Fifteen-year time trends in energy and macronutrient intake in German children and adolescents: results of the DONALD study

Adherence to Dietary Recommendations of 7-Year-Old Children from a Birth Cohort in Friuli Venezia Giulia, Italy

Few Italian and European studies have assessed adherence to dietary recommendations in primary school children using dietary records. No Italian studies have provided an index-based nutritional adequacy assessment. We provided a comprehensive overview of dietary intake in 381 7-year-old children from NAC-II cohort study, Friuli Venezia Giulia (Italy). Energy, macro-, and micronutrient intakes were derived from 3-day dietary records. Standard (median and percentage) and index-based (Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR)) approaches were used to evaluate adequacy to Italian dietary reference values at nutrient- and overall-diet-level. Percentage contribution of macronutrients to energy intake (%En) was unbalanced towards total fats and protein. In 25% of children, total fats intake exceeded the reference intake upper limit. In ~63% of children, protein intake was at least doubled in their child-specific population reference intake. Median intakes of sodium (1.7 g/day), saturated fatty acids (12.2 %En), and soluble carbohydrates (19.4 %En) exceeded the suggested dietary target in most (65–84%) children. Inadequacy was also observed for micronutrients, with median NARs ranging from 0.11 (vitamin D) to 0.90 (zinc). The median MAR was 0.75 (0.69–0.79), with 1 indicating optimal overall dietary intake. In conclusion, the enrolled children showed suboptimal intakes of several macro- and micronutrients, in line with Italian and European studies on primary school children. Based on the current findings, public health interventions may be targeted to specific nutrients or subpopulations.

Changes in Total Energy, Nutrients and Food Group Intake among Children and Adolescents during the COVID-19 Pandemic-Results of the DONALD Study

The COVID-19 pandemic may have changed the habitual lifestyles of children and adolescents, in particular, due to the closure of kindergartens and schools. To investigate the impact of the pandemic on nutrients and food intake of children and adolescents in Germany, we analyzed repeated 3-day weighed dietary records from 108 participants (3–18 years; females: n = 45, males: n = 63) of the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study. Polynomial mixed-effects regression models were used to identify prospective changes in dietary intake (total energy (TEI), carbohydrates, fat, protein, free sugar, ultra-processed foods, fruits and vegetables, sugar sweetened beverages and juices) before and during the first months of the COVID-19 pandemic. For the current analysis, we have chosen the first months of the pandemic (March 2020–August 2020), as this was the period with the most restrictions in Germany so far (kindergarten, school and restaurant closures; contact and outdoor activity restrictions). No significant changes in either the selected nutrients or food groups were observed. However, children and adolescents recorded a significantly lower TEI during the pandemic (β = −109.65, p = 0.0062). Results remained significant after the exclusion of participants with under-reported records (β = −95.77, p = 0.0063). While macronutrient intake did not change, descriptive data indicate a non-significant decrease in sugar sweetened beverages and ultra-processed foods intake. We suggest that children and adolescents from high socioeconomic families may have adapted lifestyle changes during the pandemic.

Dietary flavonoids among children and adolescents in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study: intake, food sources and trends from 1985 until 2016

Flavonoids are suggested to reduce disease risk. Since dietary habits are acquired during early life, describing age and time trends of flavonoid intake and major food sources are important for monitoring and disease prevention in later life. We aimed to describe total flavonoid intake and food sources and to investigate age and time trends of flavonoid intake in 3-18-year-olds, from the Dortmund Nutritional and Anthropometric Longitudinally Designed study from 1985 to 2016. Intake was assessed annually using 3-d weighed food records (WFR). Flavonoid values were assigned using the United States Department of Agriculture database. Foods contributing to intake were determined. Age and time trends in total flavonoid and isoflavone density were analysed by sex with PROC MIXED. In total, 1312 children completed 10 758 WFR. Across all ages, daily mean total flavonoid density was lower in boys compared with girls (134 v. 146 mg/4184 kJ) and no difference in median isoflavone density (0·04 mg/4184 kJ per d) was found. The top five foods contributing to total flavonoid intake were apple with peel (15·0/17·1 %), strawberries (5·9/6·1 %), chocolate spread (3·9/3·5 %), orange juice (3·5/3·4 %) and pasta (3·5/3·4 %) for boys and girls, respectively. Overall, in boys, total flavonoid density decreased over the course of age and time. In girls, there was no association with age or time. In both sexes, isoflavone density followed a U-shaped age trend with no change over time. From a public health perspective, the overall observed downwards trend of flavonoid intake in boys deserves attention. Future initiatives should be tailored at maintaining a high flavonoid density as children age, specifically among boys.

The obesity epidemic - Nature via nurture: A narrative review of high-income countries

Over the last three decades, the prevalence of obesity has increased rapidly in populations around the world. Despite a wealth of research, the relative contributions of the different mechanisms underlying this global epidemic are not fully understood. While there is growing consensus that the rapid rise in obesity prevalence has been driven by changes to the environment, it is evident that biology plays a central role in determining who develops obesity and who remains lean in the current obesogenic environment. This review summarises evidence on the extent to which genes and the environment influence energy intake and energy expenditure, and as a result, contribute to the ongoing global obesity epidemic. The concept of genetic susceptibility to the environment driving human variation in body weight is discussed.

[Questionnaire for measuring risk eating behaviors for excess malnutrition in adolescents]

Introduction

Introduction: there are behavioral factors that predispose to the development of excess malnutrition, and which can be key to the promotion of healthy habits. The purpose of this study was to construct and validate a questionnaire to identify risky eating behaviors in adolescents. Objective: to evaluate the psychometric properties of a questionnaire to measure risky eating behaviors related to excess malnutrition in adolescents in the province of Concepción, Chile. Materials and methods: quantitative psychometric research with correlational scope; non-experimental, cross-sectional design. The population was composed by adolescents aged 10 to 15 years in the province of Concepción, from different socio-economic levels. A total of 303 students, chosen by non-probabilistic sampling, responded to the Questionnaire on Alimentary Malnutrition Risk Behaviors, CARME. A subsample of 115 students also answered a body image questionnaire, and 80 were assessed anthropometrically. Exploratory factor analyses and correlation evaluations were performed. Results: four factors were identified for the CARME: response to food, feeding without control, consumption of highly caloric foods, and emotional feeding, with reliability between α = 0.64 and α = 0.87. Scores showed differences by sex, and relationships with perceived body image (p < 0.05), but not with nutritional status. Conclusions: the evidence supports the construct validity, reliability and criteria validity of CARME. The questionnaire would be appropriate to measure dietary risk behaviors for overweight and obesity in adolescents. However, no associations were found between nutritional status and questionnaire dimensions.

Rationale and design of the school-based SI! Program to face obesity and promote health among Spanish adolescents: A cluster-randomized controlled trial

Unhealthy habits in adolescents are increasing at an alarming rate. The school offers a promising environment in which to implement effective preventive strategies to improve adolescents' lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based health-promotion intervention aimed at all stages of compulsory education in Spain. We present the study design of the SI! Program for Secondary Schools, targeting adolescents aged 12 to 16 years.

AIM

The main goal of this study is to evaluate the impact of the SI! Program educational intervention on adolescent lifestyle behaviors and health parameters.

METHODS

The study was designed as a cluster-randomized controlled intervention trial and enrolled 1326 adolescents from 24 public secondary schools in Spain, together with their parents/caregivers. Schools and their students were randomly assigned to the intervention group (the SI! curriculum-based educational program over 2 or 4 academic years) or to the control group (usual curriculum). The primary endpoint will be the change from baseline at 2-year and 4-year follow-up in the composite Ideal Cardiovascular Health (ICH) score, consisting of four health behaviors (body mass index, dietary habits, physical activity, and smoking) and three health factors (blood pressure, total cholesterol, and glucose). Secondary endpoints will include 2-year and 4-year changes from baseline in ICH score subcomponents, the Fuster-BEWAT health scale, adiposity markers (waist circumference and body composition), polyphenol and carotenoid intake, and emotion management.

DISCUSSION

The overarching goal of the SI! Program is to instill healthy behaviors in children and adolescents that can be sustained into adulthood. The SI! Program for Secondary School is a comprehensive health-promotion intervention targeting 12-16-year-old adolescents and their immediate environment. The present study addresses the optimal timing and impact of the educational intervention on health in adolescence.

Age and time trends in sugar intake among children and adolescents: results from the DONALD study

PURPOSE

To describe age and time trends in added sugar, free sugar and total sugar intake among German 3-18-year-olds.

METHODS

Overall, 10,761 3-day dietary records kept between 1985 and 2016 by 1312 DONALD participants (660 boys, 652 girls) were analysed (%E) using polynomial mixed-effects regression models.

RESULTS

TS intake decreased with age (♂: linear, quadratic and cubic trend all p < 0.0098; ♀: linear trend p < 0.0001). While the oldest children had the lowest FS intake (linear, quadratic trend: p < 0.0001), the youngest children had the lowest AS intake (linear, quadratic trend p < 0.0001, cubic trend p = 0.0004). In terms of time trends, TS (♂: cubic trend p = 0.0052; ♀: quadratic trend p = 0.0608, cubic trend p = 0.0014) and FS (quadratic trend p = 0.0163, cubic trend p < 0.0001) intake increased between 1985 and 2005 and decreased thereafter, most notably since 2010. AS intake decreased between 1985 and 1995, increased slightly until 2005 and decreased thereafter, most notably since 2010 (linear, quadratic, cubic trend p < 0.0001). FS intake exceeded 10%E/day throughout the 30-year study period.

CONCLUSION

Our results do not support the common assumptions that sugar intake is on the rise and generally higher among adolescents than among younger children. Of note, TS, AS and FS intakes have decreased in the last decade among all age groups. Nevertheless, FS intake still exceeds the intake level recommended by the WHO.

Effect of Taste Enhancement on Consumer Acceptance of Pureed Cucumber and Green Capsicum

Vegetables have low taste intensities, which might contribute to low acceptance. The aim of this study was to investigate the effect of taste (sweetness, sourness, bitterness, umami, and saltiness) and fattiness enhancement on consumer acceptance of cucumber and green capsicum purees. Three concentrations of sugar, citric acid, caffeine, mono-sodium glutamate, NaCl, and sunflower oil were added to pureed cucumber and green capsicum. Subjects (n = 66, 35.6 ± 17.7 y) rated taste and fattiness intensity. Different subjects (n = 100, 33.2 ± 16.5 years) evaluated acceptance of all pureed vegetables. Taste intensities of vegetable purees were significantly different (P < 0.05) between the three tastant concentrations except for umami in both vegetable purees, sourness in green capsicum puree, and fattiness in cucumber puree. Only enhancement of sweetness significantly (P < 0.05) increased acceptance of both vegetable purees compared to unmodified purees. In cucumber purees, relatively small amounts of added sucrose (2%) increased acceptance already significantly, whereas in green capsicum acceptance increased significantly only with addition of 5% sucrose. Enhancement of other taste modalities did not significantly increase acceptance of both vegetable purees. Enhancing saltiness and bitterness significantly decreased acceptance of both vegetable purees. We conclude that the effect of taste enhancement on acceptance of vegetable purees differs between tastants and depends on tastant concentration and vegetable type. With the exception of sweetness, taste enhancement of taste modalities such as sourness, bitterness, umami, and saltiness was insufficient to increase acceptance of vegetable purees. We suggest that more complex taste, flavor, or texture modifications are required to enhance acceptance of vegetables.

PRACTICAL APPLICATION

Results can be used by cultivators to select and grow vegetable varieties with enhanced taste and flavor. Especially for cucumber, relatively small sweetness enhancement is sufficient to increase acceptance.

Macronutrient Composition of the Australian Population's Diet; Trends from Three National Nutrition Surveys 1983, 1995 and 2012

Although the role of individual macronutrients in the development of obesity remains controversial, changes in macronutrient composition of the diet may have played a causal role in the obesity epidemic. The aim of this analysis was to determine the percentage energy (%E) for protein, carbohydrate and fat of Australian adults' diets over time. Cross-sectional, national nutrition surveys from 1983, 1995 and 2012 assessed diet using one 24 h recall. The prevalence of obesity increased between each survey, from 9.6% to 19.7% and 27.7%. Protein (%E) differed between each survey and contributed 17.7%, 16.8% and 18.3% energy in 1983, 1995 and 2012, respectively (p < 0.001). Carbohydrate (%E) increased from 40.0% in 1983 to 44.9% in 1995 (p < 0.001), with no change in dietary fibre but declined in 2012 to 43.1%. Fat (%E) declined between each survey from 35.3%, 31.9%, to 30.9%, respectively (p < 0.001). Alcohol (%E) has declined for younger adults and men but intake increased for women aged >45 years. Prospective cohort studies with comprehensive assessment of foods consumed, together with measurements of weight and height, will advance the understanding of the relationship between macronutrients and changes in body weight and obesity.

Breast-feeding duration and child eating characteristics in relation to later vegetable intake in 2-6-year-old children in ten studies throughout Europe

OBJECTIVE

Breast-feeding is thought to facilitate young children's acceptance of new foods, including vegetables, but the evidence for this relationship appears inconsistent across studies. Increasing children's vegetable intake remains challenging; therefore the present study aimed to investigate whether breast-feeding duration predicts vegetable intake in 2-6-year-old children.

DESIGN

Actual vegetable intake was measured in studies across three European countries. General linear model analyses with breast-feeding duration, sex and age of the child and maternal education as variables were used to predict children's vegetable intake per country. Additionally, the relationships between child eating behaviour characteristics (asked through the Child Eating Behaviour Questionnaire) and vegetable intake were investigated via Pearson correlations.

SETTING

Daycare centres, schools and home settings in Denmark, Greece and the Netherlands.

SUBJECTS

Children aged 2-6 years (n 750).

RESULTS

Breast-feeding duration was positively associated with children's vegetable intake at 2-6 years old in Denmark (P<0·01) and the Netherlands (P<0·05), but not in Greece (P=0·17). Age of the child, maternal education and sex of the child did not predict vegetable intake in our sample. All countries showed an inverse relationship between food neophobia and children's vegetable intake and a positive relationship between vegetable liking and intake.

CONCLUSIONS

The present study found that breast-feeding duration is a predictor of later vegetable intake, but that current child eating behaviour characteristics, such as vegetable liking, food neophobia and enjoyment of food, also influence vegetable intake. Besides encouragement of breast-feeding duration, strategies that support vegetable liking and food enjoyment and decrease food neophobia are needed to support young children's vegetable intake.

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects and associations of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective cohort studies if they related baseline total fat intake to weight or body fatness at least 12 months later.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted body weight and blood lipid levels outcomes at six months, six to 12 months, one to two years, two to five years and more than five years for RCTs; and for cohort studies, at baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three studies were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous to combine.Effects of dietary counselling to reduce total fat intake from RCTsTwo studies recruited children aged between 4 and 11 years and a third recruited children aged 12 to 13 years. Interventions were combinations of individual and group counselling, and education sessions in clinics, schools and homes, delivered by dieticians, nutritionists, behaviourists or trained, supervised teachers. Concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability.One study of dietary counselling to lower total fat intake found that the intervention may make little or no difference to weight compared with usual diet at 12 months (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; n = 620; low-quality evidence) and at three years (MD -0.60 kg, 95% CI -2.39 to 1.19; n = 612; low-quality evidence). Education delivered as a classroom curriculum probably decreased BMI in children at 17 months (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence). The effects were smaller at longer term follow-up (five years: MD 0 kg/m2, 95% CI -0.63 to 0.63; n = 541; seven years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; n = 576; low-quality evidence).Dietary counselling probably slightly reduced total cholesterol at 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Dietary counselling probably slightly decreased low-density lipoprotein (LDL) cholesterol at 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and at five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. Dietary counselling probably made little or no difference to HDL-C at 12 months (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), and at five years (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, counselling probably made little or no difference to triglycerides in children at 12 months (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height at seven years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Associations between total fat intake, weight and body fatness from cohort studiesOver half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to dietary counselling or education to lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls. There were no consistent effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Most studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings to look at both possible benefits and harms.

Time and age trends in morning and evening protein intakes of German children and adolescents

The present study describes time and age trends in morning and evening protein intakes and sources among German children and adolescents from 1985 to 2014. A total of 9757 three-day weighed dietary records of 1246 3- to 18-year-old participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study were analysed using polynomial mixed-effects regression models. Morning protein intake increased over the study period by approximately 1 % of morning energy intake (linear trend P < 0·0001), with the youngest and the oldest children having the highest protein intake (linear, quadratic trend P < 0·0001). Evening protein intake increased over time by approximately 2 % of evening energy intake in girls (linear trend P < 0·0001) and 1 % of evening energy intake in boys (quadratic trend P = 0·0313), with decreasing intake with age (girls: linear trend P < 0·0001; boys: linear trend P = 0·0963). Time trends were largely due to increases in protein from ‘starchy foods’. In conclusion, morning and evening protein intakes increased modestly between 1985 and 2014; these increases were, however, not accompanied by increases in traditional protein sources (i.e. meat or dairy products).

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective analytical cohort studies in these children if they related baseline total fat intake to weight or body fatness at least 12 months later. We duplicated inclusion decisions and resolved disagreement by discussion with other authors.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted outcome data using the following time point ranges, when available: RCTs: baseline to six months, six to 12 months, one to two years, two to five years and more than five years; cohort studies: baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous.For the RCTs, concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability. Lower versus usual or modified total fat intake may have made little or no difference to weight over a six- to twelve month period (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; 1 RCT; n = 620; low-quality evidence), nor a two- to five-year period (MD -0.60 kg, 95% CI -2.39 to 1.19; 1 RCT; n = 612; low-quality evidence). Compared to controls, lower total fat intake (30% or less TE) probably decreased BMI in children over a one- to two-year period (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence), with no other differences evident across the other time points (two to five years: MD 0.00 kg/m2, 95% CI -0.63 to 0.63; 1 RCT; n = 541; greater than five years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; 1 RCT; n = 576; low-quality evidence). Lower fat intake probably slightly reduced total cholesterol over six to 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Lower fat intake probably slightly decreased low-density lipoprotein (LDL) cholesterol over six to 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and over two to five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. However, lower total fat intake probably made little or no difference to HDL-C over a six- to 12-month period (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), nor a two- to five-year period (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, lower total fat intake probably made little or no difference to triglycerides in children over a six- to 12-month period (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height over more than five years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Over half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to a lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls, and no consistent differences in effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Twenty-three out of 24 included studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings and look at both possible benefits and risks.

The role of smell, taste, flavour and texture cues in the identification of vegetables

It has been shown that the identification of many foods including vegetables based on flavour cues is often difficult. The effect of providing texture cues in addition to flavour cues on the identification of foods and the effect of providing taste cues only on the identification of foods have not been studied. The aim of this study was to assess the role of smell, taste, flavour and texture cues in the identification of ten vegetables commonly consumed in The Netherlands (broccoli, cauliflower, French bean, leek, bell pepper, carrot, cucumber, iceberg lettuce, onion and tomato). Subjects (n = 194) were randomly assigned to one of four test conditions which differed in the sensory cues available for vegetable identification: taste, smell (orthonasal), flavour (taste and smell) and flavour-texture (taste, smell and texture). Blindfolded subjects were asked to identify the vegetable from a list of 24 vegetables. Identification was the highest in the flavour-texture condition (87.5%). Identification was significantly lower in the flavour condition (62.8%). Identification was the lowest when only taste cues (38.3%) or only smell cues (39.4%) were provided. For four raw vegetables (carrot, cucumber, onion and tomato) providing texture cues in addition to flavour cues did not significantly change identification suggesting that flavour cues were sufficient to identify these vegetables. Identification frequency increased for all vegetables when perceived intensity of the smell, taste or flavour cue increased. We conclude that providing flavour cues (taste and smell) increases identification compared to only taste or only smell cues, combined flavour and texture cues are needed for the identification of many vegetables commonly consumed in The Netherlands.

Intake of Energy and Protein is Associated with Overweight Risk at Age 5.5 Years: Results from the Prospective TEDDY Study

OBJECTIVE

The associations of energy, protein, carbohydrate, and fat intake with weight status up to the age of 5.5 years were prospectively assessed in The Environmental Determinants of Diabetes in the Young (TEDDY) study.

METHODS

Food record data (over 3 days) and BMI measurements between 0.25 and 5.5 years were available from 5,563 children with an increased genetic risk for type 1 diabetes followed from shortly after birth. Odds ratios (ORs) were calculated for overweight and obesity by previous intake of energy, protein, carbohydrate, and fat with adjustment for potential confounders.

RESULTS

Having overweight or obesity at the age of 5.5 years was positively associated with mean energy intake in previous age intervals (e.g., adjusted OR [95% CI] for overweight: 1.06 [1.04-1.09] per 100 kcal intake at the age of 4.5-5.0 years) and with protein intake after the age of 3.5 and 4.5 years, respectively (e.g., adjusted OR for overweight: 1.06 [1.03-1.09] per 1% of energy intake at the age of 4.5-5.0 years). The respective associations with carbohydrate and fat intake were less consistent.

CONCLUSIONS

These findings indicate that energy and protein intake are positively associated with increased risk for overweight in childhood but yield no evidence for potential programming effects of protein intake in infancy.

Twenty four year time trends in fats and cholesterol intake by adolescents. Warsaw Adolescents Study

The objective of this study was to determine time trends ( 1982–2006) in total fat intake and changes in fatty acid structure intake in adolescents from Warsaw in view of increasing prevalence of obesity. Data come from four successive surveys randomly selected samples of adolescents (aged 11–15 years old), from Warsaw region. In total 9747 pupils have been examined, with response rate varying from 55% to 87% depending on year. Surveys were done always in the spring season of the year. Food intake was assessed by using 24 hours recall method of consumption by the pupils all products, including enriched, dishes and beverages as well as diet supplements, in the last 24 hours preceding the examination. The content of energy and nutrients was calculated by means of own computer softwares (DIET 2 and 4), taking into account successive revisions of the tables of food composition and nutritional values, as well as current Polish DRI. A significant decreasing trend was found in intake of total fat, of saturated fatty acids (SFA) and cholesterol. The percentage of energy from total fat, also decreased both in boys (to 35,1%) and girls (to 33,7%), what failed to reach the desired level below 30% of energy from fat which is recommended. Also significant decrease of SFA consumption was not satisfactory enough to approach the values <10% of energy recommended as was from 13% to 15%. Decreasing trends in fat intake was not in accordance with the trend in obesity prevalence in the adolescents as average BMI is going up. To stabilize the health-oriented changes especially in the diets of adolescents, further activity is desired from professionals working with prevention of adolescents obesity.

Efficacy of repeated exposure and flavour-flavour learning as mechanisms to increase preschooler's vegetable intake and acceptance

BACKGROUND

Dutch children's diets, like the diets of many children in Europe and the US are not balanced, do not contain enough vegetables and have been associated with a high prevalence of childhood obesity. Promoting children's vegetable intake is challenging.

OBJECTIVE

We investigated the relative effectiveness of repeated exposure and flavour-flavour learning in increasing vegetable intake and acceptance in preschoolers.

METHODS

During an intervention period of 7 weeks, 39 toddlers (aged 1.5 to 4 years) consumed red beet and parsnip crisps at day-care centres in Wageningen, the Netherlands. Half of the group received red beet crisps with a dip of tomato ketchup (Conditioned [C]) and parsnip with a neutral white sauce (Unconditioned, [UC]), whereas for the other half the order was reversed (red beet [UC], parsnip [C]). Preference and ad libitum consumption of vegetable crisps were measured once before and three times after the intervention over the course of a 6-month follow-up period to assess longer-term effects.

RESULTS

Intake increased significantly after the intervention for both vegetables (on average with 8 g; an increase of approximately 300%), and this effect was persistent even 6 months afterwards. The increase was irrespective of crisps being offered with C or UC dip sauce.

CONCLUSIONS

These results suggest a robust and persistent effect of repeated exposure but no effect of flavour-flavour learning. Offering pure vegetable tastes repeatedly is sufficient to increase intake.

The influence of early feeding practices on healthy diet variety score among pre-school children in four European birth cohorts

OBJECTIVE

The present study examined whether maternal diet and early infant feeding experiences relating to being breast-fed and complementary feeding influence the range of healthy foods consumed in later childhood.

DESIGN

Data from four European birth cohorts were studied. Healthy Plate Variety Score (HPVS) was calculated using FFQ. HPVS assesses the variety of healthy foods consumed within and across the five main food groups. The weighted numbers of servings consumed of each food group were summed; the maximum score was 5. Associations between infant feeding experiences, maternal diet and the HPVS were tested using generalized linear models and adjusted for appropriate confounders.

SETTING

The British Avon Longitudinal Study of Parents and Children (ALSPAC), the French Etude des Déterminants pre et postnatals de la santé et du développement de L'Enfant study (EDEN), the Portuguese Generation XXI Birth Cohort and the Greek EuroPrevall cohort.

SUBJECTS

Pre-school children and their mothers.

RESULTS

The mean HPVS for each of the cohorts ranged from 2.3 to 3.8, indicating that the majority of children were not eating a full variety of healthy foods. Never being breast-fed or being breast-fed for a short duration was associated with lower HPVS at 2, 3 and 4 years of age in all cohorts. There was no consistent association between the timing of complementary feeding and HPVS. Mother's HPVS was strongly positively associated with child's HPVS but did not greatly attenuate the relationship with breast-feeding duration.

CONCLUSIONS

Results suggest that being breast-fed for a short duration is associated with pre-school children eating a lower variety of healthy foods.

Fruit and vegetable consumption in a sample of 11-year-old children in ten European countries--the PRO GREENS cross-sectional survey

OBJECTIVE

To describe fruit and vegetable intake of 11-year-old children in ten European countries and compare it with current dietary guidelines.

DESIGN

Cross-sectional survey. Intake was assessed using a previously validated questionnaire containing a pre-coded 24 h recall and an FFQ which were completed in the classroom. Portion sizes were calculated using a standardized protocol.

SETTING

Surveys were performed in schools regionally selected in eight countries and nationally representative in two countries.

SUBJECTS

A total of 8158 children from 236 schools across Europe participating in the PRO GREENS project.

RESULTS

The total mean consumption of fruit and vegetables was between 220 and 345 g/d in the ten participating countries. Mean intakes did not reach the WHO population goal of ≥400 g/d in any of the participating countries. Girls had a significantly higher intake of total fruit and vegetables than boys in five of the countries (Sweden, Finland, Iceland, Bulgaria and Slovenia). Mean total fruit intake ranged between 114 and 240 g/d and vegetable intake between 73 and 141 g/d. When using the level ≥400 g/d as a cut-off, only 23·5 % (13·8-37·0 %) of the studied children, depending on country and gender, met the WHO recommendation (fruit juice excluded).

CONCLUSIONS

Fruit and vegetable consumption was below recommended levels among the schoolchildren in all countries and vegetable intake was lower than fruit intake. The survey shows that there is a need for promotional activities to improve fruit and vegetable consumption in this age group.

Usual energy and macronutrient intakes in 2-9-year-old European children

OBJECTIVE

Valid estimates of population intakes are essential for monitoring trends as well as for nutritional interventions, but such data are rare in young children. In particular, the problem of misreporting in dietary data is usually not accounted for. Therefore, this study aims to provide accurate estimates of intake distributions in European children.

DESIGN

Cross-sectional setting-based multi-centre study.

SUBJECTS

A total of 9560 children aged 2-9 years from eight European countries with at least one 24-h dietary recall (24-HDR).

METHODS

The 24-HDRs were classified in three reporting groups based on age- and sex-specific Goldberg cutoffs (underreports, plausible reports, overreports). Only plausible reports were considered in the final analysis (N=8611 children). The National Cancer Institute (NCI)-Method was applied to estimate population distributions of usual intakes correcting for the variance inflation in short-term dietary data.

RESULTS

The prevalence of underreporting (9.5%) was higher compared with overreporting (3.4%). Exclusion of misreports resulted in a shift of the energy and absolute macronutrient intake distributions to the right, and further led to the exclusion of extreme values, that is, mean values and lower percentiles increased, whereas upper percentiles decreased. The distributions of relative macronutrient intakes (% energy intake from fat/carbohydrates/proteins) remained almost unchanged when excluding misreports. Application of the NCI-Method resulted in markedly narrower intake distributions compared with estimates based on single 24-HDRs. Mean percentages of usual energy intake from fat, carbohydrates and proteins were 32.2, 52.1 and 15.7%, respectively, suggesting the majority of European children are complying with common macronutrient intake recommendations. In contrast, total water intake (mean: 1216.7 ml per day) lay below the recommended value for >90% of the children.

CONCLUSION

This study provides recent estimates of intake distributions of European children correcting for misreporting as well as for the daily variation in dietary data. These data may help to assess the adequacy of young children's diets in Europe.

Is there an association between food portion size and BMI among British adolescents?

The prevalence of obesity has increased simultaneously with the increase in the consumption of large food portion sizes (FPS). Studies investigating this association among adolescents are limited; fewer have addressed energy-dense foods as a potential risk factor. In the present study, the association between the portion size of the most energy-dense foods and BMI was investigated. A representative sample of 636 British adolescents (11–18 years) was used from the 2008–2011 UK National Diet and Nutrition Survey. FPS were estimated for the most energy-dense foods (those containing above 10·5 kJ/g (2·5 kcal/g)). Regression models with BMI as the outcome variable were adjusted for age, sex and misreporting energy intake (EI). A positive association was observed between total EI and BMI. For each 418 kJ (100 kcal) increase in EI, BMI increased by 0·19 kg/m2(95 % CI 0·10, 0·28;P< 0·001) for the whole sample. This association remained significant after stratifying the sample by misreporting. The portion sizes of a limited number of high-energy-dense foods (high-fibre breakfast cereals, cream and high-energy soft drinks (carbonated)) were found to be positively associated with a higher BMI among all adolescents after adjusting for misreporting. When eliminating the effect of under-reporting, larger portion sizes of a number of high-energy-dense foods (biscuits, cheese, cream and cakes) were found to be positively associated with BMI among normal reporters. The portion sizes of only high-fibre breakfast cereals and high-energy soft drinks (carbonated) were found to be positively associated with BMI among under-reporters. These findings emphasise the importance of considering under-reporting when analysing adolescents' dietary intake data. Also, there is a need to address adolescents' awareness of portion sizes of energy-dense foods to improve their food choice and future health outcomes.

Breastfeeding, early nutrition, and adult body fat

OBJECTIVE

To examine the association between breastfeeding and adult body fatness, adjusting for nutritional intake in early childhood.

STUDY DESIGN

Nutritional intakes of 73 healthy infants born in 1984 who participated in the 2-decade-long Longitudinal Study of Nutrition and Growth in Children (Etude Longitudinale Alimentation Nutrition Croissance des Enfants [ELANCE]) were estimated at age 10 months and again at age 2 years. Breastfeeding was defined as any breastfeeding, including partial breastfeeding, regardless of duration. At age 20 years, weight, height, subscapular skinfold thickness (SF), and fat mass (assessed via bioelectrical impedance analysis) were measured.

RESULTS

In this sample, 64% of the children had been breastfed. In linear regression models adjusted for mother's body mass index and father's profession, breastfeeding was not associated with any of the body fat measurements at 20 years (all P > .05). After adding nutritional intake variables (total energy and % energy from nutrients) to the models, breastfeeding became significantly associated with lower SF at 20 years. In particular, breastfed subjects had significantly lower % SF at 20 years after adjustment for energy and % fat intakes at 2 years of age, (β = -28.25% SF; 95% CI, -50.28% to -6.21%; P = .013) or when adjusting for energy and % carbohydrates at 2 years of age (β = -28.27% SF; 95% CI, -50.64% to -5.90%; P = .014).

CONCLUSION

Breastfeeding was not associated with adult body fatness taking into account the usual confounding factors. However, after also adjusting for nutritional intake covariates, a protective effect of breastfeeding emerged. Early nutrition needs to be taken into account when examining the long-term health effects of breastfeeding.

The influence of early feeding practices on fruit and vegetable intake among preschool children in 4 European birth cohorts

BACKGROUND

Fruit and vegetable intake in children remains below recommendations in many countries. The long-term effects of early parental feeding practices on fruit and vegetable intake are not clearly established.

OBJECTIVE

The purpose of the current study was to examine whether early feeding practices influence later fruit and vegetable intake in preschool children.

DESIGN

The study used data from 4 European cohorts: the British Avon Longitudinal Study of Parents and Children (ALSPAC), the French Etude des Déterminants pre et postnatals de la santé et du développement de l'Enfant study, the Portuguese Generation XXI Birth Cohort, and the Greek EuroPrevall study. Fruit and vegetable intake was assessed in each cohort by food-frequency questionnaire. Associations between early feeding practices, such as breastfeeding and timing of complementary feeding, and fruit and/or vegetable intake in 2-4-y-old children were tested by using logistic regressions, separately in each cohort, after adjustment for infant's age and sex and maternal age, educational level, smoking during pregnancy, and maternal fruit and vegetable intake.

RESULTS

Large differences in early feeding practices were highlighted across the 4 European cohorts with longer breastfeeding duration in the Generation XXI Birth Cohort and earlier introduction to complementary foods in ALSPAC. Longer breastfeeding duration was consistently related to higher fruit and vegetable intake in young children, whereas the associations with age of introduction to fruit and vegetable intake were weaker and less consistent across the cohorts. Mothers' fruit and vegetable intake (available in 3 of the cohorts) did not substantially attenuate the relation with breastfeeding duration.

CONCLUSION

The concordant positive association between breastfeeding duration and fruit and vegetable intake in different cultural contexts favors an independent specific effect.

Time trends in dietary fat intake in a sample of German children and adolescents between 2000 and 2010: not quantity, but quality is the issue

Dietary fat intake in childhood may influence the risk for developing chronic diseases. The objective of the present study was to examine secular trends in the parameters of fat intake between 2000 and 2010 in a sample of German children and adolescents (n 808) participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. Dietary data from 4380 3 d weighed dietary records were analysed using repeated-measures regression to determine time trends in fat quantity, i.e. the intake of total fat, and in fat quality, i.e. the ratios of SFA, MUFA and PUFA. In young children (2-3 years) and in adolescents (13-18 years), total fat intake remained stable over time, but decreased by 0·08 % of total energy (%E) per year in 4-12-year-old children. In 2010, median fat intake was at the upper end of the recommendations. SFA intake decreased slightly in 2-3- and 4-12-year-old children by 0·09 and 0·05 %E per year, respectively. MUFA and PUFA intakes remained stable in all the age groups except in adolescents. Here, PUFA intake decreased initially, but increased between 2005 and 2010. In 2010, only between 3 and 18 % of the respective age groups had an intake of SFA or PUFA within the recommendations. In conclusion, fat quantity and quality did not change substantially between 2000 and 2010. Fat quality, in particular, needs to be improved, since a large percentage of our sample did not meet the recommended intakes for SFA and PUFA.

Differences in food consumption according to weight status and physical activity levels among Greek children between 1992/93 and 2006/07

BACKGROUND

There is a lack of data in Greece on trends in food intake according to weight status and physical activity (PA), despite the high prevalence of obesity. The present study aimed to examine differences in these parameters among first-grade children from Crete, Greece, over a 15-year period.

METHODS

Children (aged 5.9-7.6 years) from two representative cross-sectional studies participated during 1992/93 (n = 245) and 2006/07 (n = 257). Estimated 3-day food records were used to assess food consumption and energy-density (ED) [kJ g(-1) (kcal g(-1) )]. Moderate-to-vigorous-PA (MVPA) and cardiorespiratory-fitness were assessed by questionnaires and the 20-m shuttle-run test (20mSRT), respectively.

RESULTS

In 2006/07, compared to 1992/93, both sexes had a significantly higher intake of dairy products and snacks (P < 0.001), a lower intake of cereals (P < 0.001) and higher cardiorespiratory fitness levels (P < 0.001). Among girls, fruit/vegetable consumption was higher (P < 0.05), although legume intake was lower (P < 0.005). Among overweight/obese (OW/OB) children, ED significantly decreased (P < 0.05) and the mean consumption of fruits/vegetables was higher (P < 0.001). The percentage of OW/OB boys was significantly higher (P < 0.001); however, MVPA was significant higher in this group compared to 1992/93 (P < 0.001). During the two time-periods, active children in 2006/07 appeared to have a lower ED than active ones in 1992/93 (P < 0.001).

CONCLUSIONS

Several differences in food intake were observed among first-grade children of Crete between 1992/93 and 2006/07, as characterised by significant increases in the consumption of dairy products and snacks and a decrease in the intake of cereals, among both sexes. Future school-based interventions in this population should emphasise the need to increase fruit/vegetable, unrefined cereal and legume consumption.

Food sources of nutrients among 13-year-old Portuguese adolescents

Objective

To identify food sources of nutrients in adolescents’ diets and to identify differences in food sources according to individual characteristics.

Design

A cross-sectional evaluation was carried out in the 2003/2004 school year. Self-administered questionnaires were used and a physical examination was performed. Diet was evaluated using an FFQ.

Setting

Public and private schools in Porto, Portugal.

Subjects

Adolescents aged 13 years (n 1522) enrolled at school.

Results

The main sources of energy were starchy foods (26·5 %), dairy (12·5 %) and meat (12·0 %). The major contributors to carbohydrate intake were starchy foods (38·2 %) and fruit (13·8 %) and to protein intake were meat (28·0 %), dairy products (20·3 %), starchy foods (15·3 %) and seafood (13·6 %). The main sources of total fat were meat (22·0 %), starchy foods (13·4 %) and dairy products (12·7 %). Sweets and pastries presented important contributions to energy (11·1 %), carbohydrate (12·4 %), total fat (13·3 %) and saturated fat (16·6 %) intakes. Parental education was inversely associated with the contribution of sweets and pastries to energy, carbohydrate and fat intakes and it was positively associated with the seafood contribution to protein intake.

Conclusions

The major sources of carbohydrates were starchy foods, which also accounted for a quarter of energy intake. Dairy products plus meat accounted for another quarter of energy. Meat was a major source of protein and fats. Sweets and pastries contributed more than 10 % to energy, carbohydrates, total and saturated fat. Parental education was the strongest determinant of food sources and was positively associated with a healthier contribution of food groups.

Eating behaviour and its association with social living conditions and weight status among adolescent girls: results of the cross-sectional Berlin School Children's Cohort study

Objective

To capture a more holistic picture of eating behaviour by investigating the impact of the social living conditions and weight status of parents and daughters on food consumption frequency, the context of meals and daily portion sizes.

Design

Cross-sectional Berlin School Children's Cohort study.

Setting

A total of sixty-nine schools in Berlin (3 400 000 inhabitants, eastern Germany) participated in the present study.

Subjects

A total of 1519 girls aged 11–14 years were selected. Bi- and multivariate analyses were performed to examine the impact of age, migration background, socio-economic status (SES), parental education, family situation and the weight status of parents and daughters on three different eating behaviour scores according to nutritional recommendations.

Results

For the three dependent eating behaviour variables, different patterns of influencing factors emerged. Multivariate regression (model 1) revealed that low and middle SES, two-parent migration background and older age were significant risk factors. Meal context was also significantly influenced by living with a single parent. Similar results were obtained for the daily portion size scores and maternal overweight status was the most influential. Model 2 succeeded in showing that, within the composite variable of family SES, mothers’ level of education was the dominant component.

Conclusions

SES as a whole, and especially the component of mothers’ level of education and two-parent migration background, was the strongest risk factor for an unfavourable eating pattern among adolescent girls. The results clearly indicated preventive potential. Using three different measures of eating behaviour simultaneously provided an in-depth understanding of general patterns and potential risk factors.

Energy and macronutrient intake in adolescent sprint athletes: a follow-up study

Macronutrient intake, height, weight, and body composition of 60 adolescent sprint athletes were estimated every 6 months over 3 years. Seven-day food records were analysed based on the Belgian and Dutch food databanks. The age of participants at the start of the 3-year study was 14.8 ± 1.6 years for female athletes and 14.7 ± 1.9 years for male athletes. Girls and boys gained height (3.4 ± 4.6 cm and 5.9 ± 6.6 cm respectively) and weight (5.6 ± 3.5 kg and 8.7 ± 5.5 kg respectively), whereas percent body fat remained unchanged in both girls and boys (around 17.0% and 8.5% respectively). Mean protein intake of around 1.5 g · kg⁻¹ body weight was within recommendations on each occasion for both sexes. Carbohydrate intakes between 5 and 7 g · kg⁻¹ body weight support a training programme of moderate intensity. Total and saturated fat intakes were high at the start of the study (girls: 31.8 ± 3.5% and 12.2 ± 2.0% of energy intake; boys: 30.3 ± 4.6% and 12.0 ± 1.9% of energy intake) and it appeared to be difficult to achieve and maintain lower intakes. Consistent low fluid intakes around 40 ml · kg⁻¹ body weight were observed. General non-stringent advice for improvement of the diet resulted in significant favourable changes only for the consumption of wholegrain bread, vegetables, and soft drinks. Dietary habits of adolescent sprint athletes are not always according to guidelines and are relatively stable but repeated advice can induce moderate improvements.

[Diet and eating habits in relation to the development of obesity in children and adolescents]

Diet is of major interest in research on the etiology of obesity. Research in this field comprises investigation of the role of individual nutrients and foods, nutrient composition, as well as dietary patterns and habits. Longitudinal data on the association between dietary factors and the development of obesity in childhood and adolescence are sparse; therefore, conclusions on the impact of energy density, consumption of carbohydrates and proteins, snack foods and fast food, meal patterns and speed of eating cannot be drawn. More data exist with respect to the role of energy intake and consumption of fat and sugar-sweetened beverages; however, findings are inconsistent. This could be due to methodological shortcomings that mark dietary assessment in children and adolescents. However, as a direct modulator of energy balance, diet still needs to be part of a comprehensive strategy to combat overweight and obesity in children and adolescents.

Trends in dietary carbohydrate quality during puberty from 1988 to 2007: a cause for concern?

The extent to which the quality of dietary carbohydrates (CHO) changes throughout puberty is not known. We analysed trends in the quantity and quality of CHO intake among German adolescents by separately examining trends during puberty (pubertal trends) and trends in CHO intake from 1988 to 2007 (secular trends). Linear mixed-effects regression analyses were performed in 216 participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed Study who had provided weighed 3 d dietary records at the onset of the pubertal growth spurt (defined by age at take-off) and over the subsequent 4 years. Over the course of puberty, CHO quality changed little: added sugar intake from beverages increased in girls (0·25 (se 0·12) % energy (% E)/year, P = 0·04) and added sugar intake from sweets decreased in both sexes (boys: - 0·22 (se 0·11) % E/year, P = 0·049; girls: - 0·20 (se 0·10) % E/year, P = 0·04). For both sexes, significant upward secular trends were observed for CHO (% E), glycaemic load (g/MJ) and added sugar intakes from sources other than sweets and soft drinks (% E), while absolute fibre intake (g/d) decreased (P ≤ 0·04). Concomitant increases in total added sugar intake (% E) and decreases in fibre and whole-grain densities (g/MJ) (P = 0·001-0·02) were confined to boys only. The quality of dietary CHO consumed by healthy German adolescents shows notable secular declines, but does not change markedly during puberty. Public health initiatives should be tailored to improve the overall quality of CHO nutrition.

Whole grain in children's diet: intake, food sources and trends

OBJECTIVE

To quantify the intake of grain and whole grain, and their food sources, as well as to investigate the age and time trends over the last decade in a sample of German children and adolescents.

METHODS

Dietary records from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study were used for conducting this work. A total of 5067 3-day weighed dietary records of 821 2- to 18-year-old children and adolescents collected between 1997 and 2008 were analysed using linear mixed-effect models, in which the means of the data and the covariance structure (children of the family, repeated measurements) were modelled.

RESULTS

Mean whole-grain intake was between 20 and 33 g/day in the sample and highest in 13-18 year olds. No whole grain intake was recorded in 19% of all dietary records. Total grain intake increased significantly with age (P<0.0001), even after adjustment for energy intake. Whole-grain intake (g/day) increased significantly with age in the unadjusted model (P<0.0001). This increase disappeared after adjustment for energy intake (P>0.05) and became a negative trend after adjustment for grain intake (P<0.01). There were no significant time trends during the study period. Bread had the highest effect on grain intake in the total sample (50%), followed by rice/pasta (21%), cake (13%), grain (9%), RTECs (5%) and muesli (2%).

CONCLUSIONS

The whole-grain intake in this sample of German children and adolescents was far below the FBDG. The decreasing percentage of whole grain per grain intake with age contradicts the common concept of stable dietary habits during childhood and adolescents.

Trends in energy and sugar intakes and body mass index between 1983 and 1997 among children in Great Britain

BACKGROUND

It has been suggested that rising obesity among children is partly attributable to sugary foods and soft drinks driving an increase in energy intake (EI). Yet historical data on sugar intake are sparse. The present study calculated total sugar intake de novo among 3296 children aged 10-11 and 14-15 years in 1983 and compared EI, macronutrients and sugar sources with data from 459 children of same age in the 1997 National Diet and Nutrition Survey.

METHODS

Secondary analysis of 7-day weighed diet records and anthropometric data from two British surveys. Compositional data on sugars applied to individual food codes to calculate sugar intake and sources for 1983. Trends examined before/after adjustment for low/high energy reporting (LHER) defined as EI : basal metabolic rate <1.16 or >2.65.

RESULTS

Mean EI (kJ day(-1)) was 7% lower in 1997 than in 1983, mainly as a result of lower fat intake. After excluding LHER, mean EI was 3% lower in 1997. Mean body mass index (BMI) increased by 0.7-1 kg m(-2) (2-3 kg). Total sugar intake averaged 115 g day(-1) in 1983 and 113 g day(-1) in 1997 (122 versus 127 g day(-1) excluding LHER, P = 0.08). Excluding LHER, fat energy was lower in 1997 (35.4% versus 37.8%) and sugars slightly higher (23.6% versus 22.3%). Sugar sources showed a marked shift away from table sugar with smaller falls in milk, biscuits and cakes, counterbalanced by an significant increase in sugar from soft drinks and, to a lesser extent, fruit juice and breakfast cereals.

CONCLUSIONS

Although the study design precludes drawing causal inferences regarding nutrient intake and obesity, a higher prevalence of under-reporting and lower levels of physical activity in 1997 could explain the paradox of lower reported EI and rising BMI.

Is sugar consumption detrimental to health? A review of the evidence 1995-2006

Many countries set quantitative targets for added sugars, justifying this by expressing concern about the likely impact of sugar on weight control, dental health, diet quality, or metabolic syndrome. This review considers whether current intakes of sugar are harmful to health, and analyses recent literature using a systematic approach to collate, rank, and evaluate published studies from 1995-2006. Results from high quality obesity studies did not suggest a positive association between body mass index and sugar intake. Some studies, specifically on sweetened beverages, highlighted a potential concern in relation to obesity risk, although these were limited by important methodological issues. Diet adequacy appeared to be achieved across sugar intakes of 6 to 20% energy, depending on subject age. Studies on metabolic syndrome reported no adverse effects of sugar in the long-term, even at intakes of 40-50% energy. The evidence for colorectal cancer suggested an association with sugar, but this appeared to have been confounded by energy intake and glycemic load. There was no credible evidence linking sugar with attention-deficit, dementia, or depression. Regarding dental caries, combinations of sugar amount/frequency, fluoride exposure, and food adhesiveness were more reliable predictors of caries risk than the amount of sugar alone. Overall, the available evidence did not support a single quantitative sugar guideline covering all health issues.

Optimal dietary approaches for prevention of type 2 diabetes: a life-course perspective

In recent years, several alternative dietary approaches, including high-protein and low-glycaemic-load diets, have produced faster rates of weight loss than traditional low-fat, high-carbohydrate diets. These diets share an under-recognised unifying mechanism: the reduction of postprandial glycaemia and insulinaemia. Similarly, some food patterns and specific foods (potatoes, white bread, soft drinks) characterised by hyperglycaemia are associated with higher risk of adiposity and type 2 diabetes. Profound compensatory hyperinsulinaemia, exacerbated by overweight, occurs during critical periods of physiological insulin resistance such as pregnancy and puberty. The dramatic rise in gestational diabetes and type 2 diabetes in the young may therefore be traced to food patterns that exaggerate postprandial glycaemia and insulinaemia. The dietary strategy with the strongest evidence of being able to prevent type 2 diabetes is not the accepted low-fat, high-carbohydrate diet, but alternative dietary approaches that reduce postprandial glycaemia and insulinaemia without adversely affecting other risk factors.

Energy and macronutrient intakes in Belgium: results from the first National Food Consumption Survey

Belgium until recently lacked a systematic survey of dietary habits of its inhabitants. The present study evaluated dietary composition in Belgium with respect to energy and macronutrient intakes. Information on food intake was collected using a repeated non-consecutive 24 h recall (2-8 weeks apart) with the validated software package EPIC-SOFT, in combination with a FFQ (self-administered) covering sixty food items. The database of consumed food items was linked to food composition data. Usual macronutrient intake was estimated by the Nusser method. A representative sample of the Belgian population was randomly selected from the national register following a multi-stage procedure. Information on dietary intake was obtained from 3245 subjects aged 15 years and older. Mean energy percentage (E %) of total fat (37.9 E %) and SFA (16.0 E %) was higher than the dietary reference intakes (DRI). Mean E % of total carbohydrates (45.8 E %) was lower than the DRI, while mean E % of mono/disaccharides was 20.3. Total fat and SFA intakes were higher and total carbohydrate and sugar intakes were lower in the older age categories than in the younger age categories. The percentage of energy from SFA intake was lower and that from carbohydrates was higher than that found in an earlier Belgian study. Further efforts are necessary to improve dietary macronutrient intake, taking into account differences in age categories. In addition, it will be important to monitor its changes regularly using trend analyses.

Validation of protein intake assessed from weighed dietary records against protein estimated from 24 h urine samples in children, adolescents and young adults participating in the Dortmund Nutritional and Longitudinally Designed (DONALD) Study

OBJECTIVE

To date, only a few nutritional assessment methods have been validated against the biomarker of urinary-N excretion for use in children and adolescents. The aim of the present study was to validate protein intake from one day of a weighed dietary record against protein intake estimated from a simultaneously collected 24 h urine sample.

DESIGN

Cross-sectional analyses including 439 participants of the Dortmund Nutritional and Longitudinally Designed (DONALD) Study from four age groups (3-4, 7-8, 11-13 and 18-23 years). Mean differences, Pearson correlation coefficients (r), cross-classifications and Bland-Altman plots were used to assess agreement between methods.

RESULTS

Weighed dietary records significantly underestimated mean protein intake by -6.4 (95 % CI -8.2, -4.7) g/d or -11 %, with the difference increasing across the age groups from -0.6 (95 % CI -2.7, 1.5) g/d at age 3-4 years to -13.5 (95 % CI -18.7, -8.3) g/d at age 18-23 years. Correlation coefficients were r = 0.7 for the total study sample and ranged from r = 0.5 to 0.6 in the different age groups. Both methods classified 85 % into the same/adjacent quartile for the whole study group (83-86 % for the different age groups) and 2.5 % into the opposite quartile (1.9-3.1 % for the different age groups). Bland-Altman plots for the total sample indicated that differences in protein intake increased across the range of protein intake, while this bias was not obvious within the age groups.

CONCLUSIONS

Protein intake in children and adolescents can be estimated with acceptable validity by weighed dietary records. In this age-heterogeneous sample, validity was lower among adolescents and young adults.

Changes in food and nutrient intake of 6- to 17-year-old Germans between the 1980s and 2006

OBJECTIVE

To compare the food consumption and nutrient intakes of German children and adolescents in the 1980s with present dietary habits.

DESIGN

Two cross-sectional representative surveys, the German National Food Consumption Study (Nationale Verzehrsstudie, NVS) from 1985-8 and the nutrition module 'EsKiMo' of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) from 2006, were analysed for differences in food and nutrient intakes stratified by age and sex groups.

SETTING

Secondary analyses of data from representative observational studies.

SUBJECTS

Children and adolescents aged 6-17 years living in Germany in the 1980s (n 2265) and in 2006 (n 2506).

RESULTS

Food consumption was characterised by higher amounts of vegetables/pulses, fruits/nuts and beverages and less meat products/sausages, butter, fats/oils, potatoes/potato products and bread/pastries in 2006 than in 1985-8. The overall changes in food intake were reflected in improvements of macronutrient composition, increased water intake and lower energy density of the diet. Intake of most vitamins and minerals increased in relation to energy intake, but the nutrient density of the diet for vitamins B12 and D decreased. The most critical nutrients observed in NVS and EsKiMo were folate, vitamin D, vitamin A, vitamin E, Ca and Fe. In addition, dietary fibre intake was relatively low and fatty acid and carbohydrate compositions were not favourable.

CONCLUSIONS

Further efforts will be necessary to improve dietary habits among children and adolescents.

Consumption of sugar-sweetened beverages and its association with nutrient intakes and diet quality in German children and adolescents

In the present study the relationship of sugar-sweetened beverage (SSB) consumption with the intake of single nutrients and total diet quality in German children and adolescents was evaluated using a repeated-measures regression analysis model. We used dietary data from 7145 three-day weighed records of 1069 subjects aged 2-19 years participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. Intake of macronutrients as percentage of total energy intake (%En), intake of micronutrients as percentage of German reference values (intake quality score) and nutritional quality index (NQI) as an indicator of diet quality were chosen as separate dependent variables. SSB consumption was positively associated with %En from carbohydrates (boys v. girls: +4.00 v. +4.09 En%/MJ from SSB) and added sugars (boys v. girls: +7.36 v. +9.52 En%/MJ from SSB) and negatively with %En from protein (boys v. girls: - 1.25 v. - 1.31 En%/MJ from SSB) and fat (boys: - 2.82 v. - 2.73 En%/MJ from SSB). With respect to micronutrients, SSB consumption was negatively associated with folate and Ca intake, for which mean intake levels were inadequate in girls. Absolute diet quality was negatively associated with SSB consumption, whereas the effect was larger for girls (boys v. girls: - 1.41 v. - 2.63 points of NQI/MJ from SSB). Overall, results show a diluting effect of SSB consumption on micronutrient intake and diet quality. This effect might be relevant especially in girls as the association with diet quality was larger and mean NQI levels were lower in comparison with boys.

Relation of dietary glycemic index, glycemic load, added sugar intake, or fiber intake to the development of body composition between ages 2 and 7 y

BACKGROUND

Observational studies in adults suggest that a diet with a high glycemic index (GI) or glycemic load (GL), a high intake of sugary foods, or a low fiber intake may increase the risk of overweight.

OBJECTIVES

We aimed to examine prospectively whether dietary GI, GL, added sugar intake, or fiber intake between age 2 and 7 y are associated with the development of body composition. If so, we aimed to ascertain whether these associations are modified by meal frequency.

DESIGN

Linear mixed-effect regression analyses were performed in 380 participants of the DOrtmund Nutrition and Anthropometric Longitudinally Designed (DONALD) Study for whom 4-6 weighed 3-d dietary records and anthropometric data were obtained between ages 2 and 7 y.

RESULTS

Changes in dietary GI, GL, or added sugar intake between ages 2 and 7 y were not associated with concurrent changes in percentage body fat (%BF, as estimated from skinfold thicknesses) or body mass index SD scores. An increase in fiber intake was related to a concurrent decrease in %BF between ages 2 and 7 y only in children who consumed <6 meals/d as toddlers (beta +/- SE from fully adjusted model: -0.26 +/- 0.09%BF per 1-SD increase in fiber intake, P = 0.005), whereas children with a higher meal frequency had no concurrent change (0.07 +/- 0.07%BF per 1-SD increase in fiber intake, P = 0.3).

CONCLUSIONS

Dietary GI, GL, or added sugar intake between ages 2 and 7 y does not appear to influence the development of body composition. Potential benefits associated with increasing fiber intake throughout childhood may be limited to toddlers with a lower meal frequency.

Variety and total number of food items recorded by a true longitudinal group of urban black South African children at five interceptions between 1995 and 2003: the Birth-to-Twenty (Bt20) Study

OBJECTIVE

To report on the variety and total number of food items recorded by a true longitudinal group of urban black South African children (n = 143) from the Birth-to-Twenty Study at five interceptions at the ages of 5 (1995), 7 (1997), 9 (1999), 10 (2000) and 13 (2003) years, respectively.

METHODS

Dietary intake was assessed using a semi-quantitative food-frequency questionnaire. Frequencies were calculated per week, for each interception and for all five interceptions combined, using SAS.

RESULTS

Five hundred and forty-six different individual food items were recorded 23 480 times for all five interceptions combined. The highest of 124 items was recorded in 1999 contributing 23% of the 546 items recorded. Each of the top 10 items (rice, stiff maize-meal porridge, chicken, sugar, sweets, tea, eggs, full-cream milk, carbonated beverages and oil) contributed between 2.5% and 3% and these items were recorded almost 600 times or more for all interceptions combined (n = 23 840). Rice and stiff maize-meal porridge were the top items recorded 684 and 676 times, both contributing 2.87% and 2.84%, respectively. The variety of food items and the ratio of the food groups to the total number of foods recorded in the present study were not significantly different but the denominators decreased over the five interceptions.

CONCLUSION

The variety of food items recorded did not vary between 1995 and 2003 - the fact that new items were not added to the questionnaire as the children grew older could have contributed to this phenomenon. However, there was a difference in the ranking of these items that may suggest a change in eating patterns.

Pattern of beverage consumption and long-term association with body-weight status in German adolescents – results from the DONALD study

In the present study the relationship between the consumption of different beverage groups and body-weight status in 5 years of study participation in German adolescents was investigated. We used anthropometric and dietary data from 3 d weighed records of 244 subjects between 9 and 18 years of age participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study. Only subjects with at least four out of six possible weighed dietary records were considered. A repeated-measures regression model (PROC MIXED) was used to analyse the effect of beverage consumption on body-weight status. BMI standard deviation scores (BMI-SDS) and body fat percentage (%BF) were chosen as the dependent variables. In boys, energetic beverage consumption was not associated with BMI-SDS or %BF, neither cross-sectionally nor prospectively. In girls, baseline consumption of energetic beverages did not predict baseline BMI-SDS, baseline %BF, or change in either variable over the study period. However, an increase in energetic beverage consumption over the study period was associated with an increase in BMI-SDS (+0.070 SDS/MJ increase in energetic beverage consumption; P = 0·01). Separate consideration of regular soft drinks and fruit juices revealed that, in girls, BMI-SDS increased with increased fruit juice consumption (+0·096 SDS/MJ increase in fruit juice consumption; P = 0·01), and to a lesser extent with regular soft drink consumption (+0·055 SDS/MJ increase in regular soft drink consumption; P = 0·08). In conclusion, these results suggest that an increase in energetic beverage consumption may result in weight gain, at least in adolescent girls.

Potential renal acid load in the diet of children and adolescents: impact of food groups, age and time trends

Objective

The impact of acid–base balance on health is widely accepted. Here, we describe the potential renal acid load (PRAL) in the diet of healthy German children and adolescents.

Design

The Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study is an ongoing longitudinal (open cohort) study (start 1985) collecting detailed data on diet, growth, development and metabolism in infants, children and adolescents.

Setting

Research Institute of Child Nutrition, Dortmund.

Subjects

Seven hundred and twenty children and adolescents (351 boys and 369 girls), aged 3–18 years, provided 4187 yearly collected 3-day dietary records between 1995 and 2005.

Results

Mean daily PRAL was positive in all age/sex groups (6–21 mEq day−1), and significantly higher in boys than in girls after the age of 8 years, even when calculated as mEq MJ−1. Fruits, vegetables and potatoes had a negative impact on PRAL; cheese, dairy products, cereals/bread and meat/fish/eggs had a positive impact. In a mixed linear model, PRAL, expressed as mEq day−1 and mEq MJ−1, remained stable during the study period, since time trends of PRAL-relevant food groups countervail each other. PRAL intake (mEq MJ−1) was significantly positively associated (P < 0.0001) with fat intake (% of energy intake, %E), but negatively with carbohydrate intake (%E; P < 0.0001).

Conclusions

The analysis of dietary habits in our sample of German children and adolescents showed a moderate excess of acidity. Especially older boys should be encouraged to eat more potatoes and vegetables as good sources of dietary alkalinity. The PRAL concept is compatible with current concepts for a healthy diet.

Assessing, understanding and modifying nutritional status, eating habits and physical activity in European adolescents: The HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study

Objectives

To identify the main knowledge gaps and to propose research lines that will be developed within the European Union-funded ‘Healthy Lifestyle in Europe by Nutrition in Adolescence’ (HELENA) project, concerning the nutritional status, physical fitness and physical activity of adolescents in Europe.

Design

Review of the currently existing literature.

Results

The main gaps identified were: lack of harmonised and comparable data on food intake; lack of understanding regarding the role of eating attitudes, food choices and food preferences; lack of harmonised and comparable data on levels and patterns of physical activity and physical fitness; lack of comparable data about obesity prevalence and body composition; lack of comparable data about micronutrient and immunological status; and lack of effective intervention methodologies for healthier lifestyles.

Conclusions

The HELENA Study Group should develop, test and describe harmonised and state-of-the-art methods to assess the nutritional status and lifestyle of adolescents across Europe; develop and evaluate an intervention on eating habits and physical activity; and develop and test new healthy food products attractive for European adolescents.