The New Nordic Diet is a new food culture developed in 2009-13 with key emphasis on gastronomy, health, and environment. Major research in its effect on acceptability, behaviour and learning skills, and disease prevention have been conducted by the OPUS centre at the University of Copenhagen and the people behind the award-winning restaurant Noma in Copenhagen. This course will give the participants the opportunity to experience a healthy and palatable new food and eating concept diet “The New Nordic Diet” and an understanding of how food and diets can affect mental and physical health and ensure the foundation for a healthier life style for future generations with a regional based diet and food culture. In Denmark “the Nordic cuisine”, has expanded from food eaten at the award-winning Copenhagen restaurant Noma to home-made dishes of local ingredients of whole-grain rye bread, root vegetables, berries, fresh fish and seaweed. This course is also part of the EIT Health Programme
6.1: The Adult Intervention, Part 1, the Studies, by Thomas Meinert Larsen
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From the course by University of Copenhagen
The New Nordic Diet - from Gastronomy to Health
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From the lesson
The OPUS Supermarket Intervention
In this module, we'll be looking at the effect of New Nordic Diet on adults. We will study the effect of eating the New Nordic Diet (NND) and an Average Danish Diet (ADD), respectively, in terms of body weight, body composition (fat) and risk factors for cardiovascular diseases and type 2-diabetes. You will learn about problems, barriers and benefits associated with two types of diet, focusing in particular on shopping, cooking and eating, meal structure and diet composition. Moreover, drop-out rate and the subject’s compliance with the principles behind the diet are discussed.
Meet the Instructors
Dr Arne Astrup, MD, DMSc.Professor, Head of Department
Department of Nutrition, Exercise and Sports
[MUSIC]
Hello, my name is Thomas
Meinert Larsen. I'm an associate professor
at University of Copenhagen, Department of Nutrition, Exercise, and Sports.
I've been conducting nutritional intervention
studies for more than ten years.
And I'm the leader of SHOPUS, of the SHOPUS project, a randomized
control trial that was carried out to test
the health benefits of the New Nordic Diet.
The SHOPUS project, which is the abbreviation of Shop-in-OPUS
project, I'm going to tell you more about today.
Today, I would like to help you to understand how health effects of diet
are typically evaluated and why this can
sometimes lead to different and often conflicting results.
With this in mind, I want
you to understand why we think the use of a shop
model is a better way to test the health benefits of diet.
Then, by explaining the design and results from
the SHOPUS project, I hope to teach you how
the shop model can be used to improve
the validity of the findings of nutritional intervention studies.
The usefulness of the shop model may be particularly high,
when the items being tested are not isolated ingredients or
individual food items.
But rather, whole diets that are often
complex, and where the whole process of having
the diet integrated in the everyday life is
probably as important as the diet composition itself.
First, I will explain the Shop Model to you, what
it is, why we use it, and how we use it.
So first, what is the Shop Model? In the shop model, we basically have
a normal shop with all sorts of foods available, such as
bread, breakfast cereals, vegetable and fruits, meat, fish, and so forth.
By using this shop, we are able to provide the participants all
food free of charge for the whole study period, such as 26 weeks.
Obviously, as we provide all foods for such a long
time, one very significant disadvantage of the shop model is
the costs. So, why do we use the Shop Model?
The scientific community is endorsing a
hierarchy among different types of research
and available knowledge And this also
applies for the results from nutritional research.
That we expect to end up as public
recommendations for dietary intake for the general population.
In this hierarchy, the randomized double blinded control
trials are typically consider the study
where you obtain the most credible results.
But this kind of study is usually also very expensive.
And sometimes, such studies may even be impossible to carry out.
Despite this hierarchy.
And although we have a quite large number of these randomized control trials.
The scientific consensus, and dietary recommendations have been very hard
to achieve.
Partly because the scientific results sometimes seem conflicting.
As an example, the results from epidemiological studies
often differ from results from the randomized control studies.
So, what are these studies actually?
To put it simple, the epidemiological studies are those studies
where you simply ask people what they do, without controlling
what they do, and when you follow them for a certain time period.
In the randomised studies, you typically divide the population into two
groups by lottery, and then you instruct them what to eat.
As an example of the scientific controversy,
there are a number of studies from the
control studies that reset, suggest that people
lose weight when they eat high protein diets.
Likewise, there're a number of technological studies saying
that you gain weight if you eat high-protein diets.
So, it is difficult to make recommendations
when we are not sure what to believe.
And this controversy is a significant
problem when both randomized studies and epidemiological
studies makes up a very significant contribution
to the totality of scientific information that
we have about diet and health.
Thus any solid conclusion can be difficult to reach.
I do believe, however, that part of
the scientific dispute within nutritional research may likely
be ascribed to the difficulties in getting
to know what study participants were actually eating.
In other words, there is typically a lot
of uncertainty in the way that we measure what
people eat. And that affects our results.
As an example, the tools that are typically used to obtain
information about diet intake are by using seven-day weighed food records.
Or by using food frequency questionnaires.
Weighed food record simply mean that participants are
instructed to weigh all the foods they eat.
A food frequency questionnaire is typically
a book with names and pictures of foods.
And where you ask the participants to indicate how often they eat these foods.
Both of these tools probably do not give an accurate picture of what people eat.
Therefore, even though these tools are very much used, they're not
universally accepted, and often criticised by experts in the scientific community.
Even some researchers believe
these tools are a waste of time, as they
don't give a true picture of what people eat.
So what is then the alternative?
Maybe a Shop Model is.
Therefore, we have put ourselves the aim
of establishing a research setting that would
enable us to achieve the maximum control
of the food intake by the study participants.
Also, in the more long term studies by using the Shop Model.
Now that we have
the model, how do we use it?
It basically worked the same way as
ordinary shops that each of you already know.
Each study participant visits a shop one to
three times weekly to purchase foods free of charge.
And all foods in each shopping session are then registered
in a computer model, thereby keeping track of the food intake.
Furthermore, we can program the computer so
that it only allows the purchase session to be completed if certain requirements
are fulfilled, such as a particular quantity of carbohydrates, fat or protein.
In addition, the participant is instructed to report
any foods that are eaten from outside the shop.
In this way, we can, in principle, have a full and
compete record of what the participant is eating during the study.
Even if his, if it's up to half a year.
So, a key part of the Shop Model is the computer system, in which all
foods are registered by their content of nutrients,
such as fats, carbohydrates, protein and so on.
But also with vitamins and minerals.
Most of this information is obtained from food data bases,
but some of the information is often obtained by looking
at the nutritional information provided on each food product.
As just mentioned, with the computer we can control which type of foods
are handed out to the study participants,
and the nutritional composition of these foods.
We can put up specific requirements for food selection for each of the
participants, such as putting up restrictions on
the total amount of fat or carbohydrates.
But we can also put restrictions
on the amount of vegetables and fruits,
depending on the scientific aim of the study.
In a particular serving session, you simply
start by registering who the study participant is.
And for how many days he or she will shop for.
Then you start entering the foods that
a participant has brought to the sales counter.
Once products are entered into
the program, the program will start to
calculate and accumulate nutritional content of these foods.
In the shopper's project, the computer was programmed to
show the nutritional composition in the active, ongoing purchase situation.
But, the computer was also programmed to show the composition
of foods that were collected for the last four weeks and
also for the totality of the intervention.
To help the staff and the participant to get the correct
intake of say, protein, not only does the computer calculate protein intake.
But the computer also highlights with green or red color if
the intake of protein is below or above the recommended intake.
There by the staff can easily see which foods are lacking, and
which foods are too abundant.
And if necessary, he can then instruct
the participant to change the selection of food.
Sometimes, and particularly in the first shopping sessions, we ask participants
to take out a specific food item from the shopping basket.
And to replace it into something that fits better into
the diet and matches with the targets specified with the program.
When the shopping session is complete, the participant gets
a receipt listing all the foods that are collected.
The slide shows how the computer program works.
In the upper row there's information about the specific subject.
The subject identity code, how many days he or she has collected food for the start
and end date for the actual shopping session, the diet, which is
NND or ADD.
Run-in period or intervention period, the number of members in the family and the
estimated caloric content of the foods that
are collected in the active purchase situation.
This number can be hidden during the shopping session.
In the central part of the screen, each of the food categories are listed.
So, in row one, you'll see protein, carbohydrates, added sugar,
fiber, total fat, saturated fat.
Monosaturated fat, polyunsaturated fat and alcohol.
In row two, you see the intake of organic foods of, of Nordic origin,
fruits, berries, vegetables, cabbage, root beets, legumes, and whole grains.
In row three, you'll see the meat, nuts, fresh herbs, potatoes,
wild plants and mushrooms.
Seaweed, fish, game, meat and dairy products.
For each food category, the total intake of the specific food category is listed.
The calculated intake is listed for the current shopping session, for the last
four weeks and the total accumulated for the whole intervention period.
And the lower
right part of the screen, the list of products contained in
the current shopping station are listed and can be followed continuously.
One of the projects where we have used a Shop Model is the SHOPUS Project.
The aim of the SHOPUS Project, which, as I
said early on, is a variation of shop in Opus.
Was to test whether the New Nordic Diet
could improve the health of adult participants that
were at risk of developing nutritionally related diseases.
We decided to test the New Nordic Diet against the diet that is typically eaten
by the average Danish population, which we
defined based on dietary surveys done among Danes.
This diet we called the Average Danish Diet abbreviated as ADD.
Very importantly in SHOPUS, we did
not want the participants to count calories.
Rather, we wanted them to eat until they felt satiated or satisfied.
And this is usually referred to as eating ad libitum.
This does, of course, not mean that they should eat whatever they
wanted, but more that we instructed them to eat until they felt satiated.
And then maybe, it may turn out that one diet is more satiating than the other.
And if so, this might provide an
extra weight loss and maybe other health benefits.
During the intervention, we asked the participants
to maintain their habitual, physical activity level.
So, that it was not, this would not influence our results.
So, the aim was to look at the health effects of
following the New Nordic Diet compared to the Average Danish Diet.
And we decided to let change in pro, in body weight
as a approximation for health benefits. But we also looked at other outcomes,
such as waist circumference, plot cholesterol, plot sugar regulation.
In addition to these clinical outcomes, we were also very interested to
know how well the participants were able to adhere to the diet.
And if they dropped out of the study. We chose to include adult participants,
both women and men, that were considered at risk for
developing lifestyle diseases in our
study, presenting with increased waist circumference.
And maybe having features of the so-called metabolic syndrome,
which is including increased blood sugar, cholesterol, or blood pressure.
And, of course, they had to be able to visit the shop to collect the foods.
The study was designed as a Six Month Intervention Study
where eligible participants were randomized to one of two different diets.
Hence, after the screening they were randomized to
six months of following one of the two diets.
During the six months intervention, they were instructed to collect all foods,
free of charge, from the shop, except for alcoholic beverages, coffee and tea.
Also they were given individual dietetic
counseling by trained dieticians for a total
of nine times.
And they all received a cooking course in the beginning.
In addition, they had to undergo a clinical examination before they started.
After 12 weeks of the intervention, and
by the end of the six-month intervention period.
After the six months intervention, we did not provide them with foods, or with
any dietetic guidelines, but we invited them
into our department for follow-up visits after another
six and 12 months.
However, the findings from these follow-up visits I will not cover in my talk today.
The two diets, the NND and the ADD, were carefully defined, both in terms of the
macronutrient composition but also regarding the type of
foods that we decided should constitute the diet.
We decided that the NND and the ADD, so the New Nordic Diet and
the Average Danish Diet should be relative
identical regarding total fat, protein and carbohydrate.
But that in particular, the amount of saturated fat and
added sugars should be higher in the Average Danish Diet group.
Concerning most of the food groups, we
aim to have very different intake between diets.
But for some foods such as vegetables,
berries, and game meat, we strive to achieve
a very large difference, such as two, five,
or even ten fold differences between the diets.
So that the
New Nordic Diet was clearly very different from the average Danish diet.
Also in order to help the participants to follow
the two diets, we developed a number of recipes.
So, that they knew how to turn ingredients into delicious meals.
Specifically for the New Nordic Diet we developed a
number of recipes for each particular season of the year.
These recipes were then included in the recipe book for
each of the New Nordic Diet, and Average Danish Diet diets.
For the New Nordic Diet group, the recipe book contained 180 different recipes.
Including recipes for both breakfast, lunch, dinner and snacks.
For the New Nordic Diet, the recipes were furthermore divided into
four seasons, so, into spring, summer, autumn and winter, thereby helping
the participants to prepare meals according to the season.
The New Nordic Diet group was also provided a shopping guide, which was a
plan describing which products to purchase in order for them to follow a recipe.
And to prepare meals at home.
The cookbook for the Average Danish Diet group contains somewhat fewer recipes, and
the main difference to the New Nordic Diet book was the lack of seasonal
variation in the Average Danish Diet cookbook.
To give you a real impression of the Shop Model and the way it
works, we have prepared this very informative
video of how the shopping was carried out.
This is one of the participants from the SHOPUS project participating.
Please watch this three minute video.
Marianne participated in the OPUS project.
During the project Marianne went shopping two to three times a week.
Marianne starts by registering what food she
has left from the last week's shopping.
And if she has bought any food elsewhere during the week.
By registering her food, the scientists
can monitor what the participants are eating.
Then Marianne takes a grocery list with the foods
she needs to shop today.
On the basis of a weekly meal-plan
Marianne shops for breakfast, lunch, and dinner.
Marianne always begins her shopping in the fruit and vegetable section.
This week red cabbage and celeriac are on the menu.
To avoid waste of food, some vegetables
are kept in smaller portions in a refrigerator,
Making it possible to procure the exact amount specified in the recipes.
Marianne can get all kinds of food in the shop.
For instance, herbs which is one of the foodstuffs that
Danes are to eat more often in the New Nordic Diet.
Meat of the week is red deer.
There's less meat in The New Nordic Diet than in the Danes' average diet,
just as more of the meat in the New Nordic Diet is wild game.
Besides meat, the main sources of protein in the New Nordic Diet are dairy products,
vegetables and leguminous fruits. Marianne needs cherry vinegar.
The participants in the project fill their own bottles with cherry vinegar.
At the dairy cooler Marianne gets, gets milk, cheese and yoghurt.
Split pea soup is a family favorite, so Marianne shops that as well.
While shopping, Marianne makes sure to cross out
the foodstuffs she has taken on her list.
Corn, grain and nuts are also ingredients on her list.
Last item on the shopping list is macaroons.
When the basket is full, Marianna get her items scanned at the register.
It is not the price that is
registered, instead it is the foodstuffs' nutritional value.
When all foodstuffs are scanned, the computer calculates
the amount of proteins, carbohydrates and fat in the
purchase, making sure that the participants
adhere to the dietary criteria put out.
If the distribution does not fit the the
dietary criteria of the New Nordic Diet, Marianne
picks out additional foodstuffs, in order to get
the amount of proteins, carbohydrates and fat right.
The shopping is checked by the personnel before she takes
the groceries home.
[MUSIC]
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