Traditional and modern Greenlandic food — Dietary composition, nutrients and contaminants

Science of the Total Environment 384 (2007) 106 – 119 www.elsevier.com/locate/scitotenv

Traditional and modern Greenlandic food — Dietary composition, nutrients and contaminants Bente Deutch a,⁎, Jørn Dyerberg b , Henning Sloth Pedersen a,c , Ejner Aschlund a , Jens C. Hansen a a

Centre for Arctic Environmental Medicine, Aarhus University, Building 260, Vennelyst Boulevard 6, DK-8000, Aarhus, Denmark b Capio Diagnostic,a.s., Nygaardsvej 32, DK-2100, Copenhagen O, Denmark c Centre of Primary Health Care, Box 1001, DK-3900 Nuuk, Greenland Received 8 March 2007; received in revised form 23 May 2007; accepted 25 May 2007 Available online 16 July 2007

Abstract Objectives: High levels of n-3 fatty acids and other nutrients in traditional Inuit food appear to provide some protection against the typical diseases of affluent industrialized societies: cardiovascular diseases and type 2 diabetes. An increased intake of imported food among Inuits will probably increase their frequency of these diseases. However, since the 1970s it has become evident that the marine-based Inuit diet also contains high levels of potentially toxic lipophilic organic pollutants and heavy metals. Since these two food related opposing health effects appear to be inseparable, the phenomenon has been known as “The Arctic Dilemma”. However, both the fatty acid composition and the contaminant levels vary in Greenlandic food items. Thus in principle it is possible to compose a diet where the benefits and risks are better balanced. Our objectives of this study were to compare traditional and modern meals in Greenland concerning the dietary composition, nutrients, and health indicators among the consumers. Study design: The present study was a cross-sectional dietary survey as part of the Arctic Monitoring and Assessment, Human Health Programme (AMAP). These results were compared with older dietary surveys in Greenland. Methods: Dietary components, fatty acids, and nutrients in 90 local meals collected by duplicate portion method in Uummannaq town, north Greenland 2004 and in Narsaq, south Greenland 2006, were compared with 177 duplicate meals sampled in the village of Igdslorsuit, Uummannaq, district, 1976 and also compared with other dietary studies in Greenland 1953–1987. Anthropometric measures (weight, height, and body mass index, BMI) and blood lipids were measured as health indicators among the participants. Results: Between the traditional foods sampled or analysed 30–50 years ago and the modern food from 2004 to 2006, significant differences were found in the dietary composition. The percentage of local food had decreased, to a present average of about 20% and with it the dietary content of n-3 fatty acids. Also, the intakes of many vitamins and minerals had decreased, and were below Nordic Nutrient Recommendations in 2004 and 2006. Vitamin A, B1, (B2), B12, iron, iodine, phosphorus, and selenium contents were correlated with n-3 content, whereas vitamin C, folate, and calcium contents were not and the same time very low. In the traditional food, especially from the villages, the intakes of vitamin A, vitamin D, and iron were extremely high and borderline toxic. The levels of contaminants such as organochlorins and heavy metals were also strongly correlated with the relative content of local food in the diet. The best balance between potentially beneficial and harmful substances was found for 20–30% local food, corresponding to a daily intake of 3–5 g of n-3 fatty acids. Body weight, height, body mass index (BMI), cholesterol, and S-triglycerides had increased significantly between 1976 and 2004.

⁎ Corresponding author. Tel.: +45 8942 6172. E-mail address: [email protected] (B. Deutch). 0048-9697/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.scitotenv.2007.05.042

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Conclusion: The dietary changes to a more western fare were found to be negative resulting in less adequate nutrient coverage but at the same time lower contaminant load. Thus, we recommend not to increase the consumption of local products beyond the present level but rather to improve the quality of the imported food. © 2007 Elsevier B.V. All rights reserved. Keywords: Greenland; Traditional and modern food; Fatty acids and nutrients

1. Introduction During the last 40–50 years the Greenlandic diet has changed to include an increasing amount and variety of imported foods and a decreasing amount and variety of local foods. Uhl (1955) collected and determined the nutrient content in a wide selection of commonly eaten Greenlandic sea mammals, fish, birds, local plants and berries. Their nutrient tables were used in dietary surveys to calculate nutrient composition among different population groups (Uhl, 1955; Helms, 1981, 1987). Already at that time there were dietary differences between towns and villages. Towns were the district centres usually with a large harbour and airport with year round access to imported foods, whereas villages depended much more on the local food supply. This change in diet has been paralleled by a more sedentary lifestyle and coincides with an increased average body weight and an increased risk of diabetes and ischemic heart disease, (IHD) (Deutch et al., 2005). These diseases were previously practically unknown in Greenland (Bang et al., 1971). In 1970, Bang and Dyerberg, investigated the observed low rate of cardiovascular diseases among Inuits living on a traditional fare in north west Greenland (Bang et al., 1971; Dyerberg et al., 1975, 1977, 1978). They found that the population had lower blood cholesterol and triglyceride levels, and higher HDL (high density lipoprotein), indicating a lower risk of contracting atherosclerotic diseases than Danes or Inuits living in Denmark (Dyerberg et al., 1975, 1977). They further found that the Inuit diet, consisting mainly of marine animals and fish, was rich in protein and fat and low in carbohydrates. The dietary fat, which contained a high proportion of certain mono-unsaturated and n-3 poly-unsaturated fatty acids (PUFA), was different in composition from that of a European diet. They hypothesised that this special composition of dietary fats from marine animals and fish protected the consumers against ischemic heart disease. Their results (Dyerberg, 1986) suggested biochemical pathways for n-3 PUFA as modifiers of cardiovascular risk markers, which inspired a new cascade of

research investigating the alleged positive physiological effects of long-chained n-3 PUFA. Resulting from their five Uummannaq expeditions, their studies of serum lipids and food composition in Greenlanders have become an important part of the understanding of thrombotic diseases (Bang and Dyerberg, 1981). Many of the health-promoting effects and modifiers of morbidity, observed in epidemiological studies both in Greenland and elsewhere have subsequently been confirmed by experimental studies using n-3 PUFA as dietary supplements (Deutch et al., 2000a,b; Dyerberg and Schmidt, 1993). In 1976 Bang and Dyerberg performed a detailed dietary study in the village of Igdlorssuit, Uummannaq district, where fishing, whaling and seal-hunting were still the main provisions of dietary resources with high n-3 content (Bang and Dyerberg, 1981; Bang et al., 1976, 1980). The participants were 33 local Inuits who provided blood samples for lipid analysis and collected a total of 177 duplicate daily meals. The meals were subjected to macro nutrient and fatty acid analysis. In addition, the participants gave a dietary interview of the corresponding period. From this interview the general nutrient contents of their diets were estimated using Uhl's tables (Helms pers. comm. 2004). This part of the investigation has not been published. Since the 1970s it has become evident that the Inuit diet based on marine mammals and fish, although in principle healthy, contains high amounts of lipophilic organic pollutants and heavy metals, which are potentially toxic (AMAP Assessment Report, 1998; Bjerregaard et al., 2001). As part of the ongoing Arctic Monitoring and Assessment Program (AMAP) we systematically studied the human exposure to contaminants in 8 districts in Greenland between 1999 and 2006 (Deutch et al., 2004, 2007) combined with questionnaire and dietary surveys (AMAP Assessment Report, 1998). The content of lipophilic contaminants was strongly associated with the amounts of certain n-3 fatty acids in animal and human tissue. As the adverse health effects of the contaminants and the beneficial effects of n-3 fatty acids appear to be inseparable, at least under the present state of world

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wide contamination, this phenomenon has been known as “The Arctic Dilemma”. The duplicate meals from 1976 still exist as freeze dried aliquots. Dietary and anthropometric raw data (anthropometric data, blood lipids and fatty acids, FA) are also still available. This has made it possible to compare the intake of macronutrients, fatty acids, and the contaminant burden in these traditional meals with present day meals collected by the same method and also to compare some physical health indicators among the participants from the different periods. In both the traditional and the modern meals the analyzed contaminant content (14 PCBs, 11 pesticides and heavy metals) showed a strong dependency on n-3 content and thereby on traditional food content. These results have been presented and evaluated in detail elsewhere (Deutch et al., 2006). The dietary situation in Greenland is changing in a very complex way. The present study is not intended to measure temporal trends, but rather to evaluate how the ratio of traditional and imported food affects the nutritional content of the Inuit diet versus the potential contaminant level. 2. Materials and methods From the previous dietary results (Uhl, 1955; Helms, 1987) and the 1976 food interviews, the nutrient contents per 10 MJ have been calculated for mutual comparisons and for comparisons with 2004 and 2006 results and the Nordic Nutritional Recommendations (1996), NNR. A map of Greenland with the collection sites is shown in Fig. 1. 2.1. 1976 meals and blood samples In Igdlorssuit, (now Illorsuit) a village in Uummannaq district, 16 middle-aged married couples and one single woman) were recruited by public invitation May 1976. Each person contributed 5–7 duplicate daily meals, a total of 177 food duplicates (solids only). Aided by a dietician the participants completed a food questionnaire, and recorded their liquid intake. The food portions were ground in a meat grinder, homogenized, frozen, and transported to Denmark for analysis of macronutrients and fatty acids. To reduce the volume of the food samples liquids were not included. It was considered that the liquids did not contain pertinent nutrients. The meal remnants were later freezedried for storage. The participants also provided blood samples after 12 h of fasting. The meals and blood samples were analysed at Aalborg Hospital (Denmark) for lipid composition and by gas chromatography for fatty acid

composition. The meals were further analysed for macronutrients, water, and ash content (Bang et al., 1976, 1980). In 2004 the meal samples were analysed for metals and organic contaminant content as below. Anthropometric measures, weight and height were measured using standardized hospital instruments, with the participants wearing only underwear. BMI was calculated as weight in kg divided by height in metres squared. 2.2. Meals and blood samples 2004 and 2006 Since 1976, the population of the settlement Igdlorssuit (now Illorsuit) had decreased from 145 to 120 and to less than 20 in the relevant age group. We therefore decided to perform the study in Uummannaq town (population 1460) in May 2004. Two years later we performed a similar study in Narsaq, south Greenland to compare with a different supply situation. Duplicate meals, blood samples, and questionnaires were collected from 30 local age-matched Inuits, 15 married couples who were recruited by public invitation. The participants contributed a total of 90 daily food duplicates as above. Each day the food (solids only) was brought to the local hospital, the contents were laid out; the ingredients were identified described, and weighed. The food items from each person were mixed, homogenized, and frozen at − 20 °C, and transported to Denmark for chemical analysis. As above, liquids were not included but the daily intake was registered on a separate scheme. The meals were analysed for macro and micronutrients by an accredited laboratory (“Eurofins” Kolding, Denmark). The contents of sugar and vitamins from the recorded beverage intake (mainly vitamin C from orange juice) were calculated from nutrient tables and included later. Metal content was analysed at DMU, (National Environmental Research Institute (Dept of Arctic Environment)), by Flow Injection Analysis System, FIASmethod. Fatty acids (FA) were analysed at DTU, (Technical University of Denmark (Biochemistry and Nutrition Group)) by gas chromatography (Møller, 2006). The organic pollutants chosen and the analytical methods used were in accordance with the AMAP, Human Health Assessment group (Deutch et al., 2006). According to this agreement the following organic pollutants were determined in microgram per litre (plasma) or microgram per kg lipid (food samples) at the certified laboratory, Le Centre de Toxichologie, Sainte Foy, Québec, Canada. Aldrine, chlordanes as sum of alpha-, gamma-, cisnona-, oxy-, and transnona-chlordanes, p,p′-

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Fig. 1. Map of Greenland with the collection sites.

dichlorodiphenyldochloroethane (DDE) and p,p′-dichlodiphenyltrichloroethane(DDT), hexachlorobenzene, beta-hexachlorocyclohexane (beta-HCH), mirex, and 5 toxaphene parlars 26, 32, 50, 62, 69, and their sum, the

following 14 polychlorinated biphenyl congeners PCBs: (CB28, CB52, CB99, CB101, CB105, CB118, CB128, CB138, CB153, CB156, CB170, CB180, CB183, CB187) and their sum.

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PCB Arochlor 1260 is reported for comparison with older studies (PCB arochlor 1260 = 5.2 × sum of CB138 and 153). The participants gave blood samples for analysis of cholesterol, triglycerides, fatty acids, metals, and

organic contaminants. Fatty acids (FA) were analysed at Lipid Analytical Laboratory, Guelph, Canada (13). In addition as part of the general AMAP Human Health protocol for a countrywide study, the participants answered a general questionnaire that included a 60-

Table 1 Daily intakes of energy and nutrients in Greenlandic traditional food, mean and (range) calculated per 10 MJ from previous studies Ilulissat 1953 (town)a

Ilullissat district 1953 (village)a

Uummannaq district 1976 (village)b

Qaanaq 1987 (town)c

24 17.0 (14–31) Seal and whale meat, blubber, 23 organs g/day Local fish, cod halibut, capelin 191 g/day Energy KJ daily intake 11,900 (8900–15,960) Protein, gram/10 MJ 97 (85–114) E% 16.3 Fat, gram/10 MJ 64 (46–80) E% 24.7 Carbohydrate, gram/10 MJ 346 (204–382) E% 59.0 Sugar, gram/10 MJ 88 (20–130) E% 14.9 Vit A, microgram 5900 (2450–9390) Vit B1, mg 1.2 (1.0–1.7) Vit B2, mg 2.2 (1.0–3.0) Niacin, mg 22.5 (8.3–49) Vit B6, mg Na

35 25 (15–35) 60

24 54 (36–78) 362

33 41 (11–86) 430

50 25 (12–43) 307

367

891

90

45

12,100 (9050–15,540) 85 (60–124) 14.6 73 (57–97) 38.1 337 (244–378) 57.3 112 (83–145) 19.0 951 (213–4143) 1.2 (1.0–1.4) 1.2 (0.6–2.2) 14.4 (11–22) Na

19,000 (15,100–23,900) 213 (161–345) 36.0 64 (40–110) 25.0 228 (115–320) 39.0 79 (48–128) 13.5 9170 (3383–21,769) 2.1 (1.5–3.1) 5.3 (2.8–10.7) 33 (29–43) Na

8020 (4000–14,800) 102 (27–176) 31.5 82 (24–139) 27.9 182 (31–485) 37.0 73 (32–485) 12.4 2450 (120–14,000) 1.8 (0.6–3.1) 4.4 (0.5–11) Na

Vit B12, microgram

Na

Na

Na

Vit C, mg

Vit E, microgram

12 (3–23.5) 62 (24–84) Na

21 (11–44) 5.1 (3.5–7.0) Na

21 (7.4–50) 54 (26–90) Na

26.6 (3–113) 27 (0–168) Na

12,400 (7000–27,800) 110 (69–200) 18 106 (69–255) 39 240 (144–465) 41 110 (41–184) 18.7 1042 (430–2080) 1.6 (0.8–4.7) 2.6 (1.3–7.5) 40 (21–75) 1.95 (0.9–4.1) 4.7 (2.1–22) 15.4 (1–180) 3.9 (0.1–25) Na

Folate, microgram

Na

Na

Na

Calcium, mg

668 (478–798) 17.3 (12–27)

639 (457–1211) 28 (19–48)

1325 (730–2206) 66 (53–86)

Qaqortoq 1953 (town)a Participants, N Greenlandic products E%

Vit D, microgram

Iron, mg a

Na

7.8 (2–12) 65 (2–336) 570 (169–1140) 114 (6–317)

Na 677 (44–2410) 34 (17–91)

Food registration for 12 days with weighing (Uhl, 1955). Duplicate portion method (chemical analysis of macronutrients) with interview and weighing (Dyerberg personal comm. 2004) and (Helms personal comm. 2004). c Seven-day interview with food models and weighing (Helms, 1987). In all the studies Uhl's (1955) nutrient tables were used for micronutrient calculations. Na: not available or not analysed. b

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Table 2 List of daily intakes in grams, mean and (SD) (Uummannaq 2004 and Narsaq 2006 duplicate portions (DP) and food frequency questionnaire (FFQ)) 2004 Uummannaq (DP) Greenlandic products Number of participants 30, 3 days Sea mammals: seal meat and blubber, dried whale meat and 77 (76) skin Local fish: fresh halibut, cod, char, dried cod or capellin 47 (57) Land mammals: lamb, caribou, musk ox, hare 0 Greenlandic solids total 124 (100) Greenlandic solids products, w% 22.9 (14) Energy% 13.4 Danish/imported products Meats: Beef, chicken, pork turkey, and sausages etc Bread: rye bread, white bread, crackers Rice and pasta Cheese Vegetables: cabbage , carrots Potatoes Fruit: apple, pear, orange, banana Miscellaneous: eggs, butter and margarine Sweets: sugar, chocolate , candy, cookies Sugar Energy % Imported solids total a

68 (63) 170 (66) 63 (40) 19 (28) 4 (9) 39 (47) a 13 (29) 7.5 (7) 100 (56) 16.7(7.0) 503 (197)

2004 Uummannaq (FFQ)

2006 Narsaq (DP)

2006 Narsaq (FFQ)

30, last year 107 (61)

30, 3 days 14 (22)

30 last year 22 (16)

35 (21) 24 (13) 166 (80) 25.3 (10)

35 (35) 21 (37) 70 (48) 10.8 (7) 9.4

48(43) 18 (13) 88 (50) 12.4 (8)

54 (39) 125 (100) 40 (60) 20 (29) 27 (33) 108 (90) 80 (75) 25 (20) 64 (49)

96 (76) 136 (51) 100 (50) 17 ( 33 (52) 51 (32) 99 (97) 16 (5) 79 (42) 31.7 (17) 535 (218)

76 (46) 102 (84) 108 (84) 12 (13) 24 (13) 45 (50 ) 171 (164) 27 (30) 53 (45)

549 (313)

682 (348)

The local coop was out of potatoes.

item semi-quantitative food frequency questionnaire (FFQ), which was used to estimate the habitual intake over a longer period. Danish standard portion sizes were

used to estimate the weight of the intake, except for local meat and fish, for which the portion sizes were set 30% higher.

Table 3 Daily intake of vitamins and minerals per 10 MJ, mean and (range) (Uummannaq 2004, and Narsaq 2006, chemical analysis of 3-day, duplicate portions compared with Nordic Nutritional Recommendations (NNR 1996)) Nutrient

Uummannaq 2004 n = 30

Narsaq 2006 N = 30

Daily energy intake KJ Protein gram/10 MJ E% Fat gram/10 MJ E% Carbohydrates gram/10 MJ E% Sugar gram/10 MJ E% Vitamin A (microgram) Vitamin B1 (mg) Vitamin B2 (mg) Vitamin B12 (microgram) Folate (microgram) Vitamin C (mg) Vitamin D (microgram) Vitamin E (mg) Calcium (mg) Iron (mg) Selenium (microgram)

6569 (3197–12,070) 98 (62–157) 16.7 92 (23–147) 35.1 288 (157–386) 49.0 119 (12–200) 16.7 (2–28) 1132 (200–7636) 0.86 (0.3–1.7) 1.47 (0.4–3.0) 6.04 (0.5–15) 262 (93–594) 56 (12–352) Not analysed 5.13 (2–14) 544 (85–1300) 31 (5.3–79) 154 (14–341)

4862 (1744–11,259) 85 (45–135) 14.6 72 (26–112) 27.5 344 (208–480) 58.6 186 (21–383) 31.6 (5–65) 556 (92–1394) 0.84 (0.3–1.44) 1.24 (0.45–2.0) 6.8 (1.4–24) 116 (44–258) 22 (5–253) – 7.1 –(2.2–18) 552 (195–1085) 21 (4.2–94) 134 (22–454)

NNR 1996 and (lower limit)

10–15% 30 55

1000 (600) 1.3 1.4 2 (1) 360 (100) 70 (10) 6 (2.5) 10 1100 (400) 14–21 (7) 50 (20)

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Table 4 Mineral content in food per 10 MJ (duplicate portions) Uummannaq district village, Idslorsuit 1976, Uummannaq 2004, and Narsaq 2006, mean and (SD) shown with mineral levels in whole blood Uummannaq 2004, and Narsaq 2006, (Compared by independent samples t-test p b 0.05⁎, p b 0.01⁎⁎, p b 0.001⁎⁎⁎) 1976: Uummannaq district village (Idslorsuit) 2004 Uummanaq towna) Food, mg/10 MJ Number of participants Ca Fe Mg P Zn Se microgram/10 MJ Whole blood, mg/l (“normal” values, means; range) Ca (60.5; 57–78) Fe (447; 301–530) Mg (38.8; 27–45) P (345; 311–510) Zn (7.0; 4.8–9.3)

c)

2006 Narsaqb)

33 570 (281) 114 (67) 309 (51) 1562 (338) 16.5 (5.4) 176 (105)

30 543 (285) ns 31 (20)⁎⁎⁎ 205 (61)⁎⁎⁎ 1393 (362)⁎⁎⁎ 10.4 (4.0)⁎⁎⁎ 154 (75) ns

30 551 (259) ns 21 (21)⁎ Na Na Na 134 (76) ns

Na Na Na Na Na

86.5 (11)⁎⁎⁎ 511 (78)⁎⁎⁎ 34.5 (5.8) 385 (62) 5.57 (0.9)⁎⁎⁎

55.2 (11)⁎⁎⁎ 455 (81) 36.4 (4.3) 264 (27) 5.34 (0.9)⁎⁎⁎

c)

a) Compared with Idslorsuit. b) Compared with Uummannaq. c) Compared with normal values, means of means, from more than 10 studies for each compound (Iengar et al., 1978).

It was not possible to carry out computer based micronutrient calculations of the FFQ, since the nutrient database over Greenlandic food items, worked out by Uhl (1955) and later computerized by Helms (pers comm.) no longer exists. Instead, from a semiquantitative FFQ for 4 districts in Greenland, a provisional estimate of macronutrients was made from mean values of food intake using Danish and Canadian food tables (Deutch et al., 2005). Anthropometric measures, weight and height were measured by a doctor using standardized hospital instruments with the participants wearing only underwear. BMI was calculated as weight in kg divided by height in metres squared. 2.3. Statistics All the available raw data from the 1976 study were entered in SPSS statistics program 13.0 together with the 2004 and 2006 results and the results were analysed separately and together when possible. Mean content values of macronutrients, fatty acids and selenium from the different sampling years were compared by “Independent Samples T-test”. Bivariate correlation analysis was used to show the association between local food, contaminants and nutrients. The micronutrient contents of the meals were, as mentioned earlier, analysed by different methods in 1976 and 2004–2006, therefore these results were not compared in statistical tests.

3. Results 3.1. 1955, 1976 and 1987 food composition The food composition of the 1976 meals is shown together with the other early studies with nutrient calculations per 10 MJ, Table 1. The daily intakes of energy were extremely high in 1955 especially in the villages corresponding to a very high intake of local products. The energy contribution from Greenlandic products ranged from 54% in Ilullissat district villages to 17% in a south Greenland town, Qaqortoq. Although the total energy intake was lower in 1976 the intake of local products was very high (59% weight and 41% energy). The most extreme example was a 3day diet only consisting of seal meat, fruit juice-mix, and tea with sugar. The absolutely dominating ingredient was seal meat followed by Greenland halibut and other local fish. Compared to the 1955 food, consumption of seal organs, liver, and blubber was less in 1976. The variety of Danish products was also quite limited in the past studies. In 1976 for example only white bread and no dark bread was eaten; pasta was absent, fresh fruit was almost totally absent. Vegetables and potatoes were seldom consumed. Only very few persons reported intake of alcohol. Energy from alcohol intake was not included in the total energy. The relative sugar consumption was very similar in the different groups. Almost all the micronutrients were well above Nordic Nutrient Recommendations, NNR (Table 3)

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Table 5 Fatty acid (FA) content in percent of total FA's in food (duplicate portions) and plasma phospholipids (Uummannaq district village, Idslorsuit 1976, Uummannaq 2004, and Narsaq 2006, mean and (SD). Compared by independent samples t-test p b 0.05⁎, p b 0.01⁎⁎, p b 0.001⁎⁎⁎)

Number of participants Mono-unsaturated FA Poly-unsaturated FA Saturated FA C.18:2,n-6 C.20:4,n-6 C.20:5,n-3 C.22:5,n-3 C.22:6,n-3 n-3/n-6 n-3 gram/day n-6 gram/day % of plasma phospholipids Mono-unsaturated FA Poly-unsaturated FA Saturated FA C.18:2,n-6 C.20:4,n-6 C.20:5,n-3 C.22:5,n-3 C.22:6,n-3 n-3/n-6

1976: Uummannaq district village (Idslorsuit)

2004 Uummanaq towna)

2006 Narsaqb)

33 57.5 (5.3) 19.8 (2.5) 22.7 (4.8) 4.8 (2.5) 0.35 (0.2) 4.6 (1.2) 2.6 (0.9) 6.0 (1.4) 3.3 (1.9) 8.5 (4.9) 3.3 (2.5) (n = 33) 20.1(3.5) 34.6 (7.0) 41.3 (7.6) 8.7 (4.0) 5.6 (1.5) 11.0 (3.5) Not detected 11.1 (3.5) 1.7 (0.7)

30 43.8 (5.6)⁎⁎⁎ 14.2 (3.1)⁎⁎⁎ 39.3 (7.8)⁎⁎⁎ 7.4 (3.2)⁎⁎⁎ 0.29 (0.09) ns 1.4 (1.2)⁎⁎⁎ 0.7 (0.7)⁎⁎⁎ 2.0 (1.8)⁎⁎⁎ 0.88 (0.8)⁎⁎⁎ 3.8 (3.4)⁎⁎⁎ 4.7 (2.0)⁎⁎⁎ (n = 30) 17.8 (1.5)⁎⁎ 35.7 (1.9) ns 45.0 (0.7) ns 15.3 (5.1)⁎⁎⁎ 5.5 (1.2) ns 4.5 (2.8)⁎⁎⁎ 1.3 (0.6) 6.4 (1.6)⁎⁎⁎ 0.6 (0.3)⁎⁎⁎

30 42.1 (4.0) ns 16.0 (3.0)⁎ 41.9 (5.5) ns 11.6 (2.3)⁎⁎⁎ 0.33 (0.12) ns 0.66 (0.7)⁎⁎ 0.20 (0.13)⁎⁎ 0.76 (0.5)⁎⁎⁎ 0.31 (0.14)⁎⁎⁎ 1.7 (1.0)⁎⁎⁎ 5.4 (2.1) ns 16.3 (1.8) ns 39.7 (1.9)⁎ 44.0 (1.0) ns 21.3 (3.1)⁎⁎⁎ 5.7 (1.4) ns 2.6 (1.5) ⁎⁎⁎ 1.1 (0.24) ns 5.3 (1.35) ns 0.33 (0.12)⁎⁎⁎

a) Compared with Idslorsuit. b) Compared with Uummannaq.

except vitamin B1, which was borderline and calcium which was below recommendations in most groups. Vitamin C intake was especially low in all groups and most participants were even below the lower limit. Vitamins A, D, and Iron intakes were especially high and for some village participants in the toxic range. The very high A and D intakes were associated with intake of seal liver. 3.2. 2004 and 2006 meals The results of the duplicate meals composition are shown together with the FFQ answered by the same persons. Dietary intake measured by a semi-quantitative food frequency questionnaire (FFQ) represents the habitual intake over a period of several months, thereby minimizing seasonal variations (Table 2). This comparison shows the overall agreement between the two methods, except that the content of traditional foods appears to be slightly underrepresented by the duplicate meals, and the consumption of sweets appears to be underestimated by the FFQ. By the “duplicate portion method” (DP), a total of about 40 different ingredients could be identified in the

90 portions, but for each person the number of consumed item types was smaller (10 to 15). The Greenlandic food items mainly consisted of seal meat, seal blubber, dried narwhale meat, narwhale or minke whale skin (muktuk), Greenland halibut, catfish, capelin, and arctic cod (Table 2), and in Narsaq, arctic char, and reindeer. The Danish food items were mainly white and dark bread, pork and chicken, rice, pasta, sugar, cheese, salami, and ship's biscuits. The duplicate meals contained very little fresh fruit, potatoes, and vegetables. In Uummannaq this was consistent with the supply available in the local store at this time of the year. In Narsaq the supply was much broader and more ample. The meals from Narsaq even included some locally grown vegetables (angelica, and roseroot) but still the total amount of vegetables was low. Liquid intake consisted mainly of water, coffee or tea with sugar, sweetened fruit juice, and beer. Consumption of milk was not common, but two persons in Uummannaq consumed a considerable amount of milk powder with their tea or coffee. The sugar content of the liquid intake was included in the energy calculations and turned out to be the major contributor. The alcohol energy contribution was not included since the reporting was considered unrealistically low and since it was not included in the

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Table 6 Spearman bivariate correlations between local food percent and selected contaminants and nutrients in Greenlandic food samples from Uummannaq 1976 and 2004 and Narsaq 2006 (Correlation coefficients and significance levels: p b 0.05⁎, p b 0.01⁎⁎, p b 0.001⁎⁎⁎) Local food % n-3 g/d Local food % n-3 g/d PCBs μg/d DDTs μg/d Hg μg/d Vit A μg/MJ Vit B1 mg/10 MJ Vit B12 μg/10 MJ Se μg/d

0.812⁎⁎⁎ 0.772⁎⁎⁎ 0.775⁎⁎⁎ 0.807⁎⁎⁎ 0.433⁎⁎⁎ 0.432⁎⁎⁎ 0.557⁎⁎⁎ 0.320⁎⁎

PCBs μg/d DDTs μg/d Hg μg/d

0.812⁎⁎⁎ 0.772⁎⁎⁎ 0.888⁎⁎⁎ 0.888⁎⁎⁎ 0.870⁎⁎⁎ 0.963⁎⁎⁎ 0.790⁎⁎⁎ 0.786⁎⁎⁎ 0.558⁎⁎⁎ 0.506⁎⁎⁎ 0.399⁎⁎⁎ 0.450⁎⁎⁎ 0.563⁎⁎⁎ 0.631⁎⁎⁎ 0.366⁎⁎⁎ 0.376⁎⁎⁎

0.775⁎⁎⁎ 0.870⁎⁎⁎ 0.963⁎⁎⁎ 0.783⁎⁎⁎ 0.480⁎⁎⁎ 0.444⁎⁎⁎ 0.589⁎⁎⁎ 0.330⁎⁎

previous studies. The relative content of Greenlandic food by solid weight was 22.9% in Uummannaq and only 10.8 in Narsaq. The relative energy % contributed by the local food was lower, 13.4 and 9.4 respectively, mainly due to the contribution from sugar. The mean total energy intakes from DPs were 6569 KJ in 2004 and 4862 in 2006 but with rather large ranges (Table 3). However, as mentioned alcohol was not

0.807⁎⁎⁎ 790⁎⁎⁎ 0.786⁎⁎⁎ 0.783⁎⁎⁎

Vit A μg/MJ Vit B1 mg/10 MJ Vit B12 μg/10 MJ Se μg/d 0.433⁎⁎⁎ 0.558⁎⁎⁎ 0.506⁎⁎⁎ 0.480⁎⁎⁎ 0.450⁎⁎⁎

0.450⁎⁎⁎ 0.417⁎⁎⁎ 0.464⁎⁎⁎ 0.592⁎⁎⁎ 583⁎⁎⁎ 0.436⁎⁎⁎ 0.250⁎

0.432⁎⁎⁎ 0.399⁎⁎⁎ 0.450⁎⁎⁎ 0.444⁎⁎⁎ 0.417⁎⁎⁎ 0.464⁎⁎⁎ 0.515⁎⁎⁎ 0.158 ns

0.557⁎⁎⁎ 0.563⁎⁎⁎ 0.631⁎⁎⁎ 0.589⁎⁎⁎ 0.592⁎⁎⁎ 0.583⁎⁎⁎ 515⁎⁎⁎ 274⁎⁎

0.320⁎⁎ 0.366⁎⁎⁎ 0.376⁎⁎⁎ 0.330⁎⁎ 0.436⁎⁎⁎ 0.250⁎ 0.158 ns 0.274⁎⁎

included. From a previous countrywide FFQ among the same age group, corrected according to Greenland import statistics, the energy from an average alcohol intake was estimated to 14 E% (Deutch et al., 2005). Thus the total energy intake is probably an under-estimation of the real intake. The relative solid weight part of Greenlandic food (22.9%) was close to the value obtained by semi-

Fig. 2. Traditional food and modern food, local food percentage, contaminant and nutrient content measured in duplicate meal portions from Uummannaq 1976 and 2004 and Narsaq 2006 (n = 177, 90, and 90 respectively).

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Table 7 Available health indicators (mean and range) for participants of the dietary studies compared by independent samples t-test, men with men, and women with women (p b 0.05⁎, p b 0.01⁎⁎, p b 0.001⁎⁎⁎) 1976 Idslorsuit (Uum)

1976 Idslorsuit (Umm)

1987 Qaanaaq

1987 Qaannaaq

2004 2006 2004 Uummannaqa) Uummannaqa) Narsaqb)

2006 Narsaqb)

15 women

15 men

Number of participants Age

11 men

17 women

21 men

15 women

15 men

15 women

46.7 (32–79)

40.6 (20–70)

36 (25–50) 35 (22–49)

28%

50.5 (37–67) ns 1.56 (145–164) 1.68 1.55 (147–169) 1.70 (155–178) (162–180) ns 57.5 (39–78) 67 (47–90) 57 (43–90) 86.7 (48–112)⁎⁎⁎ 23.5 16.9–29 23.7 (na) 23.7 (na) 29.7 (18–36)⁎⁎⁎ 18% 26%

46.7 (31–62) ns 1.57 (152–170) ns 67.3 (55–81)⁎⁎⁎ 26.5 (23–31) ⁎⁎⁎ 33%

4.9 ns 36–56) 1.70 ns (160–183) 83.9 ns (68–112) 29.1 ns (24–39) 60%

39.1 ns (18–50) 1.58 ns (150–179) 72.1⁎ (53–95) 28.8⁎ (21–38) 40%

Height, m

1.66 (159–176)

Weight, kg

68.2 (62–78)

BMI

24.7 (22.7–28)

Overweight BMI (25–29.9) Obese BMI N 30.0 Cholesterol mmol/ld) Triglycerides mmol/l

0%

0%

53%

13%

27%

33%

4.98 (sd = 0.78)

5.03 (sd = 0.92)

5.83 (4.6–8.1)⁎⁎⁎ 1.76 (0.6–5.5) ⁎⁎⁎

6.25 (4.8–8.6)⁎⁎⁎ 1.34 (0.6–2.5) ⁎⁎⁎

5.45 ns (3.3–8.0) 1.58 ns (0.66–3.6)

5.59 ns (3.6–8.7) 1.18 ns (0.51–2.49)

0.64 (0.36–0.94) 0.66 (0.37–1.1)

a) Compared with Idslorsuit. b) Compared with Uummannaq.

quantitative food frequency questionnaire, FFQ (25.3%). A provisional estimate of the energy using Canadian and Danish food composition tables (Deutch et al., 2005) gave an E% of the FFQ of 20.1. With true alcohol intake included, the resulting Greenlandic E% would be 2–3 points lower. The mean daily intakes per 10 MJ of vitamins and minerals (Table 3) were compared with Nordic Nutrient Recommendations (NNR 1996). In general, the micro nutrient intakes of these modern meals were lower than in the traditional food, except for vitamin C and folate, which were still low even in the modern meals. The vitamin C intake had increased slightly by 2004, but the median intake was still low (12.5 mg). This means that for almost 50% of the participants the intake was lower than 10 mg/day, which is considered the survey limit. Of the average vitamin C intake about 55% was contributed by orange juice. In 2004 only four persons had a vitamin C intake meeting the recommendations. Two of these persons had regular consumption of orange juice, but the other two did not consume fruits and vegetables to explain their vitamin C intake. However, they both had a very high consumption of milk powder (vitamin C is added to milk powder products sold in Greenland). In 2006 the median intake was 10.3 and only one person met the NNR for vitamin C (orange juice). Apparently the fruit intake (mainly green apples) did not contribute measurable to the vitamin C intake. The fibre intake (not

shown), estimated from the average intake of bread and other grain products, was also extremely low. The vitamin A intake, still mainly of animal origin, was low compared to the traditional food types, and in Narsaq below NNR. Due to low intake of vegetables and fruit the beta-carotene intake was below 10% of total vitamin A. With vitamin E just below recommendations, in general the antioxidant content of the modern diets was low, except for Se, which was high, Table 3 and 4. The apparent decreasing trend of Se was not significant. Despite the fact that almost everybody ate cheese, calcium was low for both years, and high only among the very few persons who consumed milk powder (liquid milk is not included in the DP but only 5 persons reported a daily glass of milk which would give a group average milk intake of about 30 g a day and a Ca contribution of 30–40 mg). The levels of mineral intakes are shown together with corresponding blood levels among the participants, if available (Table 4). The blood levels are compared with presumed human “normal” blood levels, which are means from at least ten studies for each compound (Iengar et al., 1978). All the mineral values are with the ranges of these means. The Uummannaq 2004 values for Ca and Fe are significantly higher than Narsaq and the “normal” values, whereas for Narsaq 2006 Ca and Zn are significantly lower than the normal values. Table 5 shows the fatty acid composition (% of total fatty acids) in duplicate meals and in plasma

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phospholipids. n-3 fatty acids occur in high amounts in food of marine origin, and the dietary differences were consequently also manifested in the fatty acid profiles of the diets and of the plasma phospolipids. In 1976, the food had a very high relative content of n-3 fatty acids, resulting in a mean daily consumption of n-3 fatty acids of 8.5 g and an n-3/n-6 ratio of 3.3. The resulting plasma n-3/n-6 ratio was 1.7. In the 2004 group, significant differences were found both in the food and plasma lipid patterns. All the n-3 FA's had decreased significantly and linoleic acid (C18:2,n-6) had increased. The n-3/n-6 ratio in food (now 0.87) was 26% of the 1976 value and the ratio in plasma (now 0.60) was 35% of the 1976 value. In Narsaq 2006 the n-3 content had gone further down, now significantly lower than Uummannaq 2004. The n-3 content of the food is a very strong indicator of local food content, r = 0.7, p b 0.0001 and a strong indicator of vitamins A and D content. There was a very strong correlation between duplicate meal n-3 content and plasma phospholipid n-3 level, p b 0.0001, although the FA's of the plasma phospholipids represent more long-term eating habits. Within both the Uummannaq and the Narsaq participants the persons with a daily n-3 intake of 3–5 g had the best general vitamin adequacy. Se, which is also a good indicator of traditional food, appears to have decreased. However, the differences were not significant due to very large ranges. The main source of Se was dried whale meat and muktuk even if eaten in relatively small amounts. All the measured levels organic contaminants and heavy metals followed the relative content of local food items, weight %, in the diet (indicated by n-3 FA content) and the associations were highly significant (Table 6 and Fig. 2). The contaminants were also strongly correlated with several selected nutrients namely vitamin A, vitamin B1 and B12 and Se. Also the anthropometric findings differed significantly between the sampling years, Table 7. In 2004 the mean height among men had increased by 4 cm but the weight by 18.5 kg. Among women the height had not increased, but the weight had increased by 10 kg. The resulting increases in BMI, in 2004 categorize 53% of men and 13% of women as obese (BMI N 30). In Narsaq 2006 the women were even 5 kg heavier and the ratio of obese 33%, whereas in 1976 no obese persons were found in either sex group (Dyerberg et al., 1977). 4. Discussion During the past 50 years, substantial changes have taken place in Greenland, and the proportion of the

population living in smaller villages has decreased by more than 30%. This represents a migration into larger villages and towns, where the food supply is different and broader. Already in 1953 when Uhl performed the surveys there were big differences between village and town, and between more northern town Ilulissat and southern Qaqortoq. To get a possible temporal trend view of the dietary changes, Illullissat district villages can be compared to Uummannaq villages, Illullissat can be compared to Uummannaq, and Narsaq to the nearby town Qaqortoq. Such a comparison will show that the consumption of local food on the average already had decreased in the towns 50 years ago, but especially in south Greenland, whereas in the villages the consumption of local food was still high in 1976. Helms (1981) also found that the energy coming from local products in Angmassalik was 74% in 1945 and only 22% in 1978. However the main purpose of this study is not to study dietary changes as such, but to look at their consequences. Thus all these surveys together can be used to illustrate how the relative composition of local and imported food, indicated by n-3 FA content, affects the dietary nutrient content and other health indicators. Since no up-to-date, comprehensive nutrient data base exists for Greenlandic foods, to determine the nutrient content in the 2004 and 2006 samples, we had to rely on a direct chemical analysis of the food collected by the “duplicate portion method” (DP). This method gives a precise analysis of the nutrient content in the collected food, and can thereby be used to characterize the sufficiency of different dietary compositions, e.g. different proportions of local and imported food, even if these are not representative for each participant's more long-term eating habits. For example, the DP is likely to underestimate total energy intake (Willet, 1998). Therefore comparisons with other methods should be regarded with caution and at best based on energy adjusted intakes e.g. per 10 MJ (Willet, 1998). Since dietary recalls, e.g. food frequency questionnaires, give more representative pictures of long-term eating habits we used these to supplement the DPs. In general, the duplicate portion method and the food frequency questionnaire agreed on the relative content of most items, such as the average percentage of Greenlandic food and major items of Greenlandic or Danish products. In 2004 differences were found for potatoes, fruit, tomatoes, and pepper fruit, for which the FFQ gave higher intakes. This can be explained by the time of the year for the sampling of the duplicate portions. The sampling took place in May when the first supply ship had not yet arrived and the local store was out of potatoes, fresh fruit, and vegetables. (In 1976 the DPs

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were collected at the same time of the year as in 2004, before the ice broke, and therefore approximately under the same supply situation). In Narsaq the DP only included very little seal meat, this finding can also be explained by a local situation of heavy ice. Compared with the DP, the FFQ covered a longer period of the year. One can therefore consider the DP to be representative for the sampling time but not for the habitual intake over a longer period. Based on mean values from a countrywide semiquantitative FFQ in 1999–2003 (Deutch et al., 2005) among 352 men and women in of the same age group we calculated the following energy percentages of macronutrients: fat 33.7%, total carbohydrate 33.5%, sugar 14.8%, protein 18.6%, alcohol 14% and a relative content of Greenlandic food 21.3 E%. Thus the energy percentages found by DP and FFQ were consistent with a countrywide FFQ and in general the two methods (DP and FFQ) gave consistent results except for the seasonal influences. The daily intake levels of vitamins and minerals, which were well above the NNR in 1955–1987, had decreased dramatically by 2004 except for calcium, which was unchanged low, and folate and vitamin C, which had increased slightly. The decrease in vitamin A intake can be explained by the decrease in consumption of seal meat but in particular in the consumption of organs, mainly liver. In general this decrease in vitamin A is not detrimental because in some areas it could reach toxic levels. However, in diets with very little vegetables, vitamin A has reached marginally low levels. The increase in mean vitamin C intake can mainly be explained by increase in consumption of orange juice, high intake of vitamin C- enriched milk powder by a few persons, and a minor increase from consumption of fresh fruit and vegetables. The 200–400% difference in folate intake is harder to explain. The best known sources of folate are liver and green vegetables. The intake of liver appears to have decreased and the intake of green vegetables has not increased. Bread and cheese are medium range sources of folate and they have both increased, which may explain part of the increase. An alternative explanation would be that the data base used in 1976 underestimated the folate content of the Greenlandic food items. The low level of calcium can be explained by the still prevailing low intake of milk products. The contributions from liquid milk and drinking water were not included. However, the milk intake was very low and the drinking water in Greenland has a low mineral content, as it originates from melted ice or snow (Jeppesen, 1987). In Uhl's (1955) report it was calculated that the most

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important sources of Ca were rye flour, wheat flour, milk products and capelin or other dried fish. The low Ca intake may be influential on the high rate of post menopausal osteoporosis in Greenland (Jeppesen, 1987; Jeppesen and Harvald, 1983). However, the blood Ca levels and other minerals did not seem to be adversely affected by the low intake. Although vitamin D was not measured in the modern meals, other researchers have found vitamin D insufficiency in Greenlanders living on westernized fare (Rejnmark et al., 2004). In any case, calcium, vitamin C, E, and folate were found to be below recommendations, and public health measures should be taken to help ensure better provision of these nutrients. Since many adult Greenlanders do not tolerate milk products well, it does not seem to be a solution to recommend increased milk consumption (except cheeses) to improve Ca status. Also the supply of milk products is not constant and prices are high. The enrichment of milk powder with vitamin C or Ca is a solution only for a small target group. It may therefore be a better solution to enrich certain other food products with Ca, for example flour, which in addition could be enriched with folate. Even if the measured vitamin C intakes were far below the recommendations, scurvy or other deficiency symptoms have not been documented among Inuits and their actual vitamin C needs are not known. Thus at the present time we would not recommend dietary enrichment with vitamin C. Looking at the physical health indicators it is an interesting finding that although the energy intake has gone down dramatically the body weight has increased, with a concomitant significant increase in S-cholesterol and -triglyceride. The lower intake of n-3 and thereby the lower plasma n-3 content is consistent with the observed increase in triglycerides. Furthermore, high BMI is a strong determinant for increment in triglycerides and in other cardiovascular risk indicators. The levels of body weight, BMI, and cardiovascular risk factors found in 2004 and 2006 are in agreement with recent results from 8 districts of Greenland (Deutch et al., 2007). However, in our countrywide FFQ (Deutch et al., 2005) we did not find an association between low ratio of local food and increased body weight. Less physical activity thus seems to be the most likely cause of the body weight increase. The more western lifestyle has most likely caused a decrease in physical activity level in Greenland (Bjerregaard et al., 2004) which may partly explain the increased BMI. The same study also shows that serum lipid cardiovascular risk factors exacerbate with westernisation.

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Nutritional adequacy among Greenland Inuits, who have very high marine food intake, is hard to compare with dietary studies among other Arctic populations or even other Inuits. However, a comparison of Canadian Inuits (Nunavut) on days with traditional food versus days without traditional food (Kuhnlein et al., 2004) supports the nutrient profiles of the present study and points to the same nutrients being marginal. Another Canadian study showed that young Inuits on more westernized fare had a 4–6 fold relative risk of vitamin A inadequacy compared with older Inuits eating more traditional food (Egeland et al., 2004). The above nutritional considerations of the Greenland diet can, however, not stand alone. Several studies have measured high levels of organic pollutants and heavy metals in local Greenlandic food products (Johansen et al., 2004) as well as in human plasma (Deutch et al., 2004, 2006). The intake of organic contaminants has gone down in Greenland, because the intake of local food has gone down (Deutch et al., 2006). In addition the level of some of the contaminants like PCB and DDT has decreased in food items, whereas other contaminants like beta-HCH, chlordanes, hexachlorobenzene, mirex, toxaphenes and mercury are increasing. Due to this we cannot recommend to increase the consumption of Greenlandic products in general above the present level. However, we have also shown highly significant decreasing trends of oxychlordane, DDE, PCB153, and Pb in blood from pregnant women in the Disko bay area 1994–2006. Although positive, this finding can mainly be explained by changed dietary habits (Deutch, unpublished data). 5. Conclusion Based upon comparison with earlier dietary studies and with traditional food samples from 1976 and samples from 2004 to 2006, our overall conclusion is that a diet with a high percentage of Greenlandic food items in general provides sufficient vitamin and mineral coverage., There are however, a few exceptions namely Ca, vitamin C, E, and folate. It also appears that a diet with an average percentage of Greenlandic food of 20–25% (the present country mean) will meet the NNR for most nutrients. A diet based exclusively on available Danish imported products can be risky in Greenland, since general availability and freshness is not always guaranteed. On the other hand a diet with very high percentage of Greenlandic food imposes a strong risk of deficiency in Ca, vitamin C and folate and has a very low content of dietary fibre. A diet with high content of Greenlandic food contains high levels of mercury and a number of organic

pollutants. There is also a risk of reaching toxic levels of vitamins A and D. We therefore recommend not increasing the consumption of Greenlandic products above the present level. If more fruit, vegetables, and potatoes were added to the Greenland diet, the vitamin C, folate and dietary fibre intake would improve. Since increased milk intake is not an option, consumption of more bread especially Danish rye bread would improve the Ca intake. Furthermore, it is important that the composition and quality of the imported products in the diet provide the best possible nutrient coverage, in particular that supplies of fresh or frozen fruit, vegetables and potatoes are ensured throughout the year. Acknowledgements The present project has been funded by the Danish Environmental Protection Agency as part of the environmental support program Dancea — Danish Cooperation for Environment in the Arctic. The authors are solely responsible for all results and conclusions presented in the report and do not necessarily reflect the position of the Danish Environmental Protection Agency. We also acknowledge the economical support from Greenland Homerule, The Commission for Scientific Research in Greenland, Greenland Lotto funds and NUNA foundation. We thank Anna Rosenquist, Peder Helms and Niels Hjørne for supplying dietary data from 1976. References AMAP Assessment Report. Arctic pollution issues; 1998. Bang HO, Dyerberg J. The lipid metabolism in Greenlanders. Meddelelser om Grønland. Man Soc 1981(2):3–18. Bang HO, Dyerberg J, Nielsen AB. Plasma lipid and lipoprotein pattern in Greenland West-coast Eskimos. Lancet 1971:1134–46 [June 5]. Bang HO, Dyerberg J, Hjørne N. The composition of food consumed by Greenland Eskimos. Acta Med Scand 1976;200:69–73. Bang HO, Dyerberg J, Sinclair HM. The composition of the Eskimo food in north western Greenland. Am J Clin Nutr 1980;30:2657–61. Bjerregaard P, Dewailly E, Ayotte P, Pars T, Ferron L, Mulvad G. Exposure of Inuit in Greenland to organochlorines through the marine diet. J Toxicol Environ Health Part A 2001;62(2):69–81. Bjerregaard P, Jørgensen ME, Borch-Johnsen K. Serum lipids of Greenland Inuit in relation to Inuit genetic heritage, westernisation and migration. Atherosclerosis 2004(174):391–8. Deutch B, Bonefeld Jørgensen E, Hansen JC. Menstrual discomfort in Danish women reduced by dietary supplements of omega-3 PUFA and B-12 (fish or seal oil capsules). Nutr Res 2000a;20(5):621–31. Deutch B, Bonefeld Jørgensen E, Hansen JC. N-3 PUFA's from fish or seal oil reduce atherogenic risk indicators in Danish women. Nutr Res 2000b;20(8):1065–77. Deutch B, Pedersen HS, Hansen JC. Dietary composition in Greenland 2000, plasma fatty acids and persistent organic pollutants. Sci Total Environ 2004;331(1-3):177–88.

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