may two underrporters were identified. The probability studied children from Piła, was observed in their peers 11, 13, 21, 30, 34, 37] energy intake from saturated be kept in the fridge for several days, so that it may of underreporting among the children included in from Szczecin [32], Great Britain [11] and 4-6.5-year- fatty acids exceeded the recommendations, with the be prepared in larger amount to use over a couple of the analysis is very low because preschool staff was old children from Belgium [13], but also in children highest values reaching 16% in Spanish 6-7-year-olds days. Adding nuts to the studied children’s daily diets strongly motivated, actively involved in keeping the of similar age, that is 6-year-old children from Nowy [30], and in all these groups of children energy intake would additionally increase their energy intake from food records and assisted by the authors while parents Sącz and the vicinity [22], 4-10-year-old children from polyunsaturated fatty acids was lower than the polyunsaturated fatty acids. were willing to cooperate and filled in the food records from the United Kingdom [3], 7-year-old children recommended except for Spanish 6-7-year-olds [30]. Another concern is that energy intake from available reliably. This is reflected in the increase of energy from Great Britain [10], 5-11-year-old children from Taking into account the high prevalence of obesity carbohydrates in the studied preschool children from intake across the percentile categories for BMI. In France [20] and children aged 5.7-7.6 years from and the studies which link obesity with excessive Piła was lower than the recommended and that energy our previous studies, we observed the increase of Crete [37]. Much higher energy intake from protein fat intake [18], as well as the high prevalence of intake from sucrose was very high. Although there are energy intake through all of the percentile categories than in the studied children, but also higher than the obesity in the studied children’s families [24], it is no reference values of energy intake from sucrose, it is except for the highest categories: obesity in 6-year-old recommended, was reported in 4-6-year-old children of great importance to limit energy intake from this recommended to consume less than 10% of energy from children from Nowy Sącz and the vicinity [22], and from Turek [27], children aged 49-60 months from macronutrient in the studied children. Moreover, monosaccharides and disaccharides, including sucrose, tendency to overweight and overweight in preschool Greece [21], 6-7-year-old children from Spain [30], a long time ago many studies showed that lower which are added to foods by manufacturer, cook or children from Turek [27]. 2-5-year-old and 6-9-year-old children from Spain content of energy from fat in children’s diets results in consumer, as well as sugars which naturally occur in Although most of the studied children had [34] and 7-9-year-old children from Portugal [28]. higher micronutrient intake [36], higher intake of fruit, honey, syrups and fruit juices [39]. This means that if adequate body weight, a substantial percentage of Similar energy intake from monounsaturated vegetables and low-fat foods within such food groups the energy intake from sucrose in the studied children them was characterised by excessive body weight. fatty acids as in the studied children from Piła was as meats and dairy [8, 36], and higher nutrient density was twice higher than the cited recommendation, It is interesting that energy intake in the studied observed in 4-6-year-old children from all over Poland of most vitamins and minerals [29]. energy intake from all added mono- and disaccharides children was lower than in their peers from all over [38]. Lower energy intake from this macronutrient, Energy intake from saturated fatty acids in the and sugars contained in honey, syrups and fruit juices Poland [38] and from Szczecin [32], and even younger but not lower than the recommended, was observed studied children needs urgent reduction, while energy must have been much higher. Polish children, aged 4.6 years, from both urban and in 4-6-year-olds from Turek [27], 6-year-olds from intake from polyunsaturated fatty acids should be Among the previously studied Polish children, rural regions [31]. However, 4-6-year-old children Nowy Sącz and the vicinity [22], 4-6.5-year-olds increased because of the substantial cardioprotective only in 4-6-year-old children from all over Poland from Turek were characterised by lower energy from Belgium [13], 4-10-year-olds from the United benefit. It is of crucial importance since ischaemic [38] energy intake from available carbohydrates was intake [27] than the studied preschoolers from Piła. Kingdom [3], 7-year-olds from Great Britain [10], heart disease and stroke are the two most common within the recommendations. In 4-6-year-old children The explanation may probably be found when taking 2-5-year-olds and 6-9-year-olds from Spain [34] and causes of death all over Europe [14]. To reverse their from Turek [27] and Szczecin [32], and in 6-year-old the date of publication into account. The results in 7-9-year-olds from Portugal [28], but the highest increasing prevalence, the prevention should start children from Nowy Sącz and the vicinity [22], energy 4-6-year-old children from all over Poland [38] were energy intake from monounsaturated fatty acids, above in childhood. It is even more important when taking intake from this macronutrient was too low, while published in 2003, those in 4,6-year-old children in 17% of energy, was observed in Cretan 5.7-7.6-year- into account the high prevalence of myocardial energy intake from sucrose was too high, similarly to 2008 [31] and those in 4-6-year-old children from olds [37] and Spanish 6-7-year-olds [30]. infarction in the studied children’s families [24]. the studied children. Among the previously studied Szczecin in 2010 [32]. Thus, lower energy intake in Unfortunately, the studied children’s diets were Moreover, modifying energy intake from saturated and children from other countries, energy intake from 4-6-year-old children from Turek published in 2014 characterised by excessive energy intake from fat and polyunsaturated fatty acids is also vital to the studied available carbohydrates was also too low [3, 10, 11, [27] and in the studied 4-6-year-old children from saturated fatty acids along with inadequate energy children’s neurodevelopment. Studies showed that 13, 20, 21, 30, 34, 37] with the lowest values, below Piła may result from the decreasing physical activity intake from polyunsaturated fatty acids. The same polyunsaturated fatty acids are involved in numerous 40%, in Spanish 6-7-year-olds [30]. Energy intake observed among preschool children since 2005 [5] observations were reported in 4-6-year-old children neuronal processes, have significant effects on brain from sucrose was not analysed in children from other which may have caused the decrease in energy intake. from all over Poland [38] and 6-year-old children function and their deficiencies and imbalances may countries. However, energy intake from non-milk Another explanation may be the differences in body from Nowy Sącz and the vicinity [22]. Also, 4-6-year- cause neurocognitive disorders [33]. Another study extrinsic sugars in 4-10-year-olds from the United weight. In 4-6-year-old children from Turek, whose old children from Szczecin were characterised by indicates that children whose diets are high in saturated Kingdom [3] was almost 15% and energy intake energy intake was lower than in the studied children, excessive energy intake from fat [32]. In 4-6-year- fatty acids exhibit compromised ability to flexibly from simple carbohydrates exceeded 20% in Spanish as many as 12% were underweight, only 4% were old children from Turek [27] energy intake from fat modulate their cognitive operations, particularly when 6-7-year-olds [30], Portuguese 7-9-year-olds [28] overweight and nobody was obese [27]. However, was within the recommended but energy intake from faced with greater cognitive challenge [16]. and British 7-year-olds [10], while in 4-6.5-year-old among 4-6-year-old children from all over Poland saturated fatty acids was too high and energy intake To solve the problem of excessive energy children from Belgium [13] it exceeded 30%. [38] and 4-6-year-old children from Szczecin [32], from polyunsaturated fatty acids was too low, that is intake from fat and saturated fatty acids along with High energy intake from sucrose in the studied whose energy intake was higher than in the studied the same as in studied children. The same tendencies inadequate energy intake from polyunsaturated fatty children from Piła shows that parents either did not realise children, the percentages of children with underweight were found in children from other countries of the acids, high-fat foods in the studied children’s diets that the amount of sweets and sweetened beverages in and considerable underweight were higher than in same age or similar. Except for 4-6.5-year-old children should be replaced with their low-fat equivalents. The their children’s diets was too high or they were not able the studied children, nevertheless, the percentages of from Belgium [13], energy intake from fat exceeding result would be not only reduced energy intake from to refuse their children sweets. For sure, parents realised obese children were also higher. 30% was reported in all the previously studied fat but also increased intake of essential vitamins and that high intake of sucrose is not good for the children’s It is highly favourable that energy intakes from groups of children: British 4-6-year-olds [11] and minerals [36]. To improve energy intake from fatty health because previous studies on nutritional knowledge protein and monounsaturated fatty acids in the 7-year-olds [10], Greek children aged 49-60 months acids, animal fat should be exchanged for rapeseed of preschoolers’ parents showed that they were aware studied preschool children from Piła were within the [21], 4-10-year-olds from the United Kingdom [3], oil which in Poland is of high quality and available of its adverse effects on teeth [6] and of the lack of any recommended. Energy intake from protein in the studied Spanish 2-5-year-olds and 6-9-year-olds [34], French at relatively low price. This oil should be used not essential micronutrients in sugar [26]. 184 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 185 children from France [19]. It is worth noting that in girls from Piła was exactly the same as in 4-6-year-old 5-11-year-olds [20] and Portuguese 7-9-year-olds only for cooking but also for spreading on bread or the latter study, the rate of underreporters was very girls from all over Poland [38], while in the studied [28]. The highest energy intake from fat, above 40%, pouring on salads and cooked vegetables. To make the low in younger children, aged 3 to 10 years, and much boys it was lower than in 4-6-year-old boys from all was observed in Cretan 5.7-7.6-year-olds [37] and taste of rapeseed oil better when spreading on bread higher in older children, aged 11 to 17 years [19]. In over Poland [38] but still within the recommendations. Spanish 6-7-year-olds [30]. In all of the mentioned or adding to vegetables, the good idea is to mix it with the studied group of preschool children from Piła, only Higher energy intake from protein, compared to the groups of children from various countries [3, 10, herbs, red pepper, garlic or ginger. Such mixture may two underrporters were identified. The probability studied children from Piła, was observed in their peers 11, 13, 21, 30, 34, 37] energy intake from saturated be kept in the fridge for several days, so that it may of underreporting among the children included in from Szczecin [32], Great Britain [11] and 4-6.5-year- fatty acids exceeded the recommendations, with the be prepared in larger amount to use over a couple of the analysis is very low because preschool staff was old children from Belgium [13], but also in children highest values reaching 16% in Spanish 6-7-year-olds days. Adding nuts to the studied children’s daily diets strongly motivated, actively involved in keeping the of similar age, that is 6-year-old children from Nowy [30], and in all these groups of children energy intake would additionally increase their energy intake from food records and assisted by the authors while parents Sącz and the vicinity [22], 4-10-year-old children from polyunsaturated fatty acids was lower than the polyunsaturated fatty acids. were willing to cooperate and filled in the food records from the United Kingdom [3], 7-year-old children recommended except for Spanish 6-7-year-olds [30]. Another concern is that energy intake from available reliably. This is reflected in the increase of energy from Great Britain [10], 5-11-year-old children from Taking into account the high prevalence of obesity carbohydrates in the studied preschool children from intake across the percentile categories for BMI. In France [20] and children aged 5.7-7.6 years from and the studies which link obesity with excessive Piła was lower than the recommended and that energy our previous studies, we observed the increase of Crete [37]. Much higher energy intake from protein fat intake [18], as well as the high prevalence of intake from sucrose was very high. Although there are energy intake through all of the percentile categories than in the studied children, but also higher than the obesity in the studied children’s families [24], it is no reference values of energy intake from sucrose, it is except for the highest categories: obesity in 6-year-old recommended, was reported in 4-6-year-old children of great importance to limit energy intake from this recommended to consume less than 10% of energy from children from Nowy Sącz and the vicinity [22], and from Turek [27], children aged 49-60 months from macronutrient in the studied children. Moreover, monosaccharides and disaccharides, including sucrose, tendency to overweight and overweight in preschool Greece [21], 6-7-year-old children from Spain [30], a long time ago many studies showed that lower which are added to foods by manufacturer, cook or children from Turek [27]. 2-5-year-old and 6-9-year-old children from Spain content of energy from fat in children’s diets results in consumer, as well as sugars which naturally occur in Although most of the studied children had [34] and 7-9-year-old children from Portugal [28]. higher micronutrient intake [36], higher intake of fruit, honey, syrups and fruit juices [39]. This means that if adequate body weight, a substantial percentage of Similar energy intake from monounsaturated vegetables and low-fat foods within such food groups the energy intake from sucrose in the studied children them was characterised by excessive body weight. fatty acids as in the studied children from Piła was as meats and dairy [8, 36], and higher nutrient density was twice higher than the cited recommendation, It is interesting that energy intake in the studied observed in 4-6-year-old children from all over Poland of most vitamins and minerals [29]. energy intake from all added mono- and disaccharides children was lower than in their peers from all over [38]. Lower energy intake from this macronutrient, Energy intake from saturated fatty acids in the and sugars contained in honey, syrups and fruit juices Poland [38] and from Szczecin [32], and even younger but not lower than the recommended, was observed studied children needs urgent reduction, while energy must have been much higher. Polish children, aged 4.6 years, from both urban and in 4-6-year-olds from Turek [27], 6-year-olds from intake from polyunsaturated fatty acids should be Among the previously studied Polish children, rural regions [31]. However, 4-6-year-old children Nowy Sącz and the vicinity [22], 4-6.5-year-olds increased because of the substantial cardioprotective only in 4-6-year-old children from all over Poland from Turek were characterised by lower energy from Belgium [13], 4-10-year-olds from the United benefit. It is of crucial importance since ischaemic [38] energy intake from available carbohydrates was intake [27] than the studied preschoolers from Piła. Kingdom [3], 7-year-olds from Great Britain [10], heart disease and stroke are the two most common within the recommendations. In 4-6-year-old children The explanation may probably be found when taking 2-5-year-olds and 6-9-year-olds from Spain [34] and causes of death all over Europe [14]. To reverse their from Turek [27] and Szczecin [32], and in 6-year-old the date of publication into account. The results in 7-9-year-olds from Portugal [28], but the highest increasing prevalence, the prevention should start children from Nowy Sącz and the vicinity [22], energy 4-6-year-old children from all over Poland [38] were energy intake from monounsaturated fatty acids, above in childhood. It is even more important when taking intake from this macronutrient was too low, while published in 2003, those in 4,6-year-old children in 17% of energy, was observed in Cretan 5.7-7.6-year- into account the high prevalence of myocardial energy intake from sucrose was too high, similarly to 2008 [31] and those in 4-6-year-old children from olds [37] and Spanish 6-7-year-olds [30]. infarction in the studied children’s families [24]. the studied children. Among the previously studied Szczecin in 2010 [32]. Thus, lower energy intake in Unfortunately, the studied children’s diets were Moreover, modifying energy intake from saturated and children from other countries, energy intake from 4-6-year-old children from Turek published in 2014 characterised by excessive energy intake from fat and polyunsaturated fatty acids is also vital to the studied available carbohydrates was also too low [3, 10, 11, [27] and in the studied 4-6-year-old children from saturated fatty acids along with inadequate energy children’s neurodevelopment. Studies showed that 13, 20, 21, 30, 34, 37] with the lowest values, below Piła may result from the decreasing physical activity intake from polyunsaturated fatty acids. The same polyunsaturated fatty acids are involved in numerous 40%, in Spanish 6-7-year-olds [30]. Energy intake observed among preschool children since 2005 [5] observations were reported in 4-6-year-old children neuronal processes, have significant effects on brain from sucrose was not analysed in children from other which may have caused the decrease in energy intake. from all over Poland [38] and 6-year-old children function and their deficiencies and imbalances may countries. However, energy intake from non-milk Another explanation may be the differences in body from Nowy Sącz and the vicinity [22]. Also, 4-6-year- cause neurocognitive disorders [33]. Another study extrinsic sugars in 4-10-year-olds from the United weight. In 4-6-year-old children from Turek, whose old children from Szczecin were characterised by indicates that children whose diets are high in saturated Kingdom [3] was almost 15% and energy intake energy intake was lower than in the studied children, excessive energy intake from fat [32]. In 4-6-year- fatty acids exhibit compromised ability to flexibly from simple carbohydrates exceeded 20% in Spanish as many as 12% were underweight, only 4% were old children from Turek [27] energy intake from fat modulate their cognitive operations, particularly when 6-7-year-olds [30], Portuguese 7-9-year-olds [28] overweight and nobody was obese [27]. However, was within the recommended but energy intake from faced with greater cognitive challenge [16]. and British 7-year-olds [10], while in 4-6.5-year-old among 4-6-year-old children from all over Poland saturated fatty acids was too high and energy intake To solve the problem of excessive energy children from Belgium [13] it exceeded 30%. [38] and 4-6-year-old children from Szczecin [32], from polyunsaturated fatty acids was too low, that is intake from fat and saturated fatty acids along with High energy intake from sucrose in the studied whose energy intake was higher than in the studied the same as in studied children. The same tendencies inadequate energy intake from polyunsaturated fatty children from Piła shows that parents either did not realise children, the percentages of children with underweight were found in children from other countries of the acids, high-fat foods in the studied children’s diets that the amount of sweets and sweetened beverages in and considerable underweight were higher than in same age or similar. Except for 4-6.5-year-old children should be replaced with their low-fat equivalents. The their children’s diets was too high or they were not able the studied children, nevertheless, the percentages of from Belgium [13], energy intake from fat exceeding result would be not only reduced energy intake from to refuse their children sweets. For sure, parents realised obese children were also higher. 30% was reported in all the previously studied fat but also increased intake of essential vitamins and that high intake of sucrose is not good for the children’s It is highly favourable that energy intakes from groups of children: British 4-6-year-olds [11] and minerals [36]. To improve energy intake from fatty health because previous studies on nutritional knowledge protein and monounsaturated fatty acids in the 7-year-olds [10], Greek children aged 49-60 months acids, animal fat should be exchanged for rapeseed of preschoolers’ parents showed that they were aware studied preschool children from Piła were within the [21], 4-10-year-olds from the United Kingdom [3], oil which in Poland is of high quality and available of its adverse effects on teeth [6] and of the lack of any recommended. Energy intake from protein in the studied Spanish 2-5-year-olds and 6-9-year-olds [34], French at relatively low price. This oil should be used not essential micronutrients in sugar [26]. 186 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 187

To increase energy intake from available on nutritional status and physical fitness – methodology the United States: Methods and development. Vital and 28. Moreira P., Padez C., Mourão I., Rosado V.: Dietary carbohydrates, more cereal products should be introduced of an intervention study in Polish preschoolers. New Health Statistics 2002;11(246):1-190. calcium and body mass index in Portuguese children. to the studied children’s diets. Eating meat or cheese Med (Wars) 2016;20(1):3-7. 18. Lee S.H., Rodriguez C.R., Hong K.: High fat caloric Eur J Clin Nutr 2005;59(7):861-867. without bread, pasta, rice or any other cereal product 5. Chalcarz W., Merkiel S.: Analysis of physical activity consumption and low levels of physical activity may 29. Nicklas T.A., Dwyer J., Mitchell P., Zive M., Montgomery was quite a frequent habit among the studied children. in preschool children from Piła. Part 1. Ordinary and induce prevalence of obesity in Hispanic American D., Lytle L., Cutler J., Evans M., Cunningham A., additional physical activity and favourite ways of spending children. International Journal of Applied Sports Bachman K., Nichaman M., Snyder P.: Impact of fat To reduce energy intake from sucrose, it is necessary leisure time. New Med (Wars) 2014;18(1):3-11. Sciences 2011;23(2):371-382. reduction on micronutrient density of children’s diets: to eliminate sugar added to tea, to give up consuming 6. Chalcarz W., Merkiel S.: Wiedza żywieniowa rodziców 19. Lioret S., Touvier M., Balin M., Huybrechts I., the CATCH Study. Prev Med 1996;25(4):478-485. sweetened beverages and to limit sweets which were dzieci przedszkolnych z Nowego Sącza i okolic. Dubuisson C., Dufour A., Bertin M., Maire B., Lafay 30. Rodríguez-Artalejo F., Garcés C., Gorgojo L., López eaten by the children even several times a day. 2. Żywienie w profilaktyce chorób dietozależnych L.: Characteristics of energy under-reporting in children García E., Martín Moreno J.M., Benavente M., del [Nutritional knowledge of parents of preschool children and adolescents. Br J Nutr 2011;105(11):1671-1680 Barrio J.L., Rubio R., Ortega H., Fernández O., de CONCLUSIONS from Nowy Sącz and the vicinity. 2. Nutritional doi:10.1017/S0007114510005465. Oya M.: Dietary patterns among children aged 6-7 y in prevention of diet-related diseases]. Żyw Człow Metab 20. Maillard G., Charles M.A., Lafay L., Thibult N., Vray four Spanish cities with widely differing cardiovascular 1. Energy intakes from macronutrients in the studied 2009;36(2):390-395 (in Polish). M., Borys J.M., Basdevant A., Eschwège E., Romon mortality. Eur J Clin Nutr 2002;56(2):141-148. preschool children need urgent modification to 7. Chalcarz W., Merkiel S., Pach D., Lasak Ż.: M.: Macronutrient energy intake and adiposity in non 31. Rogalska-Niedźwiedź M., Charzewska J., Chabros E., prevent the risk of future diet-related diseases. Charakterystyka aktywności fizycznej poznańskich obese prepubertal children aged 5-11 y (the Fleurbaix Chwojnowska Z., Wajszczyk B., Zacharewicz E.: Sposób 2. Preschoolers’ parents and preschool staff should dzieci w wieku przedszkolnym. Physical activity Laventie Ville Santé Study). Int J Obes Relat Metab żywienia dzieci czteroletnich ze wsi na tle dzieci z miast be educated about nutrition recommendations for in preschool children from Poznań. Med Sport Disord 2000;24(12):1608-1617. [Nutrition of 4-year old children from rural and urban 2008;24(5):318-329. 21. Manios Y.: Design and descriptive results of the environments]. Probl Hig Epidmiol 2008;89(1):80-84. children, especially about dietary risks of diseases 8. Dixon L.B., McKenzie J., Shannon B.M., Mitchell “Growth, Exercise and Nutrition Epidemiological 32. Sadowska J., Radziszewska M., Krzymuska A.: and impaired neurodevelopment. D.C., Smiciklas-Wright H., Tershakovec A.M.: The Study In preSchoolers”: The GENESIS Study. BMC Evaluation of nutrition manner and nutritional status effect of changes in dietary fat on the food group and Public Health 2006;6:32 doi:10.1186/1471-2458-6-32. of pre-school children. Acta Sci Pol, Technol Aliment Acknowledgements nutrient intake of 4- to 10-year-old children. Pediatrics 22. Merkiel S.: Dietary intake in 6-year-old children from 2010;9(1):105-115. The authors would like to thank the directors and the 1997;100(5):863-872. southern Poland: part 1 - energy and macronutrient 33. Schuchardt J.P., Huss M., Stauss-Grabo M., Hahn A.: staff of the preschools in Piła for their help in collecting 9. Fisher J.O., Johnson R.K., Lindquist C., Birch L.L., intakes. BMC Pediatr 2014;14:197 doi:10.1186/1471- Significance of long-chain polyunsaturated fatty acids the data on children’s dietary intake at preschool. Goran M.I.: Influence of body composition on the 2431-14-197. (PUFAs) for the development and behaviour of children. This study was financed by the National Science accuracy of reported energy intake in children. Obes 23. Merkiel S., Chalcarz W.: Challenges of dietary intake Eur J Pediatr 2010;169(2):149-164 doi:10.1007/ Centre from the resources for financing research in the Res 2000;8(8):597-603. assessment in preschool children – conclusions from s00431-009-1035-8. years 2010-2014 as a research project N N404 140437 10. Glynn L., Emmett P., Rogers I.: Food and nutrient intakes a dietary intervention study on Polish preschoolers. 34. Serra-Majem L., Ribas-Barba L., Pérez-Rodrigo C., titled: ‘Modifying dietary intake and physical activity of a population sample of 7-year-old children in the New Med (Wars) 2014;18(2):47-51. Aranceta Bartrina J.: Nutrient adequacy in Spanish in preschool children and its influence on nutrition south-west of England in 1999-2000 – what difference 24. Merkiel S., Chalcarz W.: Selected indices of health children and adolescents. Br J Nutr 2006, 96(Suppl does gender make? J Hum Nutr Dietet 2005;18(1):7-19. status in preschool children from Piła and their families 1):S49-S57. status and physical fitness’. 11. Great Britain Office for National Statistics Social Survey as a risk factor of diet-related diseases. Rocz Panstw 35. Sichert-Hellert W., Kersting M., Schoch G.: Division: National Diet and Nutrition Survey: young Zakl Hig 2015;66(2):159-165. Underreporting of energy intake in 1 to 18 year old Conflict of interest people aged 4 to 18 years. Volume 1: Report of the diet 25. Merkiel S., Chalcarz W.: The relationship between German children and adolescents. Z Ernahrungswiss The authors declare no conflict of interest. and nutrition survey. London, Stationery Office, 2000. physical fitness, urine iodine status, and body-mass 1998;37(3):242-251. 12. 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BMC Public Health 2015;15:1254 doi:10.1186/ development of diet-related diseases in preschool Żywności i Żywienia, 2003 (in Polish). Results from Years 1, 2, 3 and 4 (combined) of the Roll- s12889-015-2607-3. children from Turek]. In: Gromadzka-Ostrowska J. 39. World Health Organization: Diet, nutrition and the ing Programme (2008/2009 – 2011/2012). Available 16. Khan N.A., Raine L.B., Drollette E.S., Scudder M.R., (ed). Fizjologiczne uwarunkowania postępowania prevention of chronic diseases. Report of a Joint WHO/ https://www.gov.uk/government/publications/nation- Hillman C.H.: The relation of saturated fats and dietary dietetycznego [Physiological determinants of dietary FAO Expert Consultation. Geneva, World Health al-diet-and-nutrition-survey-results-from-years-1-to- cholesterol to childhood cognitive flexibility. Appetite approach]. Warszawa, Katedra Dietetyki, Wydział Organization, 2003. 4-combined-of-the-rolling-programme-for-2008-and- 2015;93:51-56 doi:10.1016/j.appet.2015.04.012. Nauk o Żywieniu Człowieka i Konsumpcji, Szkoła 2009-to-2011-and-2012 (Accessed: 27.01.2016). 17. Kuczmarski R.J., Ogden C.L., Guo S.S., Grummer- Główna Gospodarstwa Wiejskiego w Warszawie, 2014 Received: 23.02.2016 4. Chalcarz W., Merkiel S.: Modifying dietary intake and Strawn L.M., Flegal K.M., Mei Z., Wei R., Curtin L.R., (in Polish). Accepted: 25.04.2016 physical activity in preschool children and its influence Roche A.F., Johnson C.L.: 2000 CDC growth charts for 186 S. Merkiel, W. Chalcarz No 2 No 2 The need for modifying energy intake in preschool children from Piła, Poland 187

To increase energy intake from available on nutritional status and physical fitness – methodology the United States: Methods and development. Vital and 28. Moreira P., Padez C., Mourão I., Rosado V.: Dietary carbohydrates, more cereal products should be introduced of an intervention study in Polish preschoolers. New Health Statistics 2002;11(246):1-190. calcium and body mass index in Portuguese children. to the studied children’s diets. Eating meat or cheese Med (Wars) 2016;20(1):3-7. 18. Lee S.H., Rodriguez C.R., Hong K.: High fat caloric Eur J Clin Nutr 2005;59(7):861-867. without bread, pasta, rice or any other cereal product 5. Chalcarz W., Merkiel S.: Analysis of physical activity consumption and low levels of physical activity may 29. Nicklas T.A., Dwyer J., Mitchell P., Zive M., Montgomery was quite a frequent habit among the studied children. in preschool children from Piła. Part 1. Ordinary and induce prevalence of obesity in Hispanic American D., Lytle L., Cutler J., Evans M., Cunningham A., additional physical activity and favourite ways of spending children. International Journal of Applied Sports Bachman K., Nichaman M., Snyder P.: Impact of fat To reduce energy intake from sucrose, it is necessary leisure time. New Med (Wars) 2014;18(1):3-11. Sciences 2011;23(2):371-382. reduction on micronutrient density of children’s diets: to eliminate sugar added to tea, to give up consuming 6. Chalcarz W., Merkiel S.: Wiedza żywieniowa rodziców 19. Lioret S., Touvier M., Balin M., Huybrechts I., the CATCH Study. Prev Med 1996;25(4):478-485. sweetened beverages and to limit sweets which were dzieci przedszkolnych z Nowego Sącza i okolic. Dubuisson C., Dufour A., Bertin M., Maire B., Lafay 30. Rodríguez-Artalejo F., Garcés C., Gorgojo L., López eaten by the children even several times a day. 2. Żywienie w profilaktyce chorób dietozależnych L.: Characteristics of energy under-reporting in children García E., Martín Moreno J.M., Benavente M., del [Nutritional knowledge of parents of preschool children and adolescents. Br J Nutr 2011;105(11):1671-1680 Barrio J.L., Rubio R., Ortega H., Fernández O., de CONCLUSIONS from Nowy Sącz and the vicinity. 2. Nutritional doi:10.1017/S0007114510005465. Oya M.: Dietary patterns among children aged 6-7 y in prevention of diet-related diseases]. Żyw Człow Metab 20. Maillard G., Charles M.A., Lafay L., Thibult N., Vray four Spanish cities with widely differing cardiovascular 1. Energy intakes from macronutrients in the studied 2009;36(2):390-395 (in Polish). M., Borys J.M., Basdevant A., Eschwège E., Romon mortality. Eur J Clin Nutr 2002;56(2):141-148. preschool children need urgent modification to 7. Chalcarz W., Merkiel S., Pach D., Lasak Ż.: M.: Macronutrient energy intake and adiposity in non 31. Rogalska-Niedźwiedź M., Charzewska J., Chabros E., prevent the risk of future diet-related diseases. Charakterystyka aktywności fizycznej poznańskich obese prepubertal children aged 5-11 y (the Fleurbaix Chwojnowska Z., Wajszczyk B., Zacharewicz E.: Sposób 2. Preschoolers’ parents and preschool staff should dzieci w wieku przedszkolnym. Physical activity Laventie Ville Santé Study). Int J Obes Relat Metab żywienia dzieci czteroletnich ze wsi na tle dzieci z miast be educated about nutrition recommendations for in preschool children from Poznań. Med Sport Disord 2000;24(12):1608-1617. [Nutrition of 4-year old children from rural and urban 2008;24(5):318-329. 21. Manios Y.: Design and descriptive results of the environments]. Probl Hig Epidmiol 2008;89(1):80-84. children, especially about dietary risks of diseases 8. Dixon L.B., McKenzie J., Shannon B.M., Mitchell “Growth, Exercise and Nutrition Epidemiological 32. Sadowska J., Radziszewska M., Krzymuska A.: and impaired neurodevelopment. D.C., Smiciklas-Wright H., Tershakovec A.M.: The Study In preSchoolers”: The GENESIS Study. BMC Evaluation of nutrition manner and nutritional status effect of changes in dietary fat on the food group and Public Health 2006;6:32 doi:10.1186/1471-2458-6-32. of pre-school children. Acta Sci Pol, Technol Aliment Acknowledgements nutrient intake of 4- to 10-year-old children. Pediatrics 22. Merkiel S.: Dietary intake in 6-year-old children from 2010;9(1):105-115. The authors would like to thank the directors and the 1997;100(5):863-872. southern Poland: part 1 - energy and macronutrient 33. Schuchardt J.P., Huss M., Stauss-Grabo M., Hahn A.: staff of the preschools in Piła for their help in collecting 9. Fisher J.O., Johnson R.K., Lindquist C., Birch L.L., intakes. BMC Pediatr 2014;14:197 doi:10.1186/1471- Significance of long-chain polyunsaturated fatty acids the data on children’s dietary intake at preschool. Goran M.I.: Influence of body composition on the 2431-14-197. (PUFAs) for the development and behaviour of children. This study was financed by the National Science accuracy of reported energy intake in children. Obes 23. Merkiel S., Chalcarz W.: Challenges of dietary intake Eur J Pediatr 2010;169(2):149-164 doi:10.1007/ Centre from the resources for financing research in the Res 2000;8(8):597-603. assessment in preschool children – conclusions from s00431-009-1035-8. years 2010-2014 as a research project N N404 140437 10. Glynn L., Emmett P., Rogers I.: Food and nutrient intakes a dietary intervention study on Polish preschoolers. 34. Serra-Majem L., Ribas-Barba L., Pérez-Rodrigo C., titled: ‘Modifying dietary intake and physical activity of a population sample of 7-year-old children in the New Med (Wars) 2014;18(2):47-51. Aranceta Bartrina J.: Nutrient adequacy in Spanish in preschool children and its influence on nutrition south-west of England in 1999-2000 – what difference 24. Merkiel S., Chalcarz W.: Selected indices of health children and adolescents. Br J Nutr 2006, 96(Suppl does gender make? J Hum Nutr Dietet 2005;18(1):7-19. status in preschool children from Piła and their families 1):S49-S57. status and physical fitness’. 11. Great Britain Office for National Statistics Social Survey as a risk factor of diet-related diseases. Rocz Panstw 35. Sichert-Hellert W., Kersting M., Schoch G.: Division: National Diet and Nutrition Survey: young Zakl Hig 2015;66(2):159-165. Underreporting of energy intake in 1 to 18 year old Conflict of interest people aged 4 to 18 years. Volume 1: Report of the diet 25. Merkiel S., Chalcarz W.: The relationship between German children and adolescents. Z Ernahrungswiss The authors declare no conflict of interest. and nutrition survey. London, Stationery Office, 2000. physical fitness, urine iodine status, and body-mass 1998;37(3):242-251. 12. Henry CJ.: Basal metabolic rate studies in humans: index in 6- to 7-year-old Polish children. Int J Sport 36. Sigman-Grant M., Warland R., Hsieh G.: Selected REFERENCES measurement and development of new equations. Nutr Exerc Metab 2011;21(4):318-327. lower-fat foods positively impact nutrient quality Public Health Nutr 2005;8(7A):1133-1152. 26. Merkiel S., Chalcarz W.: Wiedza żywieniowa rodziców in diets of free-living Americans. J Am Diet Assoc 1. Alexy U., Sichert-Hellert W., Kersting M., Schultze- 13. Huybrechts I., De Henauw S.: Energy and nutrient dzieci przedszkolnych z Nowego Sącza i okolic. 2003;103(5):570-576. Pawlitschko V.: Pattern of long-term fat intake and intakes by pre-school children in Flanders-Belgium. Br 1. Wiedza ogólna o żywieniu dzieci [Nutritional 37. Smpokos E.A., Linardakis M., Papadaki A., Theodorou BMI during childhood and adolescence – results of J Nutr 2007;98(3):600-610. knowledge of parents of preschool children from Nowy A.S., Havenetidis K., Kafatos A.: Differences in energy the DONALD Study. Int J Obes Relat Metab Disord 14. Institute for Health Metrics and Evaluation: Global Sącz and the vicinity. 1. General principles of nutrition and nutrient-intake among Greek children between 2004;28(10):1203-1209. Burden of Disease (GBD) Compare. Available http:// during childhood]. Żyw Człow Metab 2009;36(2):385- 1992/93 and 2006/07. J Hum Nutr Diet 2014;27(Suppl 2. Barlow S.E., the Expert Committee: Expert Committee vizhub.healthdata.org/gbd-compare/ (Accessed 389 (in Polish). 2):230-238 doi:10.1111/jhn.12122. recommendations regarding the prevention, assessment, 18.02.2016). 27. Merkiel S., Chalcarz W., Mielczarek D.: Błędy 38. Szponar L., Sekuła W., Rychlik E., Ołtarzewski M., and treatment of child and adolescent overweight and 15. Ishii K., Shibata A., Adachi M., Nonoue K., Oka K.: w spożyciu energii z makroskładników czynnikiem Figurska K.: Badania indywidualnego spożycia obesity: summary report. Pediatrics 2007;120(Suppl Gender and grade differences in objectively measured sprzyjającym rozwojowi chorób dietozależnych żywności i stanu odżywienia w gospodarstwach 4):S164-S192. physical activity and sedentary behavior patterns among w grupie dzieci przedszkolnych z Turku [Inadequate domowych [Research on individual food intake and 3. Bates B., Lennox A., Prentice A., Bates C., Page P., Ni- Japanese children and adolescents: a cross-sectional energy intake from macronutrients favours the nutritional status in households]. Warszawa, Instytut cholson S., Swan G.: National Diet and Nutrition Survey. study. BMC Public Health 2015;15:1254 doi:10.1186/ development of diet-related diseases in preschool Żywności i Żywienia, 2003 (in Polish). Results from Years 1, 2, 3 and 4 (combined) of the Roll- s12889-015-2607-3. children from Turek]. In: Gromadzka-Ostrowska J. 39. World Health Organization: Diet, nutrition and the ing Programme (2008/2009 – 2011/2012). Available 16. Khan N.A., Raine L.B., Drollette E.S., Scudder M.R., (ed). Fizjologiczne uwarunkowania postępowania prevention of chronic diseases. Report of a Joint WHO/ https://www.gov.uk/government/publications/nation- Hillman C.H.: The relation of saturated fats and dietary dietetycznego [Physiological determinants of dietary FAO Expert Consultation. Geneva, World Health al-diet-and-nutrition-survey-results-from-years-1-to- cholesterol to childhood cognitive flexibility. Appetite approach]. Warszawa, Katedra Dietetyki, Wydział Organization, 2003. 4-combined-of-the-rolling-programme-for-2008-and- 2015;93:51-56 doi:10.1016/j.appet.2015.04.012. Nauk o Żywieniu Człowieka i Konsumpcji, Szkoła 2009-to-2011-and-2012 (Accessed: 27.01.2016). 17. Kuczmarski R.J., Ogden C.L., Guo S.S., Grummer- Główna Gospodarstwa Wiejskiego w Warszawie, 2014 Received: 23.02.2016 4. Chalcarz W., Merkiel S.: Modifying dietary intake and Strawn L.M., Flegal K.M., Mei Z., Wei R., Curtin L.R., (in Polish). Accepted: 25.04.2016 physical activity in preschool children and its influence Roche A.F., Johnson C.L.: 2000 CDC growth charts for Rocz Panstw Zakl Hig 2016;67(2):189-196 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/

ORIGINAL ARTICLE

ANALYSIS OF VISCERAL FAT IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Petra Lenártová1, Marta Habánová1, Jana Mrázová1, Peter Chlebo1, Joanna Wyka2*

1 Slovak University of Agriculture in Nitra, Faculty of Agrobiology and Food Resources, Department of Human Nutrition, Nitra, Slovakia

2 Wroclaw University of Environmental and Life Sciences, Faculty of Food Science, Department of Human Nutrition, Wroclaw, Poland

ABSTRACT Background. Cigarette smoking is a major public health problem, which leads to the formation of chronic obstructive pulmonary disease (COPD) and is one of the main causes of avoidable death and disability worldwide. Objective. The aim of study was analysis and comparison of the visceral fat in the body of the three groups of subjects (non-smokers, smokers and COPD patients) by Tanita Viscan 140. Material and Methods. The control group was composed of: (1) non-smokers (n=30), consisted of 13 males (43.4%) and 17 women (56.6%) - the average age was 52 ± 6.51 years and (2) smokers (n=30), consisted of 12 men (40%) and 18 women (60%) – the average age 46.53 ± 9.22 years. Study group consisted of patients with COPD (n=60), which consisted of 48 men (80%) and 12 women (20%). Mean age was 69.25 ± 9.90 years. The measurement of visceral fat by Tanita Viscan device 140, which uses bioelectrical impedance analysis to measure fat in the abdomen of the patient in the supine position. Results. High levels of visceral fat (women from 36.9% to 52.3% and more, men from 27.1% to 40.3% or more) were observed in 19 patients (3 women and 16 men), with 19 smokers (10 women and 9 men) and non-smokers in 22 subjects (10 women and 12 men). The average value of waist circumference measured with a Tanita Viscan 140 was in the group of patients 96.38 ± 12.27 cm, in the group of smokers 95.23 ± 10.12 cm and in group of non-smokers 96.86 ± 10.88 cm. Conclusions. The results of our work are of great importance for the health assessment not only among patients with COPD but also in the group of smokers. Therefore it would be appropriate to remind the general public, eg. by campaign for chronic obstructive pulmonary disease and its serious complications and reduce the life quality of these patients and thus help protect human health and in particular young people from the harmful effects of tobacco products.

Key words: visceral fat, smokers, chronic obstructive pulmonary disease

STRESZCZENIE Wprowadzenie. Palenie papierosów jest poważnym problemem zdrowotnym, który prowadzi do powstawania przewlekłej obturacyjnej choroby płuc (POChP) i jest jednym z głównych przyczyn śmierci i niepełnosprawności na całym świecie. Cel badań. Dokonano pomiaru zawartości w organizmie tłuszczu trzewnego za pomocą urządzenia Tanita Viscan 140, który wykorzystuje metodę bioelektrycznej impedancji do pomiaru tkanki tłuszczowej w jamie brzusznej pacjenta w pozycji leżącej. Materiał i metody. Grupa kontrolna składała się z osób niepalących (n = 30), w tym z 13 mężczyzn (43,4%) i 17 kobiet (56,6%) - średni wiek wynosił 52 ± 6,51 roku. Grupa palaczy papierosów (n = 30) składała się z 12 mężczyzn (40%) i 18 kobiet (60%) - średni wiek 46,53 ± 9,22 roku. Badaniem objęto również grupę pacjentów z POChP (n = 60), która składała się z 48 mężczyzn (80%) i 12 kobiet (20%). Średni wiek wynosił 69,25 ± 9,90 roku. Dokonano pomiaru w organizmie zawartości tłuszczu trzewnego za pomocą urządzenia Tanita Viscan 140, który wykorzystuje metodę bioelektrycznej impedancji do pomiaru tkanki tłuszczowej w jamie brzusznej pacjenta w pozycji leżącej. Wyniki. Wykazano wysoki poziom tłuszczu trzewnego (w zakresie od 36,9% do 52,3% u kobiet i w zakresie 27,1% do 40,3% u mężczyzn) u 19 chorych (3 kobiety i 16 mężczyzn) na przewlekłą obturacyjną chorobę płuc zaobserwowano, u 19 palaczy (10 kobiet i 9 mężczyzn ) i w grupie 22 niepalących osób (10 kobiet i 12 mężczyzn). Średnia wartość obwodu talii

*Corresponding author: Joanna Wyka, Uniwersytet Przyrodniczy we Wrocławiu, Katedra Żywienia Człowieka / Wroclaw University of Environmental and Life Sciences, Faculty of Food Science, Department of Human Nutrition, Chełmońskiego street 37/41, 51-630 Wroclaw, phone: +48 71 320 77 57, fax: +48 71 320 77 58; e-mail: [email protected]

ORIGINAL ARTICLE

ANALYSIS OF VISCERAL FAT IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Petra Lenártová1, Marta Habánová1, Jana Mrázová1, Peter Chlebo1, Joanna Wyka2*

1 Slovak University of Agriculture in Nitra, Faculty of Agrobiology and Food Resources, Department of Human Nutrition, Nitra, Slovakia

2 Wroclaw University of Environmental and Life Sciences, Faculty of Food Science, Department of Human Nutrition, Wroclaw, Poland

Key words: visceral fat, smokers, chronic obstructive pulmonary disease

© Copyright by the National Institute of Public Health - National Institute of Hygiene 190 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 No 2 Analysis of visceral fat in patients with COPD 191 mierzona za pomocą urządzenia Tanita Viscan 140 wynosiła: w grupie pacjentów z POChP 96,38 ± 12,27 cm, w grupie analysis to measure fat in the abdomen in lying position hormonal activity. For the foregoing reasons, we palaczy 95,23 ± 10,12 cm, a w grupie niepalących 96.86 ± 10,88 cm. proband. The device uses the most advanced way consider significant determining % body fat and Wnioski. Wyniki pracy mają istotne znaczenie dla oceny stanu zdrowia nie tylko wśród pacjentów z POChP, ale także of measuring the electrical resistance, which allows determining the level of fat in the whole study group of w grupie osób palących. Wskazana byłaby edukacja społeczeństwa poprzez organizowanie kampanii na temat poważnych analyze changes in cellular structures in the abdomen. a very substantial. The Ministry of Health, Labour and powikłań zdrowotnych i obniżeniu jakości życia pacjentów z POChP, aby w ten sposób chronić zdrowie ludzi, szczególnie It shows the concentration of fat on scale 1 to 59 (0.5 Welfare in Japan to used these criteria in the routine młodych, przed szkodliwym działaniem palenia produktów tytoniowych. increments), abdominal fat in % from 0.5 to 75% health examination since 2008 [20]. (in steps of 0.1%), waist circumference in the range Recommended values of waist circumference for Słowa kluczowe: tłuszcz trzewny, palacze papierosów, przewlekła obturacyjna choroba płuc of 50-130 cm (increased in 1 cm). Measuring waist European population is for men > 94 cm for women circumference reaches a high level of repeatability and and > 80 cm. This stricter criterion laid down by the INTRODUCTION inflammation, in the more advanced stages of disease, would reliability of the laser and several no contact sensors. International Diabetes Federation 2005 (International lead to cachexia [6] rather than overweight. However, in The measured values were statistically processed and Diabetes Federation) [11]. Obesity is a global public health threat, it is generally the most recent studies, looking at the association of high evaluated in a statistical program STATISTICA Cz Visceral fat (in the percentage; level of visceral fat) recognized as a risk factor for cardiovascular disease, BMI and COPD, approximately two thirds are overweight version 7.1. The most preferred of tests for statistical and waist circumference were measured in 30 patients arterial hypertension, diabetes and many other health or obese [25]. Chronic obstructive pulmonary disease is evaluation of our experiment, which has a comparative with COPD, 30 smokers and 30 non-smokers (Table problems [27]. generally characterized by excessive production of mucus, nature, the Kruskall-Wallis test. 1). To measure those indicators we used the device The frequency and severity of endocrine and metabolic cough, progressive airways obstruction and change in Tanita ViScan 140. disorders in obese individuals increased with the over pulmonary function [8]. The reasons for limiting the RESULTS AND DISCUSSION Since subcutaneous fat and visceral fat differ accumulation of visceral fat as compared to subjects with flow in the airways are various combinations of chronic in composition and function, and both contribute fat accumulation in the skin [21]. bronchitis, emphysema and chronic bronchiolitis [24]. The amount of visceral fat is the best criterion for to abdominal obesity [10], it is relevant to establish Available data indicate a prevalence of obesity Whereas the definition is based on purely morphological monitoring long-term changes in effective health care. the contribution of each to the association between (defined by BMI > 30 kg.m-2) in mild-to-moderate chronic criteria, its diagnosis in vivo is possible indirectly, only There is a strong link between the diseases associated abdominal obesity and lung function. Recently, it obstructive pulmonary disease (COPD) patients of about on a correct interpretation of the findings obtained in the with lifestyle and % body fat in the abdominal area. For has become clear that adipocytes present in visceral 20% [26]. physical, X-ray and functional examination [1]. example, obesity does not determine the actual weight, but fat produce more proinflammatory mediators than In addition, about 40% of male and 20% of female In patients with COPD may be present in any of these. the fat percentage in the body, which is differentiated by adipocytes present in subcutaneous fat [13]. patients with COPD are obese. With regard to fat Their relative contribution to the disease process, it is often gender. An above body fat content is the cause of various Several studies have reported that body mass index distribution about 70% of the men and 45% of the women difficult to see. Asthma differs from COPD in its pathogenic lifestyle diseases, such as hypertension, cardiovascular (BMI), especially central obesity, was significantly showed abdominal obesity (defined by waist circumference and response rate and thus should be considered as distinct diseases, disorders of serum lipids, diabetes etc. associated with impaired lung function [14, 16]. >102 cm for men, >88 cm for women). These data indicate clinical phenomenon [22]. On the other hand, even below the average value For different level of visceral fat in the women and that there is a subgroup of patients with normal weight but We hypothesize, that in subjects with abdominal of the body fat are not appropriate. Body fat is not only men body we present results separately for each of the abdominal obesity [19]. obesity the determinant of lung function impairment is the a source of energy but also has a protective function gender. Accumulation of visceral fat plays a role also in the presence of visceral fat. Therefore, it is important to gain and thermoregulation and ensures physiological metabolic syndrome. As to the relationships between the insight in the association between visceral fat and lung different risk factors of metabolic syndrome and insulin function in selected groups peoples with/without COPD as Table 1. Analysis of visceral fat by device Tanita Viscan 140 sensitivity, fat and abdominal subcutaneous stored, a pulmonary damage. We used the bioelectric impedance COPD patients Smokers Non-smokers as visceral fat is correlated with the risk of metabolic analysis technique that allows the measurement of visceral Fat (%) syndrome [3]. Overleaf of this problem is smoking, fat distribution. N 30 30 30 which is connected to lower body weight and a reduction 32.84 34.67 35.74 in appetite [2]. Therefore is smoking commonly used as MATERIAL AND METHODS ± SD 11.03 8.66 7.87 a weight control strategy, especially among young people median 36.95 32.95 34.75 and women [7]. It appears that the effect of smoking on the The research was conducted in three experimental maximum 48.80 51.20 52.60 appetite is mediated by nicotine [9]. Cigarette smoking is groups. The first group was composed of 30 patients a further important public health, leading to the formation from Specialized Hospital sv. Svorada-Zobor Nitra, minimum 10.90 11.90 18.90 of chronic obstructive pulmonary disease and is a leading who were treated by means of hospitalization or Waist circumference (cm) cause of death and avoidable disability in the world [18]. outpatient basis. Observation group consisted of N 30 30 30 Uncontrolled weight gain after stopping smoking clinically stable patients, acute deterioration of the x 96.38 95.23 96.86 is another reason preventing people stop smoking, patients were excluded from the reference file. The ± SD 12.27 10.12 10.88 therefore more than 75% of former smokers achieved control group consisted of probands from the general median 98.00 95.5 95.00 weight gain after smoking cessation [15, 17].Obesity population without chronic obstructive pulmonary maximum 117.00 118.00 125.00 has recently been identified as a major risk factor for the disease, acquired by random selection, who were minimum 75.00 80.00 73.00 development of asthma. Asthma tends to be more severe divided into two subgroups. The first control subgroup Level of visceral fat - smokers (n = 30) and a second subset of non-smokers in obese individuals, and it does not respond adequately N 30 30 30 to treatment. As a result, the combination of obesity and (n = 30) were men and women to be represented x 14.53 10.23 10.86 asthma is becoming a major public health issue in many individuals of both sexes. countries [5]. To the measurement of visceral fat was used ± SD 7.51 3.99 4.86 It was traditionally thought that COPD patients were a device Tanita ViScan 140 (Tanita® Corporation, median 14.00 11.25 11.50 less likely to be obese. The rationale was that systemic Tokyo, Japan), which uses the bioelectric impedance maximum 26.00 18.50 24.50 minimum 3.50 4.00 2.50 190 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 No 2 Analysis of visceral fat in patients with COPD 191 mierzona za pomocą urządzenia Tanita Viscan 140 wynosiła: w grupie pacjentów z POChP 96,38 ± 12,27 cm, w grupie analysis to measure fat in the abdomen in lying position hormonal activity. For the foregoing reasons, we palaczy 95,23 ± 10,12 cm, a w grupie niepalących 96.86 ± 10,88 cm. proband. The device uses the most advanced way consider significant determining % body fat and Wnioski. Wyniki pracy mają istotne znaczenie dla oceny stanu zdrowia nie tylko wśród pacjentów z POChP, ale także of measuring the electrical resistance, which allows determining the level of fat in the whole study group of w grupie osób palących. Wskazana byłaby edukacja społeczeństwa poprzez organizowanie kampanii na temat poważnych analyze changes in cellular structures in the abdomen. a very substantial. The Ministry of Health, Labour and powikłań zdrowotnych i obniżeniu jakości życia pacjentów z POChP, aby w ten sposób chronić zdrowie ludzi, szczególnie It shows the concentration of fat on scale 1 to 59 (0.5 Welfare in Japan to used these criteria in the routine młodych, przed szkodliwym działaniem palenia produktów tytoniowych. increments), abdominal fat in % from 0.5 to 75% health examination since 2008 [20]. (in steps of 0.1%), waist circumference in the range Recommended values of waist circumference for Słowa kluczowe: tłuszcz trzewny, palacze papierosów, przewlekła obturacyjna choroba płuc of 50-130 cm (increased in 1 cm). Measuring waist European population is for men > 94 cm for women circumference reaches a high level of repeatability and and > 80 cm. This stricter criterion laid down by the INTRODUCTION inflammation, in the more advanced stages of disease, would reliability of the laser and several no contact sensors. International Diabetes Federation 2005 (International lead to cachexia [6] rather than overweight. However, in The measured values were statistically processed and Diabetes Federation) [11]. Obesity is a global public health threat, it is generally the most recent studies, looking at the association of high evaluated in a statistical program STATISTICA Cz Visceral fat (in the percentage; level of visceral fat) recognized as a risk factor for cardiovascular disease, BMI and COPD, approximately two thirds are overweight version 7.1. The most preferred of tests for statistical and waist circumference were measured in 30 patients arterial hypertension, diabetes and many other health or obese [25]. Chronic obstructive pulmonary disease is evaluation of our experiment, which has a comparative with COPD, 30 smokers and 30 non-smokers (Table problems [27]. generally characterized by excessive production of mucus, nature, the Kruskall-Wallis test. 1). To measure those indicators we used the device The frequency and severity of endocrine and metabolic cough, progressive airways obstruction and change in Tanita ViScan 140. disorders in obese individuals increased with the over pulmonary function [8]. The reasons for limiting the RESULTS AND DISCUSSION Since subcutaneous fat and visceral fat differ accumulation of visceral fat as compared to subjects with flow in the airways are various combinations of chronic in composition and function, and both contribute fat accumulation in the skin [21]. bronchitis, emphysema and chronic bronchiolitis [24]. The amount of visceral fat is the best criterion for to abdominal obesity [10], it is relevant to establish Available data indicate a prevalence of obesity Whereas the definition is based on purely morphological monitoring long-term changes in effective health care. the contribution of each to the association between (defined by BMI > 30 kg.m-2) in mild-to-moderate chronic criteria, its diagnosis in vivo is possible indirectly, only There is a strong link between the diseases associated abdominal obesity and lung function. Recently, it obstructive pulmonary disease (COPD) patients of about on a correct interpretation of the findings obtained in the with lifestyle and % body fat in the abdominal area. For has become clear that adipocytes present in visceral 20% [26]. physical, X-ray and functional examination [1]. example, obesity does not determine the actual weight, but fat produce more proinflammatory mediators than In addition, about 40% of male and 20% of female In patients with COPD may be present in any of these. the fat percentage in the body, which is differentiated by adipocytes present in subcutaneous fat [13]. patients with COPD are obese. With regard to fat Their relative contribution to the disease process, it is often gender. An above body fat content is the cause of various Several studies have reported that body mass index distribution about 70% of the men and 45% of the women difficult to see. Asthma differs from COPD in its pathogenic lifestyle diseases, such as hypertension, cardiovascular (BMI), especially central obesity, was significantly showed abdominal obesity (defined by waist circumference and response rate and thus should be considered as distinct diseases, disorders of serum lipids, diabetes etc. associated with impaired lung function [14, 16]. >102 cm for men, >88 cm for women). These data indicate clinical phenomenon [22]. On the other hand, even below the average value For different level of visceral fat in the women and that there is a subgroup of patients with normal weight but We hypothesize, that in subjects with abdominal of the body fat are not appropriate. Body fat is not only men body we present results separately for each of the abdominal obesity [19]. obesity the determinant of lung function impairment is the a source of energy but also has a protective function gender. Accumulation of visceral fat plays a role also in the presence of visceral fat. Therefore, it is important to gain and thermoregulation and ensures physiological metabolic syndrome. As to the relationships between the insight in the association between visceral fat and lung different risk factors of metabolic syndrome and insulin function in selected groups peoples with/without COPD as Table 1. Analysis of visceral fat by device Tanita Viscan 140 sensitivity, fat and abdominal subcutaneous stored, a pulmonary damage. We used the bioelectric impedance COPD patients Smokers Non-smokers as visceral fat is correlated with the risk of metabolic analysis technique that allows the measurement of visceral Fat (%) syndrome [3]. Overleaf of this problem is smoking, fat distribution. N 30 30 30 which is connected to lower body weight and a reduction 32.84 34.67 35.74 in appetite [2]. Therefore is smoking commonly used as MATERIAL AND METHODS ± SD 11.03 8.66 7.87 a weight control strategy, especially among young people median 36.95 32.95 34.75 and women [7]. It appears that the effect of smoking on the The research was conducted in three experimental maximum 48.80 51.20 52.60 appetite is mediated by nicotine [9]. Cigarette smoking is groups. The first group was composed of 30 patients a further important public health, leading to the formation from Specialized Hospital sv. Svorada-Zobor Nitra, minimum 10.90 11.90 18.90 of chronic obstructive pulmonary disease and is a leading who were treated by means of hospitalization or Waist circumference (cm) cause of death and avoidable disability in the world [18]. outpatient basis. Observation group consisted of N 30 30 30 Uncontrolled weight gain after stopping smoking clinically stable patients, acute deterioration of the x 96.38 95.23 96.86 is another reason preventing people stop smoking, patients were excluded from the reference file. The ± SD 12.27 10.12 10.88 therefore more than 75% of former smokers achieved control group consisted of probands from the general median 98.00 95.5 95.00 weight gain after smoking cessation [15, 17].Obesity population without chronic obstructive pulmonary maximum 117.00 118.00 125.00 has recently been identified as a major risk factor for the disease, acquired by random selection, who were minimum 75.00 80.00 73.00 development of asthma. Asthma tends to be more severe divided into two subgroups. The first control subgroup Level of visceral fat - smokers (n = 30) and a second subset of non-smokers in obese individuals, and it does not respond adequately N 30 30 30 to treatment. As a result, the combination of obesity and (n = 30) were men and women to be represented x 14.53 10.23 10.86 asthma is becoming a major public health issue in many individuals of both sexes. countries [5]. To the measurement of visceral fat was used ± SD 7.51 3.99 4.86 It was traditionally thought that COPD patients were a device Tanita ViScan 140 (Tanita® Corporation, median 14.00 11.25 11.50 less likely to be obese. The rationale was that systemic Tokyo, Japan), which uses the bioelectric impedance maximum 26.00 18.50 24.50 minimum 3.50 4.00 2.50 192 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 No 2 Analysis of visceral fat in patients with COPD 193

Group of women Group of men The average values from indicators of visceral The average values from indicators of visceral fat analysis in women by device Tanita Viscan 140 fat analysis in women by device Tanita Viscan 140 describes Table 2. describes Table 3. Low values of visceral fat percentage (21.5% in women) was measured only in one female in non- smokers group. The average values of visceral fat percentage (women from 21.5% to 36.9%) were detected in 2 women with COPD, in the group of smokers in 8 women and non-smokers in 6 women. High values of visceral fat percentage (36.9% of women to 52.3% or more were observed in 3 patients, the 10 women – smokers and 10 non-smokers women. Figure 2. Analysis of waist circumference (cm) in women Figure 1. Analysis of visceral fat (%) in women by device Graphical representation of visceral fat (%) in observed by device Tanita Viscan 140 Tanita Viscan 140 women groups (P – patients; S – smokers; N – non- smokers) are presented in Figure 1. The average level of visceral fat (1.0 to 5.0 or from 5.5 to 9.5) corresponding to the 1th resp. 2th grade, Figure 4. Analysis of visceral fat (%) in men by device Table 2. Analysis of visceral fat in women by device Tanita Viscan 140 we observed by measurements in 2 women; in 11 Tanita Viscan 140 COPD patients Smokers Nonsmokers subjects in the group of smokers and in the group of non-smokers in 11 women. A slightly above average Low values of visceral fat percentage (13.9% in Fat (%) value of visceral fat (10.0 to 12.0 and from 12.5 to men) were measured in 2 men from group of COPD N 5 18 17 14.5) which corresponds 3th resp. 4th degree, we have patients and smoking for one proband. In the group x 39.94 39.05 38.20 found in a group of patients in 3 female, in a group of non-smokers at 0 proband. The average values of of smokers of 6 women and 5 non-smokers females. visceral fat percentage in men (from 13.9% to 27.1%) ± SD 9.82 7.28 8.64 Visceral fat above the average (15.0 to 17.0 or 17.5 were detected in 7 patients with COPD; in the group of median 43.30 39.90 38.90 or more) corresponding to 5th respectively 6th grade, smokers in 2 subjects and non-smokers in 1 man. High maximum 48.80 51.20 52.60 was found in 0 women with COPD, in the group of values of visceral fat percentage (27.1% to 40.3% or minimum 25.00 27.30 18.90 smokers by 1 female and 1 subject in the group of non- more) were observed in 16 patients, the 9 smokers and smokers. non-smokers in 12 subjects. Graphical representation Waist circumference (cm) The Figure 3 presents graphs similar levels of of visceral fat (%) in observed groups (P – patients; S – N 10 18 17 fat in the groups studied (P - patients; S - smokers; smokers; N – non-smokers) are presented in Figure 4. x 98.00 95.44 96.00 N - non-smokers). Multiple comparison P-values have The average value of waist circumference measured between all the groups found each other at endpoints with a Tanita ViScan 140 in the group of patients was ± SD 16.06 12.29 13.32 (% fat, waist circumference, visceral fat level) no 95.97 ± 11.32 cm, in the group of smokers 94.91 ± median 101.00 94.50 92.00 significant differences (P ≥ 0.05). 6.03 cm and a group of non-smokers 98.00 ± 6.84 cm maximum 117.00 118.00 125.00 (Figure 5). The average level of visceral fat (1.0 to 5.0 or minimum 75.00 80.00 73.00 from 5.5 to 9.5) corresponding to the 1th resp. 2th Level of visceral fat grade, we observed by measurements in 9 patients; in N 5 18 17 2 subjects in the group of smokers and in the group of non-smokers in 2 subjects. A slightly above average x 10.00 8.66 8.47 value of visceral fat (10.0 to 12.0 and from 12.5 to ± SD 4.19 3.82 3.83 14.5) which corresponds 3th resp. 4th degree, we have median 11.00 7.75 7.75 found in a group of patients in 2 patients, in a group maximum 14.00 17.00 17.00 of smokers of 8 subjects and 7 non-smokers. Visceral fat above the average (15.0 to 17.0 or 17.5 or more) minimum 3.50 4.00 2.50 corresponding to 5th respectively 6th grade, was found in 14 patients (males), in the group of smokers by 2 The average value of waist circumference of smokers 95.44 ± 12.29 cm and a group of non- Figure 3. Evaluation of visceral fat levels in women by subjects and 4 subjects in the group of non-smokers. measured with a Tanita Viscan 140 in the women smokers 96.00 ± 13.32 cm (Figure 2). device Tanita Viscan 140 group of patients was 98.00 ± 16.06 cm, in the group 192 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 No 2 Analysis of visceral fat in patients with COPD 193

Group of women Group of men The average values from indicators of visceral The average values from indicators of visceral fat analysis in women by device Tanita Viscan 140 fat analysis in women by device Tanita Viscan 140 describes Table 2. describes Table 3. Low values of visceral fat percentage (21.5% in women) was measured only in one female in non- smokers group. The average values of visceral fat percentage (women from 21.5% to 36.9%) were detected in 2 women with COPD, in the group of smokers in 8 women and non-smokers in 6 women. High values of visceral fat percentage (36.9% of women to 52.3% or more were observed in 3 patients, the 10 women – smokers and 10 non-smokers women. Figure 2. Analysis of waist circumference (cm) in women Figure 1. Analysis of visceral fat (%) in women by device Graphical representation of visceral fat (%) in observed by device Tanita Viscan 140 Tanita Viscan 140 women groups (P – patients; S – smokers; N – non- smokers) are presented in Figure 1. The average level of visceral fat (1.0 to 5.0 or from 5.5 to 9.5) corresponding to the 1th resp. 2th grade, Figure 4. Analysis of visceral fat (%) in men by device Table 2. Analysis of visceral fat in women by device Tanita Viscan 140 we observed by measurements in 2 women; in 11 Tanita Viscan 140 COPD patients Smokers Nonsmokers subjects in the group of smokers and in the group of non-smokers in 11 women. A slightly above average Low values of visceral fat percentage (13.9% in Fat (%) value of visceral fat (10.0 to 12.0 and from 12.5 to men) were measured in 2 men from group of COPD N 5 18 17 14.5) which corresponds 3th resp. 4th degree, we have patients and smoking for one proband. In the group x 39.94 39.05 38.20 found in a group of patients in 3 female, in a group of non-smokers at 0 proband. The average values of of smokers of 6 women and 5 non-smokers females. visceral fat percentage in men (from 13.9% to 27.1%) ± SD 9.82 7.28 8.64 Visceral fat above the average (15.0 to 17.0 or 17.5 were detected in 7 patients with COPD; in the group of median 43.30 39.90 38.90 or more) corresponding to 5th respectively 6th grade, smokers in 2 subjects and non-smokers in 1 man. High maximum 48.80 51.20 52.60 was found in 0 women with COPD, in the group of values of visceral fat percentage (27.1% to 40.3% or minimum 25.00 27.30 18.90 smokers by 1 female and 1 subject in the group of non- more) were observed in 16 patients, the 9 smokers and smokers. non-smokers in 12 subjects. Graphical representation Waist circumference (cm) The Figure 3 presents graphs similar levels of of visceral fat (%) in observed groups (P – patients; S – N 10 18 17 fat in the groups studied (P - patients; S - smokers; smokers; N – non-smokers) are presented in Figure 4. x 98.00 95.44 96.00 N - non-smokers). Multiple comparison P-values have The average value of waist circumference measured between all the groups found each other at endpoints with a Tanita ViScan 140 in the group of patients was ± SD 16.06 12.29 13.32 (% fat, waist circumference, visceral fat level) no 95.97 ± 11.32 cm, in the group of smokers 94.91 ± median 101.00 94.50 92.00 significant differences (P ≥ 0.05). 6.03 cm and a group of non-smokers 98.00 ± 6.84 cm maximum 117.00 118.00 125.00 (Figure 5). The average level of visceral fat (1.0 to 5.0 or minimum 75.00 80.00 73.00 from 5.5 to 9.5) corresponding to the 1th resp. 2th Level of visceral fat grade, we observed by measurements in 9 patients; in N 5 18 17 2 subjects in the group of smokers and in the group of non-smokers in 2 subjects. A slightly above average x 10.00 8.66 8.47 value of visceral fat (10.0 to 12.0 and from 12.5 to ± SD 4.19 3.82 3.83 14.5) which corresponds 3th resp. 4th degree, we have median 11.00 7.75 7.75 found in a group of patients in 2 patients, in a group maximum 14.00 17.00 17.00 of smokers of 8 subjects and 7 non-smokers. Visceral fat above the average (15.0 to 17.0 or 17.5 or more) minimum 3.50 4.00 2.50 corresponding to 5th respectively 6th grade, was found in 14 patients (males), in the group of smokers by 2 The average value of waist circumference of smokers 95.44 ± 12.29 cm and a group of non- Figure 3. Evaluation of visceral fat levels in women by subjects and 4 subjects in the group of non-smokers. measured with a Tanita Viscan 140 in the women smokers 96.00 ± 13.32 cm (Figure 2). device Tanita Viscan 140 group of patients was 98.00 ± 16.06 cm, in the group 194 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 No 2 Analysis of visceral fat in patients with COPD 195

Table 3. Analysis of visceral fat in men by device Tanita Viscan 140 From the results analyzing in the group of women REFERENCES COPD patients Smokers Nonsmokers we have found, that in terms of content abdominal fat were achieved the highest average value among 1. Bakoss P.: Epidemiologia. Ed. Science, Bratislava 2008 Fat (%) patients with COPD (39.94±9.82%), mean values in (in Slovak) N 25 12 13 the group of smokers (39.05±7.28%) and the lowest 2. Bellinger L., Cepeda-Benito A., Wellman P.J.: Meal patterns in male rats during and after intermittent x 31.42 28.10 32.52 average in the group of nonsmokers (38.20±8.64%). The same finding, we have reached the parameters nicotine administration. Pharmacol Biochem Behav ± SD 10.88 6.11 5.52 waist circumference and the level of visceral fat. The 2003;74:495-504. 3. 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Arch Fam Med Multiple comparison P-values have between all the groups combination with BMI to further refine the assessment agroecological conditions of the Slovak Republic and 1992;2:233-237. found each other at endpoints (% fat, waist circumference, of the level of cardiovascular risk associated with their utilisation in improving of population health’. 16. Leone N., Courbon D., Thomas F., Bean K., Jégo B., visceral fat level) no significant differences (P ≥ 0.05). obesity. Leynaert B., Zureik M.: Lung function impairment and Conflict of interest metabolic syndrome: The critical role of abdominal The authors declares no conflict of interest. obesity. American Journal of Respiratory and Critical Care Medicine. 2009;179:509-516. 196 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):197-204 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ 17. Lerman C., Berrettini W., Pinto A., Patterson F., Crystal- 23. Piotrowska, E., Broniecka, A., Biernat, J., Wyka, J., Manour, S., Wileyto E.P.: Changes in food reward Bronkowska, M.: Influence of non-dietary factors on the following smoking cessation: a pharmacogenetic prevalence of abdominal obesity as a major component ORIGINAL ARTICLE investigation. Psychopharmacol 2004;174:571-577. of the metabolic syndrome 17-18-year- old youth. Rocz 18. Marshall E.: Epidemiology. Public enemy number one: Panstw Zakl Hig 2015;66(1):85-92 [PMID: 25813078; POTENTIAL HAZARDS OF TOXIC METALS FOUND IN TOOTHPASTES tobacco or obesity? Science 2004;304:804-814. http://www.ncbi.nlm.nih.gov/pubmed/25813078]. 19. Marquis K., Maltais F., Duguay V., Bezeau A.M., 24. Rozborilová E.: Chronic obstructive pulmonary disease. COMMONLY USED IN NIGERIA LeBlanc P., Jobin J. et al.: The metabolic syndrome in Ed. Via Practica, Bratislava 2005 (in Slovak). 1* 2 2 patients with chronic obstructive pulmonary disease. J 25. Sava F., Laviolette L., Bernard S., Breton M.J., Orish Ebere Orisakwe , Kenneth Obinna Okolo , Zelinjo Nkeiruka Igweze , 3 1 Cardiopulm Rehabil 2005;25(4):226-232. Bourbeau J., Maltais F.: The impact of obesity on Godwin Chukwuebuka Ajaezi , Nnaemeka Arinze Udowelle 20. Ministry of Health, Labour and Welfare: The criteria of walking and cycling performance and response to specific health examination and specific health guide pulmonary rehabilitation in COPD. BMC Pulm Med 1Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria line in Japan. Ed. Tokyo Ministry of Health, Labour and 2010;10:55-60. 2Faculty of Pharmacy, Madonna University Elele, Port Harcourt, Rivers State, Nigeria Welfare, Tokyo 2008. 26. Steuten L.M., Creutzberg E.C., Vrijhoef H.J., Wouters 3Department of Medical Laboratory Science, Faculty of Science, Rivers State University of Science 21. Montague C.T., O’rahilly S.: The perils of portliness: E.F.: COPD as a multicomponent disease: inventory of and Technology Port Harcourt, Port Harcourt, Rivers State, Nigeria cause and consequences of visceral adiposity. Diabetes dyspnoea, underweight, obesity and fat free mass depletion 2000;49:883-888. in primary care. Prim Care Respir J 2006;15(2):84-91. 22. Pawels R., Sonia Buist A., Calvery P., Jenkins C., Hurd 27. Wang Y.C., McPherson K., Marsh T.: Health and ABSTRACT S.: Global strategy for the diagnosis, management and economic burden of the projected obesity trends in the Background. Toothpastes have multi-functional configurations as oral care products. They can however constitute a pos- prevention of chronic obstructive pulmonary disease. USA and the UK. Lancet 2011;378:815-825. sible source, amongst others, of toxic metal exposure in public health. Indeed, the public health impact of personal hygiene NHLBI/WHO Global Initiative for Chronic Obstructive and consumer products is largely unknown. Lung Disease (GOLD). Am J Respir Crit Care Med Received: 05.11.2015 Objective. To determine the level of toxic metals (lead, cadmium, cobalt, chromium, nickel) in toothpastes available in 2001;16:1256-1276. Accepted: 08.03.2016 Nigeria, (home produced and imported), and assess the potential risk to the people. Material and Method. The samples of toothpastes commonly used in Nigeria were tested. Using a market basket protocol thirty five different brands of toothpaste were used. Samples were digest by addition of 10 mL mixture of conc. nitric and

hydrochloric acids (HCl:HNO3, 3:1), followed by heating to dryness. 20 mL deionized water was added, stirred and filtered. The filtrate was made up in standard volumetric flask andlead, cadmium, chromium, cobalt and nickel concentrations were determined using the atomic absorption spectrophotometry 205A. The daily intake of metals and target hazard quotient (THQ) were then calculated. Results. Pepsodent and Flodent had the highest levels of lead at respectively 23.575 and 18.092 mg/kg while Colgate Herbal had the highest nickel of 18.535 mg/kg. The daily intake estimates of all imported toothpaste samples were below the stated upper limits (UL). All target hazard quotients were also found to be below one. Conclusions. Although the UL, THQ and daily intake rates were all normal, the high levels of lead in some of the toothpastes an important concern to public health suggesting that pre-marketing safety studies of toothpastes may be worthwhile for the regulatory authorities.

Key words: toothpaste, risk for health, determination of metals in toothpastes

INTRODUCTION mination of potential toxic metals in personal hygiene and consumer products especially lead and cadmium Toothpaste has multi-functional configuration as which have no known biological function is crucial for an oral care product. These functions which include the safety appraisal and sources classification of hu- cleaning teeth, fighting tartar, providing fluoride pro- man and environmental exposures. The public is gen- tection, freshening breath and whitening teeth have erally unaware of these types of everyday exposure made their demand and use very high [13]. Adverse from chemical constituents of consumer products and health outcomes due to poor-quality products have their health consequences. Zolaly et al. [31] included been reported [11]. Although no serious health condi- the use of toothpaste as one of the possible sources of tions were reported from use of adulterated toothpaste, lead exposure. there was a cautionary note to consumers to avoid Environmental contamination by lead and cad- using toothpaste made in China after contaminated mium is a matter of concern in many countries in- toothpaste was seized in some countries. The deter- cluding Nigeria for several decades [28]. In view of

*Corresponding author: Orish Ebere Orisakwe, Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Rivers, State PMB 5323, Nigeria; e-mail: [email protected]

© Copyright by the National Institute of Public Health - National Institute of Hygiene 196 P. Lenártová, M. Habánová, J. Mrázová et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):197-204 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ 17. Lerman C., Berrettini W., Pinto A., Patterson F., Crystal- 23. Piotrowska, E., Broniecka, A., Biernat, J., Wyka, J., Manour, S., Wileyto E.P.: Changes in food reward Bronkowska, M.: Influence of non-dietary factors on the following smoking cessation: a pharmacogenetic prevalence of abdominal obesity as a major component ORIGINAL ARTICLE investigation. Psychopharmacol 2004;174:571-577. of the metabolic syndrome 17-18-year- old youth. Rocz 18. Marshall E.: Epidemiology. Public enemy number one: Panstw Zakl Hig 2015;66(1):85-92 [PMID: 25813078; POTENTIAL HAZARDS OF TOXIC METALS FOUND IN TOOTHPASTES tobacco or obesity? Science 2004;304:804-814. http://www.ncbi.nlm.nih.gov/pubmed/25813078]. 19. Marquis K., Maltais F., Duguay V., Bezeau A.M., 24. Rozborilová E.: Chronic obstructive pulmonary disease. COMMONLY USED IN NIGERIA LeBlanc P., Jobin J. et al.: The metabolic syndrome in Ed. Via Practica, Bratislava 2005 (in Slovak). 1* 2 2 patients with chronic obstructive pulmonary disease. J 25. Sava F., Laviolette L., Bernard S., Breton M.J., Orish Ebere Orisakwe , Kenneth Obinna Okolo , Zelinjo Nkeiruka Igweze , 3 1 Cardiopulm Rehabil 2005;25(4):226-232. Bourbeau J., Maltais F.: The impact of obesity on Godwin Chukwuebuka Ajaezi , Nnaemeka Arinze Udowelle 20. Ministry of Health, Labour and Welfare: The criteria of walking and cycling performance and response to specific health examination and specific health guide pulmonary rehabilitation in COPD. BMC Pulm Med 1Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria line in Japan. Ed. Tokyo Ministry of Health, Labour and 2010;10:55-60. 2Faculty of Pharmacy, Madonna University Elele, Port Harcourt, Rivers State, Nigeria Welfare, Tokyo 2008. 26. Steuten L.M., Creutzberg E.C., Vrijhoef H.J., Wouters 3Department of Medical Laboratory Science, Faculty of Science, Rivers State University of Science 21. Montague C.T., O’rahilly S.: The perils of portliness: E.F.: COPD as a multicomponent disease: inventory of and Technology Port Harcourt, Port Harcourt, Rivers State, Nigeria cause and consequences of visceral adiposity. Diabetes dyspnoea, underweight, obesity and fat free mass depletion 2000;49:883-888. in primary care. Prim Care Respir J 2006;15(2):84-91. 22. Pawels R., Sonia Buist A., Calvery P., Jenkins C., Hurd 27. Wang Y.C., McPherson K., Marsh T.: Health and ABSTRACT S.: Global strategy for the diagnosis, management and economic burden of the projected obesity trends in the Background. Toothpastes have multi-functional configurations as oral care products. They can however constitute a pos- prevention of chronic obstructive pulmonary disease. USA and the UK. Lancet 2011;378:815-825. sible source, amongst others, of toxic metal exposure in public health. Indeed, the public health impact of personal hygiene NHLBI/WHO Global Initiative for Chronic Obstructive and consumer products is largely unknown. Lung Disease (GOLD). Am J Respir Crit Care Med Received: 05.11.2015 Objective. To determine the level of toxic metals (lead, cadmium, cobalt, chromium, nickel) in toothpastes available in 2001;16:1256-1276. Accepted: 08.03.2016 Nigeria, (home produced and imported), and assess the potential risk to the people. Material and Method. The samples of toothpastes commonly used in Nigeria were tested. Using a market basket protocol thirty five different brands of toothpaste were used. Samples were digest by addition of 10 mL mixture of conc. nitric and

Key words: toothpaste, risk for health, determination of metals in toothpastes

*Corresponding author: Orish Ebere Orisakwe, Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Rivers, State PMB 5323, Nigeria; e-mail: [email protected]

© Copyright by the National Institute of Public Health - National Institute of Hygiene 198 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 No 2 Potential hazards of toxic metals found in toothpastes commonly used in Nigeria 199 the trade liberalisation and the lax in enforcement of Data analyses The total THQ (TTHQ) of heavy metals for the indi- and cadmium in the imported tooth pastes. Flodent had importation regulations, the Nigerian market has been Daily metal intake (DMI) estimate vidual parameter assayed was calculated according to the highest values for lead, cobalt, chromium, and cad- inundated with all manners of personal care and oral Toothpaste ingestion is highest in children and the Chien et al. [5] as the sum of the individual THQ of the mium as 18.09, 16.34, 10.85 and 2.49 mg/kg respec- hygiene products. The public health impact of these mean amount of toothpaste loaded onto the toothbrush potential toxic metals. tively, while Colgate Herbal had the highest amount of products is largely unknown due to poor record keep- per brushing episode is around 0.55 g [14, 20]. Since it The total THQ is the sum of the following composi- nickel, 18.54 mg/kg. ing. In this risk assessment, we have investigated the has been estimated that a mean of 48% of this amount tions: The used oral reference doses (RfD) and upper tol- potential toxic metal hazards of imported and Nige- is ingested, 0.264 g/person/day toothpaste was adapted Total THQ (TTHQ) = THQ (toxicant 1) + THQ (toxi- erable daily intakes for metals (UL) are presented in rian manufactured toothpastes by comparing levels in this study [14, 20]. cant 2) + ...... + THQ (toxicant n). Table 3. No UL for chromium and cobalt has been set of lead, cadmium, chromium, cobalt, and nickel with yet. The potential toxic metal intake through the daily DMI (mg/day) = C x D / B permissible limits given by World Health Organisation metal intake weight RESULTS AND DISCUSSION consumption of the various local toothpaste is shown (WHO) and United States Environmental Protection Where: on Figure 1. Both chromium and cadmium had neg- Agency (USEPA). The daily intake of metals approach The different concentrations of the metals lead, co- ligible daily intakes. For lead, all daily intake values C metal is the metal concentration in sample taken for by Richards et al. [20], Kobayashi et al. [14] and Gar- analysis (in mg/kg). balt, chromium, nickel, and cadmium in the local tooth were below the UL as established by Garcia-Rico et cia-Rico et al. [10] the total hazard quotient (THQ) of paste samples is summarised in Table 1. Pepsodent B weight is the body weight (60 kg in this study). al. [10]. This was also true for nickel. For cadmium, Singh et al. [25] have been adapted in the risk assess- had the highest levels of lead cobalt and nickel, 23.58, D intake is the daily intake (0.264 g/person/day) [14, 20] Sensodyne (Tooth Care F) value for daily intake ex- ment of these toothpastes. 12.71 and 18.63 mg/kg respectively. Oral B Pro-Expert ceeded the UL established by Garcia-Rico et al. [10]. Target hazard quotients (THQ) Dent Fresh had the lowest lead level of 4.51 mg/kg, Figure 2 shows daily intake of potential toxic metals MATERIAL AND METHODS Target hazard quotients (THQ) were developed by while Red Oil Gel had highest amount of cadmium from use of the imported toothpaste. The daily intake the Environmental Protection Agency (EPA) in the US 1.28 mg/kg. estimates of all the imported toothpaste samples were Using basket market protocol thirty five different for the estimation of potential health risks associated Table 2 presents the different concentrations of the found to be below the stated upper limits by Garcia- brands of toothpastes purchased from supermarkets/ with long term exposure to non-carcinogenic chemi- potential toxic metals lead, cobalt, chromium, nickel, Rico et al. [10]. shopping malls in Port Harcourt, Rivers State, Nigeria, cal pollutants [27]. These include not only intake of in March 2013, were used for this study. The tooth- metals but another significant data as exposure fre- paste samples were divided into two groups: (1) local quency and duration, body weight, oral slope cancer - manufactured in Nigeria and (2) foreign or imported. factor and the oral reference dose (RfD). The THQ is Sensodyne tooth care The samples were ashed and digested in Teflon labora- a ratio between the measured concentration and the Sensodyne tory ware that had been cleaned in a high-efficiency oral reference dose (RfD), weighted by the length and Sensodyne particulate air (HEPA) filtered (class 100), trace-met- frequency of exposure, amount ingested and body al-clean laboratory to minimize contamination. This weight. The metals of concern have been recorded to Pepsodent protocol involved sequential cleaning of the lab ware be potential carcinogenic substances [12]. The THQ in a series of baths in solutions (1 week each) and <1 means the exposed population is assumed to be safe rinses (five per solution) in a three-step order, namely and 1 < THQ < 5 means that the exposed population is a detergent solution and deionized water rinses, then in a level of concern interval. THQ parameter is a di- ﬂuoride 6 N HCl (reagent grade) solution and ultra-pure water mensionless index and THQ values are additive, but rinses, finally 7.5 N HNO3 (trace metal grade) solution not multiplicative. and ultra pure water rinses. The lab ware was then air The Target Hazard Quotients for non-carcinogens dried in a polypropylene laminar air flow-exhausting was determined based on the modified formulae of hood. Dry ashing method was used by adding 30mL Chien et al. [4]. of each sample into a conical flask and heated on a hot plate at 200oC, for 45mins, then in a furnace at 500oC -3 Close up THQ = (EFr x EDtot x TIR x C / RfDo x BWa x AT n) x 10 until the volume was drastically reduced to near dry- Close up ness. Digestion was done by addition of 10 mL conc. Where the parameter values are the following: aqua regia (HCl:HNO3, 3:1), it was then heated to dryness. 20 mL de-ionised water was added, stirred and EFr = Exposure Frequency = 365 days/year Close up filtered. The filtrate was made up in standard volumet- EDtot = Exposure Duration = 35 years (chronic exposure) ric flask. Lead, cadmium, nickel, chromium and cobalt TIR = Toothpaste Ingestion Rate = 0.264 g/person/day were determined with flame Atomic Absorption Spec- [14, 20] trophotometry 205A. The limit of detection (LOD) for C = Concentration of metal in toothpaste = mg/kg Cd, Cr, Co and Ni was 0.001 mg/kg, whereas for Pb RfDo = oral Reference Dose = mg/kg/day was 0.01 mg/kg, with blank values reading as 0.00 mg/ Figure 1. Daily intake of potential toxic metals (Pb, Co, Cr, Ni, Cd) from the use of toothpastes manufactured in Nigeria BWa = average body weight, adult = 60 kg, children = kg for all the metals in deionised water with electri- 15 kg cal conductivity value of lower than 5 μS/cm. Samples AT n = average exposure time for non-carcinogens in days were analysed in triplicate. Replicate analyses of sev- (EFr(365 days/year) x EDtot(number of exposure years, eral samples indicate the range of error to be ± 2% for assuming 35 years in this study) all the metals in the toothpaste samples presented. 10-3 = the unit of conversion 198 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 No 2 Potential hazards of toxic metals found in toothpastes commonly used in Nigeria 199 the trade liberalisation and the lax in enforcement of Data analyses The total THQ (TTHQ) of heavy metals for the indi- and cadmium in the imported tooth pastes. Flodent had importation regulations, the Nigerian market has been Daily metal intake (DMI) estimate vidual parameter assayed was calculated according to the highest values for lead, cobalt, chromium, and cad- inundated with all manners of personal care and oral Toothpaste ingestion is highest in children and the Chien et al. [5] as the sum of the individual THQ of the mium as 18.09, 16.34, 10.85 and 2.49 mg/kg respec- hygiene products. The public health impact of these mean amount of toothpaste loaded onto the toothbrush potential toxic metals. tively, while Colgate Herbal had the highest amount of products is largely unknown due to poor record keep- per brushing episode is around 0.55 g [14, 20]. Since it The total THQ is the sum of the following composi- nickel, 18.54 mg/kg. ing. In this risk assessment, we have investigated the has been estimated that a mean of 48% of this amount tions: The used oral reference doses (RfD) and upper tol- potential toxic metal hazards of imported and Nige- is ingested, 0.264 g/person/day toothpaste was adapted Total THQ (TTHQ) = THQ (toxicant 1) + THQ (toxi- erable daily intakes for metals (UL) are presented in rian manufactured toothpastes by comparing levels in this study [14, 20]. cant 2) + ...... + THQ (toxicant n). Table 3. No UL for chromium and cobalt has been set of lead, cadmium, chromium, cobalt, and nickel with yet. The potential toxic metal intake through the daily DMI (mg/day) = C x D / B permissible limits given by World Health Organisation metal intake weight RESULTS AND DISCUSSION consumption of the various local toothpaste is shown (WHO) and United States Environmental Protection Where: on Figure 1. Both chromium and cadmium had neg- Agency (USEPA). The daily intake of metals approach The different concentrations of the metals lead, co- ligible daily intakes. For lead, all daily intake values C metal is the metal concentration in sample taken for by Richards et al. [20], Kobayashi et al. [14] and Gar- analysis (in mg/kg). balt, chromium, nickel, and cadmium in the local tooth were below the UL as established by Garcia-Rico et cia-Rico et al. [10] the total hazard quotient (THQ) of paste samples is summarised in Table 1. Pepsodent B weight is the body weight (60 kg in this study). al. [10]. This was also true for nickel. For cadmium, Singh et al. [25] have been adapted in the risk assess- had the highest levels of lead cobalt and nickel, 23.58, D intake is the daily intake (0.264 g/person/day) [14, 20] Sensodyne (Tooth Care F) value for daily intake ex- ment of these toothpastes. 12.71 and 18.63 mg/kg respectively. Oral B Pro-Expert ceeded the UL established by Garcia-Rico et al. [10]. Target hazard quotients (THQ) Dent Fresh had the lowest lead level of 4.51 mg/kg, Figure 2 shows daily intake of potential toxic metals MATERIAL AND METHODS Target hazard quotients (THQ) were developed by while Red Oil Gel had highest amount of cadmium from use of the imported toothpaste. The daily intake the Environmental Protection Agency (EPA) in the US 1.28 mg/kg. estimates of all the imported toothpaste samples were Using basket market protocol thirty five different for the estimation of potential health risks associated Table 2 presents the different concentrations of the found to be below the stated upper limits by Garcia- brands of toothpastes purchased from supermarkets/ with long term exposure to non-carcinogenic chemi- potential toxic metals lead, cobalt, chromium, nickel, Rico et al. [10]. shopping malls in Port Harcourt, Rivers State, Nigeria, cal pollutants [27]. These include not only intake of in March 2013, were used for this study. The tooth- metals but another significant data as exposure fre- paste samples were divided into two groups: (1) local quency and duration, body weight, oral slope cancer - manufactured in Nigeria and (2) foreign or imported. factor and the oral reference dose (RfD). The THQ is Sensodyne tooth care The samples were ashed and digested in Teflon labora- a ratio between the measured concentration and the Sensodyne tory ware that had been cleaned in a high-efficiency oral reference dose (RfD), weighted by the length and Sensodyne particulate air (HEPA) filtered (class 100), trace-met- frequency of exposure, amount ingested and body al-clean laboratory to minimize contamination. This weight. The metals of concern have been recorded to Pepsodent protocol involved sequential cleaning of the lab ware be potential carcinogenic substances [12]. The THQ in a series of baths in solutions (1 week each) and <1 means the exposed population is assumed to be safe rinses (five per solution) in a three-step order, namely and 1 < THQ < 5 means that the exposed population is a detergent solution and deionized water rinses, then in a level of concern interval. THQ parameter is a di- ﬂuoride 6 N HCl (reagent grade) solution and ultra-pure water mensionless index and THQ values are additive, but rinses, finally 7.5 N HNO3 (trace metal grade) solution not multiplicative. and ultra pure water rinses. The lab ware was then air The Target Hazard Quotients for non-carcinogens dried in a polypropylene laminar air flow-exhausting was determined based on the modified formulae of hood. Dry ashing method was used by adding 30mL Chien et al. [4]. of each sample into a conical flask and heated on a hot plate at 200oC, for 45mins, then in a furnace at 500oC -3 Close up THQ = (EFr x EDtot x TIR x C / RfDo x BWa x AT n) x 10 until the volume was drastically reduced to near dry- Close up ness. Digestion was done by addition of 10 mL conc. Where the parameter values are the following: aqua regia (HCl:HNO3, 3:1), it was then heated to dryness. 20 mL de-ionised water was added, stirred and EFr = Exposure Frequency = 365 days/year Close up filtered. The filtrate was made up in standard volumet- EDtot = Exposure Duration = 35 years (chronic exposure) ric flask. Lead, cadmium, nickel, chromium and cobalt TIR = Toothpaste Ingestion Rate = 0.264 g/person/day were determined with flame Atomic Absorption Spec- [14, 20] trophotometry 205A. The limit of detection (LOD) for C = Concentration of metal in toothpaste = mg/kg Cd, Cr, Co and Ni was 0.001 mg/kg, whereas for Pb RfDo = oral Reference Dose = mg/kg/day was 0.01 mg/kg, with blank values reading as 0.00 mg/ Figure 1. Daily intake of potential toxic metals (Pb, Co, Cr, Ni, Cd) from the use of toothpastes manufactured in Nigeria BWa = average body weight, adult = 60 kg, children = kg for all the metals in deionised water with electri- 15 kg cal conductivity value of lower than 5 μS/cm. Samples AT n = average exposure time for non-carcinogens in days were analysed in triplicate. Replicate analyses of sev- (EFr(365 days/year) x EDtot(number of exposure years, eral samples indicate the range of error to be ± 2% for assuming 35 years in this study) all the metals in the toothpaste samples presented. 10-3 = the unit of conversion 200 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 No 2 Potential hazards of toxic metals found in toothpastes commonly used in Nigeria 201

Table 1. The levels (mg/kg) of potential toxic metals in the local toothpastes manufactured in Nigeria of the potential toxic metals from the use of imported is a risk assessment of toothpaste commonly used in toothpastes is shown on Figure 4. All target hazard Nigeria. In Nigeria there is indiscriminate use of tooth- Local toothpastes Lead Cobalt Chromium Nickel Cadmium quotients were also found to be below one. Similarly paste (flavoured or regular) across the ages. Moreover Close Up Complete 8 Actions 11.033 1.989 <0.001 14.505 0.043 the DMI and THQ values for children (not shown in most children start brushing as early as two years. The Close Up Fine Free Dual Sensation 11.412 2.869 0.001 14.312 <0.001 the figures) were even lower than adults. percentage of toothpaste ingested diminish signifi- Close Up Herbal (Family Teeth) 14.871 5.992 3.897 17.050 0.043 The sulfhydryl-reactive toxic metals like cadmi- cantly as the children’s age increase, regardless of the Close Up Loves Deep (53) 12.116 4.769 <0.001 12.101 <0.001 um, lead and mercury have no beneficial biological amount of toothpaste used [14, 20]. Some studies have function and their accumulation in the body has se- reported increase in the amount of toothpaste ingested Close Up Red Hot (3X) 13.103 3.428 0.002 13.789 <0.001 rious adverse health effects. These metals burden tax for toothpastes flavoured for children [1, 14, 18] but Close Up White On 10.689 5.137 <0.001 15.121 0.001 nutritional status, which impact negatively on anti-ox- others showed no difference in amount ingested be- Dabour Herbal (Mint x Lemon) 17.888 8.178 <0.001 8.573 0.329 idative and detoxification processes. The present study tween these and flavoured toothpastes [15]. Macleans Complete Care 13.004 5.108 1.024 6.798 <0.001 Macleans Herbal 8.768 5.032 2.211 7.024 <0.001 Medicamente Dabour Natural 8.699 5.328 0.542 9.302 <0.001 Milk Teeth Macleans 1 – 6 11.103 4.865 1.543 5.472 0.043 MyMy Herbal Flouride Teeth 8.718 7.997 1.231 13.554 0.978 MyMy Power Gel (Dental Fresh) 12.672 4.197 0.001 9.692 <0.001 Nanny Herbal 9.321 4.672 <0.001 11.169 0.001 Oral B Pro-Expert Dent Fresh 4.514 2.283 0.596 7.979 0.144 Pepsodent 23.575 12.712 <0.001 18.631 0.284 Red Olive Gel 15.369 10.891 5.968 8.421 1.284 Sensodyne Gentle Whitening 10.794 3.101 0.031 12.235 0.484 Sensodyne Original St. Chloride 9.973 3.412 1.385 10.897 0.456 Sensodyne (Tooth Care F) 10.321 2.978 <0.001 11.872 0.453

Table 2. The levels (mg/kg) of potential toxic metals in the imported toothpastes

Imported toothpastes Lead Cobalt Chromium Nickel Cadmium

Aqua Fresh Mink Mint 13.694 5.172 0.032 14.179 0.342 Aqua Fresh Minty 15.650 13.157 10.706 18.219 2.238 Close Up Complete 6.329 2.698 4.116 11.821 <0.001 Close Up Fine Breeze 6.365 1.055 <0.001 10.655 <0.001 Colgate Fresh Confidence (External Red) 12.234 3.324 0.024 10.520 0.249 Colgate Fresh Confidence (Main Gate) 11.439 4.123 0.012 11.253 0.543 Colgate (Great Regular Flavour) 13.482 3.431 <0.001 8.975 1.316 Figure 2. Daily intake of potential toxic metals (Pb, Co, Cr, Ni, Cd) from the use of the imported toothpastes Colgate Herbal 16.314 11.554 3.217 18.535 2.218 Colgate Junior 13.130 2.742 <0.001 9.992 0.363 Although all the THQ values were less than one for BLL above 10 µg/dl used toothpaste. Since caries cause Colgate Strengthen, Teeth Freshen 10.842 2.114 0.010 13.863 0.331 all the local toothpaste samples suggesting no potential the minerals to diffuse through the enamel surface in Colgate Total 9.401 3.102 <0.001 9.013 0.292 health risk associated with their use. It is however im- the process known as demineralization, the high level Colgate Triple Action 11.369 2.341 0.019 12.023 0.214 portant to note the high levels of lead, cobalt and nickel, of lead in this study is of notable public health impor- Flodent 18.092 16.336 10.854 18.146 2.490 23.58, 12.71 and 18.63 mg/kg respectively in one of the tance given the increasing incidence of caries in Nigeria Meriadent P Protection 14.443 4.476 0.022 11.986 0.034 commonest used toothpastes like Pepsodent especially [2]. Baranowska et al. [3] found a positive correlation Oral B 10.438 4.031 5.324 13.142 0.412 in children. Although the magnitude of the amount of between age and lead level in human teeth. Shirasawa potential toxic metal ingested from the toothpaste ap- et al. [24] found that lead levels in modern teeth in Ja- Table 3. Oral reference doses (RfD) and upper tolerable Figure 3 shows the Target Hazard Quotients (THQ) pears small, it must be remembered that this quantity is pan were higher than those obtained from teeth from daily intakes (UL) for investigated metals of potential toxic metals from the use of locally manu- “in addition to” the potential toxic metal ingested from the human remains of earlier periods, indicating that the RfD (mg/kg/day) UL (mg/day) factured toothpastes. These THQs were calculated us- Element other sources like, water, beverages and food prepared pollution from lead is now greater than it was in the re- [26] [6, 14] ing the oral reference doses (mg/kg/day) (Cr – 1.5; Ni -2 -3 -3 with water, etc. It should be emphasized again that to- mote past. Reports from three dermatitis clinics, show Pb 0.004 0.240 – 2.0 x 10 ; Pb – 4.0 x 10 ; Cd – 1.0 x 10 and Co – 4.3 tal potential toxic metal ingestion is the most important that cheilitis, an inflammatory condition of the lips, is x 10-2) of the individual metal as stipulated by USEPA Cd 0.001 0.064 consideration. According to the work of Zolaly et al. often caused by toothpastes [8, 9, 16]. The daily intake [26] and Food and Nutrition Board [7]. The THQ val- Cr 1.5 - [31] on the association between blood lead levels (BLL) of lead and nickel were below the UL, whereas the daily ues were less than one for all the toothpaste manufac- and environmental exposure among Saudi school chil- intake of cadmium from Sensodyne (Tooth Care F) ex- Ni 0.020 1 tured in Nigeria. The Target Hazard Quotients (THQ) dren in some districts of Al-Madinah, 95.8% that had ceeded the UL established by Garcia-Rico et al. [10]. Co 0.043 - 200 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 No 2 Potential hazards of toxic metals found in toothpastes commonly used in Nigeria 201

Table 2. The levels (mg/kg) of potential toxic metals in the imported toothpastes

Imported toothpastes Lead Cobalt Chromium Nickel Cadmium

Aqua Fresh Mink Mint 13.694 5.172 0.032 14.179 0.342 Aqua Fresh Minty 15.650 13.157 10.706 18.219 2.238 Close Up Complete 6.329 2.698 4.116 11.821 <0.001 Close Up Fine Breeze 6.365 1.055 <0.001 10.655 <0.001 Colgate Fresh Confidence (External Red) 12.234 3.324 0.024 10.520 0.249 Colgate Fresh Confidence (Main Gate) 11.439 4.123 0.012 11.253 0.543 Colgate (Great Regular Flavour) 13.482 3.431 <0.001 8.975 1.316 Figure 2. Daily intake of potential toxic metals (Pb, Co, Cr, Ni, Cd) from the use of the imported toothpastes Colgate Herbal 16.314 11.554 3.217 18.535 2.218 Colgate Junior 13.130 2.742 <0.001 9.992 0.363 Although all the THQ values were less than one for BLL above 10 µg/dl used toothpaste. Since caries cause Colgate Strengthen, Teeth Freshen 10.842 2.114 0.010 13.863 0.331 all the local toothpaste samples suggesting no potential the minerals to diffuse through the enamel surface in Colgate Total 9.401 3.102 <0.001 9.013 0.292 health risk associated with their use. It is however im- the process known as demineralization, the high level Colgate Triple Action 11.369 2.341 0.019 12.023 0.214 portant to note the high levels of lead, cobalt and nickel, of lead in this study is of notable public health impor- Flodent 18.092 16.336 10.854 18.146 2.490 23.58, 12.71 and 18.63 mg/kg respectively in one of the tance given the increasing incidence of caries in Nigeria Meriadent P Protection 14.443 4.476 0.022 11.986 0.034 commonest used toothpastes like Pepsodent especially [2]. Baranowska et al. [3] found a positive correlation Oral B 10.438 4.031 5.324 13.142 0.412 in children. Although the magnitude of the amount of between age and lead level in human teeth. Shirasawa potential toxic metal ingested from the toothpaste ap- et al. [24] found that lead levels in modern teeth in Ja- Table 3. Oral reference doses (RfD) and upper tolerable Figure 3 shows the Target Hazard Quotients (THQ) pears small, it must be remembered that this quantity is pan were higher than those obtained from teeth from daily intakes (UL) for investigated metals of potential toxic metals from the use of locally manu- “in addition to” the potential toxic metal ingested from the human remains of earlier periods, indicating that the RfD (mg/kg/day) UL (mg/day) factured toothpastes. These THQs were calculated us- Element other sources like, water, beverages and food prepared pollution from lead is now greater than it was in the re- [26] [6, 14] ing the oral reference doses (mg/kg/day) (Cr – 1.5; Ni -2 -3 -3 with water, etc. It should be emphasized again that to- mote past. Reports from three dermatitis clinics, show Pb 0.004 0.240 – 2.0 x 10 ; Pb – 4.0 x 10 ; Cd – 1.0 x 10 and Co – 4.3 tal potential toxic metal ingestion is the most important that cheilitis, an inflammatory condition of the lips, is x 10-2) of the individual metal as stipulated by USEPA Cd 0.001 0.064 consideration. According to the work of Zolaly et al. often caused by toothpastes [8, 9, 16]. The daily intake [26] and Food and Nutrition Board [7]. The THQ val- Cr 1.5 - [31] on the association between blood lead levels (BLL) of lead and nickel were below the UL, whereas the daily ues were less than one for all the toothpaste manufac- and environmental exposure among Saudi school chil- intake of cadmium from Sensodyne (Tooth Care F) ex- Ni 0.020 1 tured in Nigeria. The Target Hazard Quotients (THQ) dren in some districts of Al-Madinah, 95.8% that had ceeded the UL established by Garcia-Rico et al. [10]. Co 0.043 - 202 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 No 2 Potential hazards of toxic metals found in toothpastes commonly used in Nigeria 203

The daily intake estimates of all the imported toothpaste 2. Alomary A., Al-Momani I. F., Massadeh A.M.: Lead samples were found to be below the stated upper limits and cadmium in human teeth from Jordan by atomic by Garcia-Rico et al. [10]. Human exposure to cadmi- absorption spectrometry: Some factors influencing um from consumables can reach up to 60% of PTWI in their concentrations. Science of the Total Environment some regions of the world and the possible contribution 2006;369(1):69-75. from these consumables may be significant [23]. Renal 3. Baranowska I., Barchański L., Bąk M., Smolec B., Mzyk Z.: X-ray fluorescence spectrometry in multiel- dysfunction for instance is expected in sensitive popu- emental analysis of hair and teeth. Pol J Environ Stud lation groups at cadmium exposure levels of half of the 2004;13:639-646 present PTWI. Cadmium is a non-essential trace ele- 4. Cheng Y., Schwartz J., Sparrow D., Aro A., Weiss S.T., ment with deleterious effects on cardiovascular, gastro- Hu H.: Bone lead and blood lead levels in relation to intestinal, neurological, renal, and respiratory systems baseline blood pressure and the prospective develop- [22]. Lead exposure is causally related to a modest in- ment of hypertension: the Normative Aging Study. Am crease in both blood pressure and hypertension [4]. Evi- J Epidemiol. 2001;153(2): 164–71. dence suggests that the consequences of this effect are 5. Chien C.L., Hung T.C., Choang K.Y., Yeh, C.Y., Meng substantial, because hypertension is the leading cause P.J., Shieh M.J., Han B.C.: Daily intake of TBT, Cu, of mortality resulting from cardiovascular disease. An Zn, Cd and As for fishermen in Taiwan. Science of Total association between bone lead and mortality as a result Environment 2002;285:177-185. 6. Food and Drug Administration. Dietary reference in- of cardiovascular disease has been reported. Men with takes for vitamin A, vitamin K, arsenic, boron, chro- the highest levels of bone lead had more than five times mium, copper, iodine, iron, manganese, molybdenum, the risk of dying of cardiovascular disease compared to nickel, silicon, vanadium, and zinc. Report of the Panel men with the lowest levels of bone lead [30]. on Micronutrients. National Academy Press, Washing- Subchronic and chronic oral exposure of cobalt in ton, DC, Food and Drug Administration. Dietary sup- man has been associated with effects on the hemato- plements. Center for Food Safety and Applied Nutri- logical, thyroid and cardiovascular systems. Some case tion, FDA, 2001. reports have also indicated the occurrence of reversible 7. Food and Nutrition Board. Dietary Reference Intakes neurological responses. Cobalt crosses the placenta, (DRIs): Recommended Intakes for Individuals. Nation- produces dose-dependent maternal toxicity and was al Academy of Sciences, Washington, DC, USA, 2004. found to be embryotoxic with increased frequency of 8. Francalanci S., Sertoli A., Giorgini S., Pigatto P., San- fetuses with lower bodyweight or skeletal retardation tucci B., Valsecchi R.: Multicentre study of allergic contact cheilitis from toothpastes. Contact Dermatol and embryo-lethality. In chronic studies, cobalt affects Figure 3. Target Hazard Quotients (THQ) of potential toxic metals from use of toothpastes manufactured in Nigeria 2000;43:216-222. fertility in a time- and dose-dependent manner. There is 9. Freeman S., Stephens R.: Cheilitis: analysis of 75 cases a decrease in sperm motility, testicular weight, epididy- referred to a contact dermatitis clinic. Dermatitis 1999; Oral B mal sperm concentration and fertility [17, 19]. 10(4):198-200. Exposure to nickel was linked with genotoxic, Meriadent P protection 10. Garcia-Rico L., Leyva-Perez J., Jara-Marini M.E.: immunotoxic, reproductive toxic, neurotoxic and Content and daily intake of copper, zinc, lead, cadmi- Flodent carcinogenic effects [29]. Sainio and Kanerva [21] um, and mercury from dietary supplements in Mexico. Colgate triple action described the need for improving regulation and la- Food Chem Toxicol 2007;45:1599-1605. Colgate total belling of toothpastes, and forecast the creation of an 11. Haller C. A.: Made in China. J Med. Toxicol. international standard. 2008;4(2):141-142. Colgate strenghten, teeth freshen 12. Hayes R.B.: The carcinogenicity of metals in humans. Colgate junior CONCLUSION Cancer Causes Control 1997;8(3): 371– 85. Colgate herbal 13. http://www.reuters.com/article/topNews/idUSWAT00 764420070601?feedType=RSS. Accessed January 24, Colgate (great regular ﬂavour) The results of our study confirm that pre-market- 2008. Colgate fresh conﬁdence (Main gate) ing safety studies for the toothpastes may be worth- 14. Kobayashi CAN, Belini M.R., Italiani F.M., Pauleto while for the regulatory authorities.

Imported Toothpaste Close up fresh conﬁdence (External red) ARC, Julianelli de Arau´ jo J, Tessarolli V, Grizzo LT, Pessan JP, Machado MAAM, Buzalaf MAR.: Factors in- Close up ﬁne breeze Conflict of interest fluencing fluoride ingestion from dentifrice by children. Close up complete The authors declare no conflict of interest. Community Dent Oral Epidemiol 2011;39: 426–432. Aqua fresh minty 15. Levy S.M., McGrady J.A., Bhuridej P. et al.: Factors af- REFERENCES fecting dentifrice use and ingestion among a sample of Aqua fresh mink mint U.S. preschoolers. Pediatr Dent 2000;22: 389–394. 0 0.005 0.01 0.015 0.02 0.025 0.03 0.035 0.04 1. Adair SM, Piscitelli WP, McKnight-Hanes C.: Com- 16. Lim S.W., Goh C.L.: Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Target Hazard Quotient parison of the use of a child and an adult dentifrice by a sample of preschool children. Pediatr Dent 1997;19: Singapore. Contact Dermat, 2000;43:222-326. 99–103. Pb Co Cr Ni Cd

Figure 4. Target Hazard Quotients (THQ) values from the use of imported toothpastes 202 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 No 2 Potential hazards of toxic metals found in toothpastes commonly used in Nigeria 203

The daily intake estimates of all the imported toothpaste 2. Alomary A., Al-Momani I. F., Massadeh A.M.: Lead samples were found to be below the stated upper limits and cadmium in human teeth from Jordan by atomic by Garcia-Rico et al. [10]. Human exposure to cadmi- absorption spectrometry: Some factors influencing um from consumables can reach up to 60% of PTWI in their concentrations. Science of the Total Environment some regions of the world and the possible contribution 2006;369(1):69-75. 3. Baranowska I., Barchański L., Bąk M., Smolec B., from these consumables may be significant [23]. Renal Mzyk Z.: X-ray fluorescence spectrometry in multiel- dysfunction for instance is expected in sensitive popu- emental analysis of hair and teeth. Pol J Environ Stud lation groups at cadmium exposure levels of half of the 2004;13:639-646 present PTWI. Cadmium is a non-essential trace ele- 4. Cheng Y., Schwartz J., Sparrow D., Aro A., Weiss S.T., ment with deleterious effects on cardiovascular, gastro- Hu H.: Bone lead and blood lead levels in relation to intestinal, neurological, renal, and respiratory systems baseline blood pressure and the prospective develop- [22]. Lead exposure is causally related to a modest in- ment of hypertension: the Normative Aging Study. Am crease in both blood pressure and hypertension [4]. Evi- J Epidemiol. 2001;153(2): 164–71. dence suggests that the consequences of this effect are 5. Chien C.L., Hung T.C., Choang K.Y., Yeh, C.Y., Meng substantial, because hypertension is the leading cause P.J., Shieh M.J., Han B.C.: Daily intake of TBT, Cu, of mortality resulting from cardiovascular disease. An Zn, Cd and As for fishermen in Taiwan. Science of Total association between bone lead and mortality as a result Environment 2002;285:177-185. 6. Food and Drug Administration. Dietary reference in- of cardiovascular disease has been reported. Men with takes for vitamin A, vitamin K, arsenic, boron, chro- the highest levels of bone lead had more than five times mium, copper, iodine, iron, manganese, molybdenum, the risk of dying of cardiovascular disease compared to nickel, silicon, vanadium, and zinc. Report of the Panel men with the lowest levels of bone lead [30]. on Micronutrients. National Academy Press, Washing- Subchronic and chronic oral exposure of cobalt in ton, DC, Food and Drug Administration. Dietary sup- man has been associated with effects on the hemato- plements. Center for Food Safety and Applied Nutri- logical, thyroid and cardiovascular systems. Some case tion, FDA, 2001. reports have also indicated the occurrence of reversible 7. Food and Nutrition Board. Dietary Reference Intakes neurological responses. Cobalt crosses the placenta, (DRIs): Recommended Intakes for Individuals. Nation- produces dose-dependent maternal toxicity and was al Academy of Sciences, Washington, DC, USA, 2004. found to be embryotoxic with increased frequency of 8. Francalanci S., Sertoli A., Giorgini S., Pigatto P., San- fetuses with lower bodyweight or skeletal retardation tucci B., Valsecchi R.: Multicentre study of allergic contact cheilitis from toothpastes. Contact Dermatol and embryo-lethality. In chronic studies, cobalt affects Figure 3. Target Hazard Quotients (THQ) of potential toxic metals from use of toothpastes manufactured in Nigeria 2000;43:216-222. fertility in a time- and dose-dependent manner. There is 9. Freeman S., Stephens R.: Cheilitis: analysis of 75 cases a decrease in sperm motility, testicular weight, epididy- referred to a contact dermatitis clinic. Dermatitis 1999; Oral B mal sperm concentration and fertility [17, 19]. 10(4):198-200. Exposure to nickel was linked with genotoxic, Meriadent P protection 10. Garcia-Rico L., Leyva-Perez J., Jara-Marini M.E.: immunotoxic, reproductive toxic, neurotoxic and Content and daily intake of copper, zinc, lead, cadmi- Flodent carcinogenic effects [29]. Sainio and Kanerva [21] um, and mercury from dietary supplements in Mexico. Colgate triple action described the need for improving regulation and la- Food Chem Toxicol 2007;45:1599-1605. Colgate total belling of toothpastes, and forecast the creation of an 11. Haller C. A.: Made in China. J Med. Toxicol. international standard. 2008;4(2):141-142. Colgate strenghten, teeth freshen 12. Hayes R.B.: The carcinogenicity of metals in humans. Colgate junior CONCLUSION Cancer Causes Control 1997;8(3): 371– 85. Colgate herbal 13. http://www.reuters.com/article/topNews/idUSWAT00 764420070601?feedType=RSS. Accessed January 24, Colgate (great regular ﬂavour) The results of our study confirm that pre-market- 2008. Colgate fresh conﬁdence (Main gate) ing safety studies for the toothpastes may be worth- 14. Kobayashi CAN, Belini M.R., Italiani F.M., Pauleto while for the regulatory authorities.

Figure 4. Target Hazard Quotients (THQ) values from the use of imported toothpastes 204 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):205-208 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ 17. Lukac N., Massanyi P., Zakrzewski M., Toman R., 26. USEPA. Integrated Risk Information System-database. Cigankova V., Stawarz R.: Cobalt-induced alterations in Philadelphia PA, Washington, DC, 2007. hamster testes in vivo. J. Environ Sci Health, Part A, 27. USEPA. Office of Water Regulations and Standard: 2007;42:3, 389-392. Guidance manual for assessing human health risks from INSTRUCTION FOR AUTHORS 18. Oliveira MJL, Paiva SM, Martins LHPM., Pordeus chemically contaminated, fish and shellfish U.S. Envi- I.A, Lima Y.B.O.,Cury J.A.: Influence of rinsing and ronmental Protection Agency, Washington, DC, EPA- Quarterly Roczniki Państwowego Zakładu Higieny [Annals of the National Institute of Hygiene] is the peer- expectoration after toothbrushing on fluoride dose and 503/8-89-002, 1989. reviewed scientific journal that publishes original articles, reviews, short communications, letters to the editor ingested amount by use of conventional and children’s 28. Vig K., Megharaj M., Sethunathan N., Naidu R.: Bio- and book reviews. fluoride dentifrices. Braz Dent J 2006;17(2): 100–105. availability and toxicity of cadmium to microorganisms Journal is devoted to the studies concerning scientificproblems of food and water safety, nutrition, environmen- 19. Pedigo N.G., George WJ., Anderson M.B.: Effects of and their activities in soil: a review. Adv. Environ. Res. tal hygiene, toxicology and risk assessment, public health and other related areas. acute and chronic exposure to cobalt on male reproduc- 2003;8: 121-128. Since 2013, Volume 64, number 1 all the papers are published in English. tion in mice. Reprod. Toxicol. 1988. 2: 45–53. 29. Wataha J.C., Lockwood P.E., Marek M., Ghazi M.: 20. Richards A, Banting D.W.: Fluoride toothpastes. In: Fe- Ability of Ni-containing biomedical alloys to activate- jerskov O, Ekstrand J, Burt BA, (eds). Fluoride in den- monocytes and endothelial cells in vitro. J Biomed Ma- Articles for publication in the Roczniki Panstwowego Zakladu Higieny (Rocz Panstw Zakl Hig) should be sent tistry, 2nd ed. Copenhagen: Munksgaard 1996; 328–46. ter Res 1999;45:251–257. to the following address: 21. Sainio E., Kanerva L.: Contact allergens in toothpastes 30. Weisskopf M.G., Jain N., Nie H. L., Sparrow D., Voko- Roczniki Państwowego Zakładu Higieny and a review of their hypersensitivity. Contact Dermat nas P., Schwartz J., Hu H.: A prospective study of Narodowy Instytut Zdrowia Publicznego - Państwowy Zakład Higieny 1995; 33:100-105. bone lead concentration and death from all causes, car- 24 Chocimska street, 00-791 Warsaw, Poland or e-mailed: [email protected] 22. Satarug S., Garrett S.H., Sens M.A, Sens D.A.: Cad- diovascular diseases, and cancer in the Department of mium, environmental exposure and health outcomes. Veterans Affairs Normative Aging Study. Circulation Environ Health Perspect, 2010;118(2):183-90. 2009;120(12):1056–64. RULES FOR THE ACCEPTANCE OF THE MANUSCRIPTS 23. Schrey P., Wittsiepe J., Budde U., Heinzow B., Idel H., 31. Zolaly M. A., Hanafi M. I., Shawky N., El-Harbi K., Mo- Wilhelm M.: Dietary intake of lead, cadmium, copper hamadin A. M.: Association between blood lead levels Editorial policy and basic information and zinc by children from the German North Sea island and environmental exposure among Saudi school chil- Amrum. Int J. Hyg Environ Health 2000;203(1):1-9. dren in certain districts of Al-Madinah. Inter J Gen Med Only high scientific quality articles complying with the scope of the journal will be considered for the publica- 24. Shirasawa K., Ektessabi A., Koizumi A., Azechi M., Sie 2011;5: 355-364. S.: Assessment of the environment using synchrotron tion. radiation micro-beams. J Electron Spectrosc Relat Received: 04.11.2015 Phenom. 2004;37–40:827–30. Accepted: 21.03.2016 Copyright. All the copyrights to the articles published in the Roczniki Państwowego Zakładu Higieny are 25. Singh A., Sharma R.K., Agrawal M., Marshall F. M.: reserved for the publisher: the National Institute of Public Health – National Institute of Hygiene. It means that Risk Assessment of Heavy Metal Toxicity through Con- after article is published the authors transfer the copyright to the publisher and cannot publish this article or its taminated Vegetables from Waste Water Irrigated Area parts elsewhere for commercial purposes without the written permission from the publisher. of Varanasi, India. Tropical Ecology 2010;51(2S): 375- 387. License Creative Commons. Submitting the manuscript to Editorial Office means that the Authors declares that they have read the full text of the Creative Commons Attribution – Non Commercial 3.0 Poland license (CC-BY-NC) available at: http://creativecommons.org/licenses/by-nc/3.0/pl/deed.en.

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© Copyright by the National Institute of Public Health - National Institute of Hygiene 204 O. E. Orisakwe, K. O. Okolo, Z. N. Igweze et al. No 2 Rocz Panstw Zakl Hig 2016;67(2):205-208 http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ 17. Lukac N., Massanyi P., Zakrzewski M., Toman R., 26. USEPA. Integrated Risk Information System-database. Cigankova V., Stawarz R.: Cobalt-induced alterations in Philadelphia PA, Washington, DC, 2007. hamster testes in vivo. J. Environ Sci Health, Part A, 27. USEPA. Office of Water Regulations and Standard: 2007;42:3, 389-392. Guidance manual for assessing human health risks from INSTRUCTION FOR AUTHORS 18. Oliveira MJL, Paiva SM, Martins LHPM., Pordeus chemically contaminated, fish and shellfish U.S. Envi- I.A, Lima Y.B.O.,Cury J.A.: Influence of rinsing and ronmental Protection Agency, Washington, DC, EPA- Quarterly Roczniki Państwowego Zakładu Higieny [Annals of the National Institute of Hygiene] is the peer- expectoration after toothbrushing on fluoride dose and 503/8-89-002, 1989. reviewed scientific journal that publishes original articles, reviews, short communications, letters to the editor ingested amount by use of conventional and children’s 28. Vig K., Megharaj M., Sethunathan N., Naidu R.: Bio- and book reviews. fluoride dentifrices. Braz Dent J 2006;17(2): 100–105. availability and toxicity of cadmium to microorganisms Journal is devoted to the studies concerning scientificproblems of food and water safety, nutrition, environmen- 19. Pedigo N.G., George WJ., Anderson M.B.: Effects of and their activities in soil: a review. Adv. Environ. Res. tal hygiene, toxicology and risk assessment, public health and other related areas. acute and chronic exposure to cobalt on male reproduc- 2003;8: 121-128. Since 2013, Volume 64, number 1 all the papers are published in English. tion in mice. Reprod. Toxicol. 1988. 2: 45–53. 29. Wataha J.C., Lockwood P.E., Marek M., Ghazi M.: 20. Richards A, Banting D.W.: Fluoride toothpastes. In: Fe- Ability of Ni-containing biomedical alloys to activate- jerskov O, Ekstrand J, Burt BA, (eds). Fluoride in den- monocytes and endothelial cells in vitro. J Biomed Ma- Articles for publication in the Roczniki Panstwowego Zakladu Higieny (Rocz Panstw Zakl Hig) should be sent tistry, 2nd ed. Copenhagen: Munksgaard 1996; 328–46. ter Res 1999;45:251–257. to the following address: 21. Sainio E., Kanerva L.: Contact allergens in toothpastes 30. Weisskopf M.G., Jain N., Nie H. L., Sparrow D., Voko- Roczniki Państwowego Zakładu Higieny and a review of their hypersensitivity. Contact Dermat nas P., Schwartz J., Hu H.: A prospective study of Narodowy Instytut Zdrowia Publicznego - Państwowy Zakład Higieny 1995; 33:100-105. bone lead concentration and death from all causes, car- 24 Chocimska street, 00-791 Warsaw, Poland or e-mailed: [email protected] 22. Satarug S., Garrett S.H., Sens M.A, Sens D.A.: Cad- diovascular diseases, and cancer in the Department of mium, environmental exposure and health outcomes. Veterans Affairs Normative Aging Study. Circulation Environ Health Perspect, 2010;118(2):183-90. 2009;120(12):1056–64. RULES FOR THE ACCEPTANCE OF THE MANUSCRIPTS 23. Schrey P., Wittsiepe J., Budde U., Heinzow B., Idel H., 31. Zolaly M. A., Hanafi M. I., Shawky N., El-Harbi K., Mo- Wilhelm M.: Dietary intake of lead, cadmium, copper hamadin A. M.: Association between blood lead levels Editorial policy and basic information and zinc by children from the German North Sea island and environmental exposure among Saudi school chil- Amrum. Int J. Hyg Environ Health 2000;203(1):1-9. dren in certain districts of Al-Madinah. Inter J Gen Med Only high scientific quality articles complying with the scope of the journal will be considered for the publica- 24. Shirasawa K., Ektessabi A., Koizumi A., Azechi M., Sie 2011;5: 355-364. S.: Assessment of the environment using synchrotron tion. radiation micro-beams. J Electron Spectrosc Relat Received: 04.11.2015 Phenom. 2004;37–40:827–30. Accepted: 21.03.2016 Copyright. All the copyrights to the articles published in the Roczniki Państwowego Zakładu Higieny are 25. Singh A., Sharma R.K., Agrawal M., Marshall F. M.: reserved for the publisher: the National Institute of Public Health – National Institute of Hygiene. It means that Risk Assessment of Heavy Metal Toxicity through Con- after article is published the authors transfer the copyright to the publisher and cannot publish this article or its taminated Vegetables from Waste Water Irrigated Area parts elsewhere for commercial purposes without the written permission from the publisher. of Varanasi, India. Tropical Ecology 2010;51(2S): 375- 387. License Creative Commons. Submitting the manuscript to Editorial Office means that the Authors declares that they have read the full text of the Creative Commons Attribution – Non Commercial 3.0 Poland license (CC-BY-NC) available at: http://creativecommons.org/licenses/by-nc/3.0/pl/deed.en.

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Article in a periodical: 1. Snopczyński T., Struciński P., Góralczyk K., Czaja K., Hernik A., Korcz W., Kucharska A., Ludwicki J.K.: Zastosowanie metody QuEChERS w połączeniu z chromatografią gazową z detektorem wychwy- tu elektronów (GC-ECD) w analizie pozostałości pestycydów w żywności [Application of the QuECh- ERS method coupled with gas chromatography with electron capture detection (GC-ECD) in analysis of pesticide residues in food]. Rocz Panstw Zakl Hig 2011;62(2):145-151 (in Polish). 2. Lopes M.C., Giudici K.V., Marchioni D.M., Fisberg R.M., Martini L.A.: Relationships between n-3 polyunsaturated fatty acid intake, serum 25 hydroxyvitamin D, food consumption, and nutritional status among adolescents. Nutr Res 2015;35(8):681-688. 3. Shridhar G., Rajendra N., Murigendra H., Shridevi P., Prasad M., Mujeeb M.A., Arun S., Neeraj D., Vikas S., Suneel D., Vijay K.: Modern diet and its impact on human health. J Nutr Food Sci 2015;5:6 doi:10.4172/2155-9600.1000430. 4. Wu M., Yu G., Cao Z., Wu D., Liu K., Deng S., Huang J., Wang B., Wang Y.: Characterization and human exposure assessment of organophosphate flame retardants in indoor dust from several microenviron- ments of Beijing, China. Chemosphere 2015, doi:10.1016/j.chemosphere.2015.12.111.

Books and chapter in a book: 5. Riley D.M., Fishbeck P.S.: History of methylene chloride in consumer products. In: Salem H., Olajos E.J. (eds.). Toxicology in Risk Assessment. London, Taylor & Francis, 2000.

Legislative acts: 6. Commission Regulation (EC) No 1881/2006 of 19 December 2006 setting maximum levels for certain contaminants in foodstuffs. Off J EU L 364, 20.12.2006.

Internet source: 7. The Rapid Alert System for Food and Feed (RASFF) Portal. Available https://webgate.ec.europa.eu/ rasff-window/portal (accessed 18.10.2010)

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Snopczyński T., Struciński P., GóralczykPublished K.since, Czaja 1950 K., Hernik A., Korcz W., Kucharska A., Ludwicki J.K.: Zastosowanie metody QuEChERS w połączeniu z chromatografią gazową z detektorem wychwy- Quarterly,tu 4 elektronówissues in 1 volume (GC-ECD) per year w (Noanalizie 1 - March, pozostałości No 2 - June, pestycydów No 3 - September, w żywności No 4[Application - December) of the QuECh- The journalERS is devoted method to coupled research with studies gas onchromatography food and water safety,with electron nutrition, capture environmental detection hygiene, (GC-ECD) toxicology in analysis of and risk assessment,pesticide publicresidues health in food]. and other Rocz related Panstw areas Zakl Hig 2011;62(2):145-151 (in Polish). SUBSCRIPTION 2. Lopes M.C., Giudici K.V., Marchioni D.M., Fisberg R.M., Martini L.A.: Relationships between n-3 Available atpolyunsaturated http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ fatty acid intake, serum 25 hydroxyvitamin D, food consumption, and nutritional status among adolescents. Nutr Res 2015;35(8):681-688. Edited3. and Shridhar published G.by, theRajendra National N. Institute, Murigendra of Public H. Health, Shridevi - National P., Prasad Institute M. of, Hygiene,Mujeeb M.A.Warsaw,, Arun Poland S., Neeraj D., Vikas S., Suneel D., Vijay K.: Modern diet and its impact on human health. J Nutr Food Sci 2015;5:6 The subscription information is available at: doi:10.4172/2155-9600.1000430.EDITORIAL BOARD 4. Wu M., Yu G., Cao Z.Editor-in-Chief, Wu D., Liu K. ,– Deng Kazimiera S., Huang Ćwiek-Ludwicka J., Wang B., Wang Y.: Characterization and human Library of the National Institute of Public Health - National Institute of Hygiene exposure assessment of organophosphateDeputy Editor – flame Paweł Strucińskiretardants in indoor dust from several microenviron- 24 Chocimska street, 00-791 Warsaw, Poland Editorial Secretary – Agnieszka Hernik ments of Beijing, China. Chemosphere 2015, doi:10.1016/j.chemosphere.2015.12.111. Editorial Assistant – Grzegorz Święćkowski Linguistic Editor – Piotr Hołownia Phone: +48 22 54 21 262 or +48 22 54 21 264 Books and chapter in a book: Statistical Editor – Daniel Rabczenko e-mail: [email protected] 5. Riley D.M., Fishbeck P.S.: History of methylene chloride in consumer products. In: Salem H., Olajos E.J. (eds.). Toxicology in Risk Assessment.SUBJECT EDITORS London, Taylor & Francis, 2000. Kazimierz Karłowski – food safety Legislative acts: Ewa Bulska – food and environmental analysis 6. Commission Regulation (EC)Anna NoGronowska-Senger 1881/2006 of 19 – nutritionDecember 2006 setting maximum levels for certain contaminants in foodstuffs.Barbara Off Gworek J EU L –364, environmental 20.12.2006. hygiene Jan K. Ludwicki – toxicology and risk assessment Roczniki Państwowego Zakładu Higieny [Annals of the National Institute of Hygiene] Internet source: Mirosław J. Wysocki, Magdalena Bielska-Lasota – public health may be ordered through Library of the National Institute of Public Health - National Institute 7. The Rapid Alert System for Food and Feed (RASFF) Portal. Available https://webgate.ec.europa.eu/ INTERNATIONAL SCIENTIFIC BOARD of Hygiene mailing address: [email protected] Stanisławrasff-window/portal Berger, Warsaw, Poland (accessed 18.10.2010) Krzysztof Pachocki, Warsaw, Poland Jens Peter Bonde, Copenhagen, Denmark Andrea Raab, Aberdeen, Scotland, UK Tables. 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