Intakes of whole grain in an Italian sample of children, adolescents and adults
Eur J Nutr
Intakes of whole grain in an Italian sample of children, adolescents and adults
Stefania Sette 0
Laura D'Addezio 0
Raffaela Piccinelli 0
Sinead Hopkins 0
Cinzia Le Donne 0
Marika Ferrari 0
Lorenza Mistura 0
Aida Turrini 0
0 Cereal Partners Worldwide , Lausanne , Switzerland
1 Stefania Sette
Purpose There is wide evidence that regular consumption of whole grain foods may reduce the risk of chronic diseases. The aim of this work was to quantify the intake of whole grains and identify main dietary sources in the Italian population. Methods Whole grain intakes were calculated in a sample of 2830 adults/older adults and of 440 children/adolescents from the last national survey INRAN-SCAI 2005-06. Food consumption was assessed from a 3-day food record. The whole grain content of foods was estimated mainly from quantitative ingredient declarations on labels. Results Mean whole grain intakes were 3.7 g/day in adults/older adults and 2.1 g/day in children/adolescents. Overall, 23 % of the sample reported consumption of whole grain foods during the survey, among which mean whole grain intakes ranged from 6.0 g/day in female children to 19.1 g/day in female older adults. The main sources of whole grains were breakfast cereals in children/adolescents (32 %) and bread in adults/older adults (46 %). Consumption of whole grain among adults was associated with significantly higher daily intakes and adequacy of dietary fibre, several vitamins (thiamine, riboflavin, vitamin B ) 6 and minerals (iron, calcium, potassium, phosphorus, zinc,
Diet quality
-
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Introduction
magnesium) compared to non-consumption. Among
children, whole grain intake was associated with significantly
higher intakes of iron and magnesium.
Conclusions The study reveals very low whole grain
intakes across all age groups of the Italian population.
Considering the positive association in consumers between
whole grain intakes and fibre and micro-nutrient intakes,
public health strategies to increase whole grain
consumption should be considered.
Whole grain · Nutrients · Food source ·
Numerous epidemiological studies provide evidence that
consumption of whole grains as part of a balanced diet may
reduce the risk of chronic diseases such as cardiovascular
disease (CVD), type 2 diabetes and some types of cancer
(mainly gastrointestinal); moreover, a habitual
consumption of whole grain foods may contribute to weight
management [
1–7
]. Findings from randomized controlled trials
have been less consistent with some studies showing
positive effects of a diet rich in whole grain foods on blood
pressure [
8
], insulin sensitivity [
9
] and plasma cholesterol
[
10
] and others showing no effects on these outcomes [
11–
14
]. The mechanism of action of these beneficial effects is
not clear, but it is likely due to the synergy of many
bioactive components present in whole grain products, i.e.
dietary fibre, vitamin E, a range of B vitamins, minerals and
phytochemicals that may have a protective role with regard
to health [15]. Indeed, a moderate consumption of whole
grains (usually one to three servings per day equating to
16–48 g/day) has been associated with a more adequate
nutrient intake and better diet quality in several populations
[
16–21
].
Although there is no globally accepted definition for
whole grain, the definition proposed by the American
Association of Cereal Chemists International (AACCI) has been
widely adopted and states that “whole grains consist of the
intact, ground, cracked or flaked caryopsis whose principal
anatomical components—the starchy endosperm, germ and
bran—are present in the same relative proportions as they
exist in the intact kernel” [
22
]. Recently, the consortium
of the HEALTHGRAIN EU project [
23
] published a more
comprehensive definition with the aim of harmonizing
current EU definitions and to better reflect industry practices
for the production of flour and consumer products. While
similar to the AACCI definition, the HEALTHGRAIN
definition allows for small losses of the total grain (<2 %)
and bran (<10 %)—that occur through processing methods
consistent with safety and quality. With regard to what
constitutes a whole grain food, there is a general lack of
consensus currently among scientists and national regulatory
bodies.
The average intake of whole grain in both adults and
children remains very low in America and Europe ranging from 4
to 55 g/day in children/adolescents and from 5 to 55 g/day in
adults [
17–21, 24–28
]. In the UK, 18 % of adults (19+ years)
and 15 % of children (1.5–18 years) do not consume any
whole grain and only around one-fifth of adults and children
consume one serving/day (equal to 16 g/day) [20]. Similarly,
in the USA only 3 % of children/adolescents (2–18 years of
age) and 8 % of adults (≥19 years of age) consume at least
three 16 g servings per day [
29
]. In contrast, whole grain
intakes tend to be higher in Scandinavian countries. In
Denmark, whole grain intakes increased from 28 to 54 g/day in
children (4–14 years old) and from 32 to 55 g/day in adults
(15–75 years old) following the successful implementation of
the Danish Whole Grain Campaign [
24, 28
].
In 2014, the WHO and EU published the revised
European Code against Cancer, in which it is recommended to
have a healthy diet with inclusion of plenty of whole grains,
pulses, vegetables and fruits [
30
]. Moreover, the
consumption of whole grains is recommended in the dietary
guidelines of many countries. These guidelines range from
being quantitative in the USA (48 g/day) and Denmark
(75 g/10 MJ), to non-specific advice such as “products
made from grains such as bread, pasta, rice should be
preferably whole grain” in many other countries including UK
[
31
] Germany [
32
] Greece [
33
], France [
34
] and also Italy
[
35
]. The recommendation presented in the most recent
Mediterranean Diet pyramid [
36
] provides more
quantitative guidance on the consumption of whole grain cereals,
recommending the consumption of one or two servings of
cereals at each main meal (in the form of bread, pasta, rice,
couscous and others) and preferably whole grains.
In European countries, particularly in southern Europe,
there is a lack of information on whole grain intakes. The
aim of the present study was to perform a secondary
analysis of the Italian food consumption database INRAN-SCAI
2005–06 to estimate whole grain intakes and major food
sources of whole grains in children/adolescents and adults/
older adults and to examine the association of whole grain
consumption with daily nutrient intakes and adequacy.
Methods
Study population and data collection
The INRAN-SCAI 2005–06 study was a cross-sectional
survey conducted on a representative sample of 1300
households randomly selected and stratified into the four
main geographical areas of Italy (North-West, North-East,
Centre, South and Islands) between October 2005 and
December 2006. In total, 1329 households participated in
the food survey corresponding to 3323 individuals (1501
males and 1822 females), aged 0.1–97.7 years. Detailed
information about the INRAN-SCAI 2005–06 survey
design, procedures and methodologies can be found on the
previous published papers [
37, 38
].
A 3-day semi-structured diary was used to collect the
food consumption of each subject. Participants recorded
all foods and drinks consumed both inside and outside the
home over 3 consecutive days. The quantity consumed for
each food/beverage/supplements was determined using
household measures and estimated portion sizes
according to detailed guidance notes (with instructions to quantify
the portions used by children) and photographs atlas
developed on the basis of EPIC-SOFT picture book. For children
below 8 years and for any subject who was not able to do
so, the diaries were filled in by the person who took care of
him/her. Moreover, information on the brand of
manufactured and packaged foods was collected as much as
possible, mainly for fortified foods and supplements.
For each participant, self-reported height and weight
were recorded. Information on socio-demographics
(education, occupation, marital status), lifestyle (smoking,
dieting, dietary pattern—Mediterranean/traditional vs others:
vegetarian, vegan, fruitarian, macrobiotic, etc.—physical
activity, sedentary activity, use of supplements and
fortified foods, out-of-home meals) and nutritional knowledge
variables (knowledge of diet–health relationship, frequency
of reading food labels) was determined by a
self-administered questionnaire at the time dietary records were
collected. For children/adolescents, the information available
was limited to the level of education of the family
(highest level among adult family members), physical activity
and hours of sedentary activity per day. In order to capture
all seasonal differences in intake, the sampled households
were proportionally distributed among seasons (excluding
Christmas and Easter periods): 25 % in autumn, 25 % in
winter, 26 % in spring and 24 % in summer. In addition, the
survey calendar was scheduled to take an adequate
proportion of weekdays and weekend days at group level (78 and
22 %).
The survey was purely observational and non-invasive;
ethical aspects were related only to the collection of
information on food habits that may be related to health and thus
might be sensitive. At the time of the survey, INRAN
institute was part of the National Statistical System (SISTAN)
and adhered to the principle of statistical confidentiality,
moreover, as Public Body INRAN adopted the current
regulation on guarantees individual data protection. An
additional ethical committee review of the study protocol was
considered unnecessary.
For the present study, all individuals above 3 years
of age were considered; only one female subject (aged
66 years) that declared to be on a specific diet (high
consumption of bran and whole grain products) during the
survey was excluded. The sample was subdivided into two age
groups: children/adolescents (3- to 17-year-old individuals,
no. 440) and adults/older adults (individuals of age 18 and
above, no. 2830). Data on energy and nutrients intake were
obtained using the updated version of national food
composition database [
38
]. In the case of foods and beverages
that were fortified or enriched with one or more essential
nutrients (included functional foods and foods for special
purpose), the nutrient content was retrieved at brand level
from nutritional labels.
Calculation of whole grain intakes
For the purpose of this study, the term “whole grain” was
defined in accordance with that outlined by
HEALTHGRAIN [
23
], as presented in the introduction of this paper.
It should be noted, however, that Italian regulation permits
the use of the term “whole grain” to be applied to
products made from whole wheat flour purchased as such from
milling companies and also to products made with white
flour to which varying amounts of bran have been added
back. In the first case, “whole wheat flour” is listed as one
ingredient, but in the latter case, the ingredients are listed
separately (wheat flour, bran, middling) [
39
]. For the
present analysis, products containing “whole wheat flour” and
products made with oats, rice, maize/corn, barley, rye and
other cereals were considered.
Of the fifty-one original food sub-categories in the
INRAN-SCAI food consumption database, nine were
identified as containing whole grain (“Bread”, “Pasta and pasta
substitutes”, “Rice”, “Wheat, other cereals and flours”,
“Breakfast cereals”, “Biscuits”, “Savoury fine bakery
products”, “Cakes and sweet snacks”). In addition, the food
groups “Yoghurt and fermented milk”, “Milk based
desserts and substitutes”, “Ice cream, ice lolly and substitutes”
and “Miscellaneous” were also checked for the presence of
whole grain ingredients, as in the case of yogurt with
cereals. All products in the above categories were considered,
and no limit was set on the minimum whole grain content
for inclusion in the analysis.
From the total list of 226 foods containing grains
(including 6 additional foods from non-grain food groups,
5 yogurts and 1 baby food), a sub-list of 76 potential whole
grain products was extracted. After a further screening,
13 foods were excluded as they were found not to contain
whole grain. Overall, 63 food items were found to contain
whole grain, of which 29 individual food items were
codified at brand level (fortified products or foods for special
purpose). The remaining 34 foods which had a generic food
code also had corresponding brand information recorded in
the food consumption database.
Details regarding the whole grain content of food
products with available brand information were obtained from
the specific label of the product collected during the survey
period (2005–2006 years), from the Mintel market research
database [
40
] or from manufacturer’s websites. When
brand-specific data were not available, the average whole
grain content of similar products was used, or in case of
mixed dishes, the recipe values were applied. In the case of
whole meal bread purchased in bakeries, quantitative
ingredient declarations (QUIDs) are not required by law and
there is no clear regulation on the specific amount of whole
wheat flour that should be used in the recipe in order to
call the bread “whole meal”. Furthermore, it is not possible
to know whether “whole wheat flour” or white flour with
added bran was used in the recipe. For the current analysis,
it was assumed that all whole meal bakery bread was made
with whole wheat flour and the whole wheat flour content
was estimated based on the average content of three
traditional recipes, equating to 49 %.
In summary, the whole grain content of the 63 foods was
obtained as follow: 44 % of the products from the specific
label or Mintel database, 33 % from the average of similar
products, 6 % from recipes and the remainder (17 %) were
assigned an estimated value based on knowledge of
common whole grain foods (e.g. brown rice). For each
product, the amount of total whole grain per 100 g and by grain
source (i.e. wheat, oats, rice, maize/corn, barley, rye, other)
was recorded in a whole grains database. Whole grain
foods were re-aggregated as follow: (1) Bread; (2) Pasta;
(3) Rice; (4) Wheat, Other cereals & flours; (5) Ready to
eat Breakfast cereals (RTEBC); (6) Sweet biscuits; (7)
Savoury fine bakery products; (8) Cakes and sweet snacks;
and (9) Other foods (e.g. yogurt with cereals). The
quantities of whole grain consumed and associated nutrient
intakes were calculated, at individual level, as per capita/
day amount, by meal and by eating occasion (portion).
Nutrient density expressed as amount of dietary fibre,
cholesterol, vitamins and minerals per energy (amount/10 MJ)
was also calculated.
Statistical analysis
The mean of the 3 days was used to estimate the whole
grain consumption for each subject. Mean, standard
deviation, median and percentiles of distribution of whole grain
intakes by socio-demographic and lifestyle factors were
calculated for the total population and for consumers only.
Whole grain intakes are reported separately for children
(3–9.9 years old, no. 193), adolescents (10–17.9 years
old, no. 247), adults (18–64.9 years old, no. 2313) and the
older adults (≥65 years old, no. 517), but for subsequent
analyses, children and adolescents were merged as were
the adults and the older adults due to the small sample size.
As there are no specific quantitative recommendations for
whole grain intake in Italy, the adequacy of daily whole
grain intakes was assessed based on US recommendation
of three servings per day (or 48 g/day) [
41
].
Tertile analysis was also carried out in relation to whole
grain intakes. Comparison of mean daily macro- and
micro-nutrient intakes in non-consumers and across tertiles
of mean daily whole grain intakes was made for the two
age groups using the Wilcoxon test or the
Kruskal–Wallis test as appropriate, since the daily intake data were not
normally distributed. In addition, mean daily intakes of
food groups (g/day) in non-consumers and across tertiles
of whole grain intakes were analysed. The Dunn’s post
hoc test was used to identify the significant pairwise
differences across the groups of subjects (non-consumers and
the three consumers’ groups defined according to tertiles of
consumption). Multiple logistic regression analysis,
backward stepwise method, was used to assess the relationship
between socio-demographic and lifestyle characteristics
and whole grain consumption (yes vs. no), and was
performed for adults/older adults and for children/adolescents
separately. Results are presented as crude and adjusted
odds ratios (OR) with 95 % confidence intervals in order to
evaluate the probability of being whole grains consumers.
The adequacy of mean daily nutrient intakes in adults
was compared between non-consumers of whole grain and
across tertiles of whole grain intake using the Probability of
Adequate Nutrient Intake index (PANDiet) [
42
]. The
PANDiet uses the probabilistic approach to estimate the
adequacy of the nutrient intake of an individual; it takes into
account the number of days surveyed, the mean nutrient
intake and its intra-variability, the nutrient reference value
and its variability; the PANDiet is based on the mean of two
scores: the adequacy and the moderation. The reference
values of nutrients for Italian population to calculate the
PANDiet index are reported in the Online resource—Table
A. As the PANDiet index is not validated for children and
adolescents, nutrient adequacy was assessed by calculating
for each nutrient the ratio of the daily individual intakes to
standard recommended amounts [
43
] by subject’s gender
and age category.
For all the analyses, two-sided p values lower than 0.05
were considered statistically significant for all the tests
applied. The analyses were performed using the Statistical
Analysis System computer software package (SAS package
version 9.01; SAS Institute Inc., Cary, NC).
Results
Table 1 shows daily intakes of whole grain in the total
population and consumers only by age groups and gender.
In the total sample, children and adolescents consumed an
average of 2.0 and 2.2 g/day of whole grain, respectively,
whereas adults and the older adults consumed 3.8 and
3.3 g/day, respectively. Overall, 24 % of the sample of
children, adolescents and adults consumed whole grain
products during the 3-day recording period, whereas only 18 %
of older adults were consumers of whole grain. Among
female consumers, mean daily intake of whole grain
increased with age (P < 0.01) and ranged from 6.0 g/day
in children to 19.1 g/day in older adults. Similarly, for male
consumers, mean intakes in adults (18.7 g/day) and older
adults (16.4 g/day) were significantly higher than in the
children/adolescents sample (10.1 g/day) (P < 0.01).
Significant gender differences were observed only in adults/
older adults both in total population and consumers only
(P < 0.0001 and <0.05), whereby intakes were higher in
women than in men when considering the total population
(4.3 vs 2.9 g/day), whereas in consumers only the intakes
were 15.4 g/day in females and 18.3 g/day in males.
However, among adults aged 18–64 years, there were twice as
many whole grain consumers among women (30.5 %) than
among men (15.7 %). In the total sample of adults and
older adults, whole grain intakes were significantly higher
in people living in North-Western (5.4 g/day) and Central
(5.4 g/day) regions compared to those living in the South
and Islands (2.0 g/day). Moreover, whole grain intakes
were higher in adults with a high education level with
respect to those with a low level (data not shown). For the
total population of children and adolescents, significant
differences by socio-demographic and lifestyle factors were
not found.
Table 2 reports the results of logistic regression
analysis carried out on adults/older adults to determine
predictors of whole grain consumption. Females, younger adults
(18–64 years), subjects living in North-Western and Central
NS
NS
NS
NS
NS
NS
NS
SD standard deviation, NS non-significant
* P value from Wilcoxon test for comparison across age groups
** P values from Wilcoxon test for comparison by gender, age groups pooled
regions compared to the South and Islands and those on
a diet were significantly more likely to be consumers of
whole grain. In addition, those who rarely consumed
fortified foods and who reported poor knowledge of diet–health
relationship, and infrequent reading of food labels were
significantly less likely to be consumers of whole grain. No
predictors were significant for the subsample of children/
adolescents (data not shown).
Figure 1 shows the percent contribution from the
different food groups to total whole grain intake in the
consumers sample of children/adolescents and adults/older adults,
respectively. In children/adolescents, the main food group
contributor to whole grain intakes was RTEBCs (32 %),
followed by bread and biscuits (27 and 23 %, respectively).
In adults/older adults, bread was the main source,
providing 46 % of whole grain intakes, while biscuits and savoury
fine bakery products accounted for 20 and 15 %,
respectively. In both age groups, wheat was the major type of
grain contributing to whole grain intake, providing 65 and
80 % of total whole grain intakes, respectively, in children/
adolescents and adults/older adults. Oats were the second
highest contributor, providing 22 and 7 %, respectively.
The proportion of consumers achieving various levels of
whole grain servings according to US whole grain
recommendation is outlined in Table 3. The majority of children/
adolescent consumers (63 %) had less than 1/2 servings
per day (corresponding to <8 g/day), and about 17 % of
them reached or exceeded 1 serving per day (≥16 g/day).
Almost 69 % of adults/older adults consumers had less than
1 whole grain servings per day (<16 g/day), 19 % of them
consumed between 2 and 3 servings per day, and only 5 %
reached or exceeded the recommended 3 servings per day
(48 g/day).
Mean daily intakes of energy, macro- and
micro-nutrients in non-consumers versus consumers of whole grain
across the tertiles of intake for children/adolescents and
Table 2 Odds ratios (OR) and
95 % confidence intervals (CI)
from logistic regression analysis
showing the association of
whole grain consumption (yes
vs no) with different predictor
variables
Adults/older adults
Crude OR (95 % CI)
Adjusted OR (95 % CI)a
adults/older adults are shown in Tables 4 and 5,
respectively. For adults/older adults, significant differences
were observed for total energy, % total energy from total
sugar, dietary fibre and several micro-nutrients. Percent
total energy from total sugar in whole grain consumers
(ranging 16.0–16.8 %) was significantly higher than in
Number of servings
<1/2
<8 g/day
%, percent on consumers only; %p, percent on total population (including non-consumers)
non-consumers (14.1 %) (P < 0.001), and energy-adjusted
intakes of dietary fibre were significantly higher in whole
grain consumers (ranging 22.2–26.1 g/day) than in
nonconsumers (20.9 g/day) (P < 0.001). Energy-adjusted mean
intakes of most minerals (iron, calcium, potassium,
phosphorus, zinc, magnesium) and vitamins (thiamine,
riboflavin, vitamin C, vitamin B6 and vitamin A) were
significantly higher as the daily intake of whole grain increased
(P < 0.001). Although there was a trend for increasing
dietary fibre and micro-nutrient intake with increasing whole
grain intake in children/adolescents, significant differences
only emerged for iron and magnesium (P < 0.05).
The mean of the PANDiet score of adult non-consumers
of whole grain products was 59.23 and tended to increase
with the increase in whole grain consumption, reaching
61.83 in the highest tertile of consumption (significant
different at P < 0.0001). The adequacy score of
non-consumers was significantly lower with respect to consumers, and
so were the single items, except for total carbohydrates,
total fat, polyunsaturated fatty acids, niacin, vitamin B12
and vitamin D; the moderation score was not significantly
different. The only item that was significantly higher in
consumers was the cholesterol (Online resource—Table B).
In the children/adolescents sample, the adequacy of
riboflavin, thiamine, vitamin B12 and iron intakes, calculated
as the ratio of the daily individual intakes to standard
gender and age recommended amounts [
43
], was significantly
higher in whole grain consumers versus non-consumers
(P < 0.05, online resource—Table C).
Discussion
To the best of our knowledge, this study represents the first
attempt to provide an evaluation of whole grain intakes in
the Italian population. Our findings show a very low daily
intake of whole grain in all age groups with only a quarter
of the population reporting consumption of whole grain
over the 3-day survey period. Furthermore, mean intakes
among consumers ranged from only 6 g/day in female
children to 19 g/day in female older adults and only 5 % of
the adults/older adults sample achieved the US quantitative
whole grain recommendation of 48 g/day. Wheat was the
major source of whole grain provided mainly through
consumption of bread and breakfast cereals.
The comparison of whole grain intakes between
countries needs to be interpreted with caution as survey
methods and sampling frames can differ [
44
] and the criteria for
defining whole grain and a whole grain food may also vary
from one country to the other [
45
]. Nonetheless, our results
indicate that whole grain intakes are much below the
reported intakes in other populations. Studies in the USA
[
29, 46
], UK [21], Germany [
25
], Ireland [
26, 27
],
Denmark, Norway and Sweden [24] reported a daily
consumption of more than 13 g/day in children/adolescents (range
13–54 g/day) and 20 g/day in adults/older adults (range
20–51 g/day). Only in France [
19
] the whole grain intakes
were comparable to those found in Italy (5 g/day in adults/
older adults and 4 g/day in children/adolescents).
Furthermore, the proportion of the Italian population reporting
consumption of whole grain foods is well below the rate
of consumers in other countries (ranging 32–90 %) [
19, 20,
24–27, 29
]. These low whole grain intakes are supported by
a recent analysis of alkylresorcinol concentrations (a valid
biomarker of whole grain wheat and rye intake) in the
Italian cohort of the European Prospective Investigation into
Cancer [
47
]. The main contributor to whole grain intakes
was bread in adults/older adults, contributing about half of
the intake, while breakfast cereals were the main source in
children/adolescents (32 % of the total whole grain intake).
Similar findings were reported in other European and US
populations, suggesting that bread and breakfast cereals
are well accepted whole grain foods among consumers.
For example, bread accounted for approximately 30–80 %
Table 4 Mean daily intakes of
energy, macro-nutrients (as %
of total energy intake), dietary
fibre, vitamins and minerals (as
10 MJ) for non-consumer of
whole grain and across tertiles
of mean daily whole grain
intakes in children/adolescents
Age (years)
BMI z score†
Energy
(MJ/day)
(kcal/day)
% Energy from:
Protein
Fat
Carbohydrates
Total sugar
Alcohol
Dietary fibre (g/10 MJ)
Iron (mg/10 MJ)
Calcium (mg/10 MJ)
Potassium (mg/10 MJ)
Phosphorus (mg/10 MJ)
Zinc (mg/10 MJ)
Magnesium (mg/10 MJ)
Thiamine (mg/10 MJ)
Riboflavin (mg/10 MJ)
Vitamin C (mg/10 MJ)
Vitamin B6 (mg/10 MJ)
Vitamin A (µg/10 MJ)
Retinol (µg/10 MJ)
β-Carotene (µg/10 MJ)
Vitamin E (mg/10 MJ)
Vitamin D (µg/10 MJ)
Vitamin B12 (µg/10 MJ
Non-consumers Consumers
0.1–2.7 g/day
SD standard deviation, NS non-significant
* P values from the Kruskal–Wallis test, non-consumers versus tertiles of consumption
† The data on weight and height were self-reported. BMI z score based on age and gender specific was
calculated using WHO AnthroPlus software version 1.0.4 (http://www.who.int/growthref/tools/en/)
a,b Mean values with unlike superscript letters were significantly different according to Dunn’s post hoc
test for pairwise comparison, P < 0.05
of total whole grain intakes in adults in France, Ireland,
UK, Norway, Denmark and the USA [
19–21, 24, 27, 29
],
while breakfast cereals accounted for 25–50 % of intakes
in children/adolescents in Ireland, France and the USA [
19,
26, 29
]. Notably, biscuits made a substantial contribution
to total whole grain intakes (~20 %) in Italian children and
adults, while whole grain pasta did not appear in the diets
of children and adolescents at all and contributed only 2 %
to total whole grain intakes in adults.
The very low consumption of whole grain observed in
the Italian population appears to be in paradox with the
traditional Mediterranean diet which was first described in
this region in the early 1960s and was characterized by a
high intake of vegetables, legumes, fruits, olive oil, nuts,
cereals (mostly unrefined), moderate intakes of milk and
dairy products and fish and low intake of meat and meat
products [
48
]. Over the last 50 years, the traditional
Mediterranean diet has progressively disappeared in Italy. Food
balance sheets for this period indicate that there has been a
marked increase in the consumption of products of animal
origin (meat and sausages, milk, cheese, animal fats) and a
parallel decrease in the consumption of cereals, while the
Table 5 Mean daily intakes of
energy, macro-nutrients (as %
of total energy intake), dietary
fibre, vitamins and minerals (as
10 MJ) for non-consumer of
whole grain and across tertiles
of mean daily whole grain
intakes in adults/older adults
a,b,c,d Mean values with unlike superscript letters were significantly different according to Dunn’s post hoc
test for pairwise comparison, P < 0.05
consumption of fruit and vegetables has increased slightly,
as confirmed by the literature [
49
].
The reasons for such low intakes of whole grain in the
Italian population are likely to be similar to those reported
in other European countries and the USA which include
a lack of knowledge on whole grain and its health
benefits, difficulties in identifying foods made from whole
grains, poor taste or texture perception of these products
and the higher price [
50, 51
]. In line with these findings,
we observed that those participants who practised more
health conscious behaviours such as dieting, reading of
food labels and use of fortified foods and who reported a
good knowledge level on diet and health were more likely
to be consumers of whole grain. Moreover, the subjects
living in North-Western and Central regions compared to
the South and Islands were significantly more likely to be
consumers of whole grain, reflecting regional differences
in the acceptance of whole grain foods. A study carried
out as part of the HEALTHGRAIN project investigated
consumer beliefs about whole grain products in four
European countries and the impact of different types of health
claims on the selection of grain products [50]. Interestingly,
P*
NS
0.0004
results showed that while Italian consumers generally rated
whole grain foods positively in terms of their health
benefits, they similarly rated refined grain foods and failed
to identify the superior nutritional profile of whole grain
above refined grain products. In addition, the use of health
claims or whole grain labels did not positively influence
Italian consumer’s willingness to buy whole grain products
[
52
]. A further finding from this study indicates that
perceived taste is another limiting factor to whole grain
consumption in Italy as Italian consumers rated whole grain
bread, pasta and biscuits as inferior in taste compared to
their white flour alternatives [
53, 54
]. Hence, these findings
present challenges for healthcare providers, educators and
the food industry in promoting whole grain consumption in
Italy, but they also give insights into potential strategies for
addressing these barriers.
In both Denmark [
55
] and Singapore [
56
],
successful national campaigns employing concurrent approaches
which included increasing the availability of whole grain
products and consumer awareness of their health benefits
and the use of a specific logos to help consumers identify
whole grain products resulted in significant increases in
whole grain intakes in these populations. Similar targeted
strategies may be effective in Italy with greater emphasis
placed on increasing the awareness of the benefits of whole
grain above refined grain and by increasing the availability
of palatable whole grain alternatives to customarily
consumed foods such as bread and pasta. As taste preferences
are often established in childhood and can track into
adulthood, exposing children to a range of whole grain foods
from an early age is important. The school setting thus
offers a suitable environment for early exposure to whole
grain foods. In the USA since 2012, the National Schools
breakfast and lunch programme must offer at least half of
grains as whole grain in rich sources and this requirement
increased to 100 % of grains offered for the 2014–2015
school year [
57
]. In some Italian municipalities, mainly in
the Northern regions, the technical documents of school
canteens recommend the use of whole wheat bread
during meals served at lunch time, as suggested by the Italian
Dietary Guidelines [
35
]. No quantitative advice is given,
however, and the extent to which these guidelines are
followed is unclear. Furthermore, these initiatives are carried
out only at local level, a national directive on whole grain
is not considered. However, an update of the Italian dietary
guidelines is scheduled in the next year.
Another factor which may contribute to the low whole
grain intakes in the Italian population is the lack of a
quantitative recommendation for whole grain in the current
Italian dietary guidelines [
35
]. Italians are advised to eat
5–10 portions of cereals (bread, rice, pasta, spelt, barley)
according to energy requirement with only a suggestion to
prefer whole grain products due to their naturally higher
fibre content. A minimum target of whole grain servings is
not specified. The Mediterranean Diet pyramid is slightly
more descriptive recommending one or two servings of
cereals per meal in the form of bread, pasta, rice, couscous
and others and preferably whole grain versions,
highlighting that some valuable nutrients (magnesium, phosphorus,
etc.) and fibre can be lost during processing [
36
]. Very few
national dietary guidelines define a specific quantity of
whole grain: the USA recommends at least three 16 g
servings per day [
41
] while the Danish recommend 75 g/day
of whole grain (per 10 MJ energy intake) [
58
]. Estimated
intakes in the Italian population fall substantially short
of these recommendations with less than 5 % of the
Italian consumers achieving the US target. Despite these low
intakes, our findings showed that adults consuming ≥15 g/
day of whole grain (equivalent to around one serving per
day or more based on the US guidelines) had significantly
higher intakes of dietary fibre and several minerals and
vitamins compared to non-consumers of whole grain. This
is consistent with findings from other population subgroups
whose whole grain intake exceeds approximately 10 g/day
[
19, 21, 29
]. Similar trends were also observed for
children/adolescents but only reached significance for iron and
magnesium, a finding which may be explained by the small
sample size studied. Furthermore, the overall diet quality of
adult whole grain consumers as measured by the PANDiet
score tended to increase as whole grain intakes increased,
and this appeared to be driven by more adequate intakes of
dietary fibre, B vitamins (excluding niacin and B12),
calcium, magnesium, zinc, phosphorous, potassium and iron
(Online resource—Table B). The proportion of consumers
achieving the recommended daily intake of dietary fibre
(25 g/day) was twice as many (31 %) in the highest tertile
of whole grain intake compared to non-consumers (14 %),
suggesting that whole grain foods are a good vehicle for
increasing fibre intakes in the Italian population which are
currently sub-optimal in the majority of people [
38
].
These differences in nutritional intake can be accounted
for, at least in part, the contribution of nutrients found in
whole grain foods themselves. Whole grains contain higher
amounts of fibre and several micro-nutrients including
vitamin E, vitamin B6, folate, magnesium and zinc than
refined grain [
59
]. For example, a comparison between the
whole wheat bread versus the refined wheat bread in
Italian Food composition database reveals a higher amounts of
many nutrients: dietary fibre (6.5 vs 3.4 g/100 g), iron (25
vs 13.7 mg/100 g), zinc (1.6 vs 0.9 mg/100 g), magnesium
(86 vs 15 mg/100 g), vitamin B6 (0.12 vs 0.07 mg/100 g),
folate (72 vs 47 mcg/100 g). However, differences in
nutrient intake may also result from a more careful approach
to healthy food choices in general by consumers of whole
grains. For example, adult/older adults consumers of
whole grains consumed greater daily amounts of fruits and
vegetables (477 g/day in consumers vs 431 g/day in
nonconsumers) and milk and milk products (218 vs 179 g/
day), and less meat (102 g/day in consumers vs 113 g/day
in non-consumers) and alcoholic beverages (83 g/day in
consumers vs 113 g/day in non-consumers) than
non-consumers of whole grain (Online resource—Table D). Finally,
it should also be noted that there was a higher proportion
of fortified foods consumers in the whole grain consumers
group (adults and elderlies: 29 vs 9 %; children and
adolescents 70 vs 25 %) which may have contributed to the
higher micro-nutrient intakes observed in this group. For
some of these nutrients (iron, riboflavin, thiamine, vitamin
B6), this is mainly due to the higher consumption of
fortified “Ready to eat Breakfast cereals”. The 28 % of “Ready
to eat Breakfast cereals” consumers were present in the
whole grain consumption group. Hence, the consumption
of whole grain foods may contribute to and also act as a
marker for a more healthful diet and healthier lifestyles.
There are several strengths and limitations of the
current study that should be acknowledged. One of the main
strengths was the nationally representative nature of the
sample which covered all four main geographical areas
and all classes of age. Furthermore, it was possible to
estimate the intake of packaged whole grain products using the
brands and labels of products consumed at the specific time
of the dietary survey. However, the assessment of whole
grain content of some products on the basis of current food
labels and/or websites may be erroneous especially if
products have undergone reformulation. The estimation of the
whole grain content of wholemeal bread in particular may
have been subject to error as most bread was purchased in
bakeries and as such did not have corresponding QUIDs,
unlike packaged bread. Moreover, we made an assumption
that all bakery breads contained whole wheat flour rather
than white flour with added bran so it is possible that some
breads included in the current analysis were not whole
grain as defined by the Health Grain Forum [
23
]. Thus, this
could have resulted in an over-estimation of whole grain
intakes. In addition, the effect of over- and under-reporting
was not taken into consideration in the present analysis
which may have resulted in an over- or under-estimation of
whole grain intakes. A further limitation is the small
number of children/adolescents in the studied sample which
precluded analyses of statistical associations specifically in
these age groups. Finally, the data presented were collected
almost 10 years ago and may not reflect any recent changes
dietary patterns including whole grain. A new national
dietary survey is due to commence, however, in 2016/17,
which should facilitate an estimate of trends in food
consumption, included whole grains over the last decade.
In conclusion, whole grain was consumed in only a
quarter of Italian children and adults, and among these,
consumers intakes were substantially lower than quantitative whole
grain recommendations. The main food sources of whole
grain were breakfast cereals in younger people and bread
in the adults, with wheat being the primary grain source. In
spite of these low intakes, the positive association between
whole grain consumption and dietary fibre and
micronutrient intakes indicates that it could be an important
vehicle for increasing intakes of these essential nutrients in
the Italian diet. A greater understanding of the barriers to
whole grain consumption affecting the Italian population is
needed so that effective strategies to increase whole grain
consumption can be devised.
Acknowledgments The present study was funded by Cereal
Partners Worldwide (CPW) SA, Switzerland. S.H. is employed by CPW.
The authors’ contributions are as follows: S.H. and A.T. designed
the study; S.S. was responsible for manuscript preparation, L.D. was
responsible of statistical analysis with the help of S.S., the
classification and calculation of data on whole grains were carried out by
R.P. All authors participated in the interpretation of the results and
made critical comments during the preparation of the manuscript. The
authors thank A. Pettinelli for her excellent technical assistance.
Compliance with ethical standards
Conflict of interest The work in this article was funded by Cereal
Partners Worldwide who had no influence over the data analysis. There
are no other conflicts of interest to declare.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
made.
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