WebDASC: a web-based dietary assessment software for 8-11-year-old Danish children

AI nutritionist: Intelligent software as the next generation pioneer of precision nutrition

With the rapid development of information technology and artificial intelligence (AI), people have acquired the abilities and are encouraged to develop intelligent tools and software, which begins to shed light on intelligent and precise food nutrition. Despite the rapid development of such software, disparities still exist in terms of methodology, contents, and implementation strategies. Hence, a set of panoramic profiles is urgently needed to elucidate their values and guide their future development. Here a comprehensive review was conducted aiming to summarize and compare the objects, contents, intelligent algorithms, and functions realized by the already released software in current research. Consequently, 177 AI nutritionists in recent years were collected and analyzed. The advantages, limitations, and trends concerning their application scenarios were analyzed. It was found that AI nutritionists have been gradually advancing the production modes and efficiency of food recognition, dietary recording/monitoring, nutritional assessment, and nutrient/recipe recommendation. Most AI nutritionists have a relatively low level of intelligence. However, new trends combining advanced AI algorithms, intelligent sensors and big data are coming with new applications in real-time and precision nutrition. AI models concerning molecular-level behaviors are becoming the new focus to drive AI nutritionists. Multi-center and multi-level studies have also gradually been realized to be necessary.

A cross-sectional study of the association between food literacy and dietary intake among Danish adolescents

Food literacy is theorized to be associated with healthy dietary intake. However, empirical knowledge on the association between adolescents' food literacy and dietary intake is limited. The aim of this study was to investigate the association between food literacy and dietary intake among Danish schoolchildren aged 11-13 years. The study applied a cross-sectional design using baseline data from a cluster-based quasi-experimental controlled study in a sample (n = 377) of Danish school children. Mixed model analyses were performed to investigate the associations between overall food literacy as well as its five competencies ("to know", "to do", "to sense", "to care", and "to want") and dietary intake of vegetables, fruit, fish, meat, discretionary foods, and sugar-sweetened beverages. Positive associations were found between overall food literacy (E = 1.493, p = 0.002) as well as the competencies "to know" (E = 1.249, p = 0.027), "to do" (E = 1.236, p = 0.028), "to sense" (E = 1.183, p = 0.029), and "to care" (E = 1.249, p = 0.018) and intake of vegetables. The study also found a positive association between the competency "to want" and intake of fruit (E = 13.50, p = 0.037), "to care" and intake of fish (E = 2.050, p < 0.001), and a negative association between the competency "to want" and intake of meat (E = 0.748, p = 0.003) and sugar-sweetened beverages (E = 0.576, p = 0.0021). No associations were found between overall food literacy or any of its five competencies and intake of discretionary foods. These findings suggest that improving specific aspects of food literacy may have a potential to promote healthier dietary intake, though additional research is needed.

User Requirements in Developing a Novel Dietary Assessment Tool for Children: Mixed Methods Study

BACKGROUND

The prevalence of childhood obesity and comorbidities is rising alarmingly, and diet is an important modifiable determinant. Numerous dietary interventions in children have been developed to reduce childhood obesity and overweight rates, but their long-term effects are unsatisfactory. Stakeholders call for more personalized approaches, which require detailed dietary intake data. In the case of primary school children, caregivers are key to providing such dietary information. However, as school-aged children are not under the full supervision of one specific caregiver anymore, data are likely to be biased. Recent technological advancements provide opportunities for the role of children themselves, which would serve the overall quality of the obtained dietary data.

OBJECTIVE

This study aims to conduct a child-centered exploratory sequential mixed methods study to identify user requirements for a dietary assessment tool for children aged 5 to 6 years.

METHODS

Formative, nonsystematic narrative literature research was undertaken to delineate initial user requirements and inform prototype ideation in an expert panel workshop (n=11). This yielded 3 prototype dietary assessment tools: FoodBear (tangible piggy bank), myBear (smartphone or tablet app), and FoodCam (physical camera). All 3 prototypes were tested for usability by means of a usability task (video analyses) and user experience (This or That method) among 14 Dutch children aged 5 to 6 years (n=8, 57% boys and n=6, 43% girls).

RESULTS

Most children were able to complete FoodBear's (11/14, 79%), myBear's (10/14, 71%), and FoodCam's (9/14, 64%) usability tasks, but all children required assistance (14/14, 100%) and most of the children encountered usability problems (13/14, 93%). Usability issues were related to food group categorization and recognition, frustrations owing to unsatisfactory functioning of (parts) of the prototypes, recall of food products, and the distinction between eating moments. No short-term differences in product preference between the 3 prototypes were observed, but autonomy, challenge, gaming elements, being tablet based, appearance, social elements, and time frame were identified as determinants of liking the product.

CONCLUSIONS

Our results suggest that children can play a complementary role in dietary data collection to enhance the data collected by their parents. Incorporation of a training program, auditory or visual prompts, reminders and feedback, a user-friendly and intuitive interaction design, child-friendly food groups or icons, and room for children's autonomy were identified as requirements for the future development of a novel and usable dietary assessment tool for children aged 5 to 6 years. Our findings can serve as valuable guidance for ongoing innovations in the field of children's dietary assessment and the provision of personalized dietary support.

Discretionary foods and drinks in Norwegian children and adolescents' diet: data from the national dietary survey Ungkost 3

OBJECTIVE

This study aimed to identify the amount of discretionary foods and drinks consumed by Norwegian children and adolescents, describe how such products contribute to the intake of total energy and nutrients, and study the distribution in intake of discretionary foods and drinks across different meals. Secondly, the aim was to explore factors associated with those children and adolescents having the highest consumption of discretionary foods and drinks.

DESIGN

Secondary analysis of data from a national survey of dietary intake among Norwegian children and adolescents.

SETTING

Schools in fifty randomly selected municipalities in Norway.

PARTICIPANTS

The study population included 636 pupils in 4th grade (9-11 years) and 687 pupils in 8th grade (12-14 years).

RESULTS

Discretionary foods and drinks contributed to about 20 % of the children and adolescents' total energy intake. These products contributed to about two-thirds of the participants' intake of added sugar, and limited amounts of dietary fibre, vitamins and minerals. The quartile which had the lowest proportion of their energy intake from discretionary foods and drinks seemed to have a higher intake of whole grains, and fish and seafood.

CONCLUSIONS

Almost all 4th and 8th graders in Norway consumed discretionary foods and drinks, and these products contributed to a substantial proportion of the total energy intake and limited amounts of nutrients. Those children and adolescents consuming the least discretionary foods and drinks had a higher intake of whole grains, fish and seafood, indicating healthier and more sustainable food habits.

Effect of School-Based Educational Intervention on Promoting Healthy Dietary Habits in Danish Schoolchildren: The FOODcamp Case Study

The present study aimed to evaluate the effect of the school-based educational intervention "FOODcamp" on dietary habits among 6th-7th graders (aged 11-13 years), focusing on the food groups: fruits and vegetables, fish, meat, discretionary food, and sugar-sweetened beverages. In this cluster-based quasi-experimental controlled intervention study, 16 intervention classes (322 children) and 16 control classes (267 children) from nine schools were recruited during the school year 2019-2020. The children were asked to record their food intake for four consecutive days (Wednesday to Saturday) before (baseline) and after (follow-up) attending FOODcamp, using a validated self-administered web-based dietary record. Eligible dietary intake registrations from 124 and 118 children from the control and interventions classes, respectively, were included in the final statistical analysis. Hierarchical mixed model analysis was used to evaluate the effect of the intervention. No statistically significant effects of participating in FOODcamp were found on the average food intake of the food groups eaten regularly (vegetables, fruit, vegetables/fruit/juice combined, or meat) (p > 0.05). Among the food groups not eaten regularly (fish, discretionary foods, and sugar-sweetened beverages), a non-significant tendency to lower odds of consuming sugar-sweetened beverages from baseline to follow-up (OR = 0.512; 95% CI: 0.261-1.003; p = 0.0510) was seen among FOODcamp participants compared to control participants. In conclusion, this study found no effect of the educational intervention FOODcamp on the dietary intake of vegetables, fruit, vegetable/fruit/juice combined, meat, fish, or sugar-sweetened beverages. The intake frequency of sugar-sweetened beverages tended to decrease among FOODcamp participants.

How Brazilian Schoolchildren Identify, Classify, and Label Foods and Beverages-A Card Sorting Methodology

This study examined how Brazilian schoolchildren identified, classified, and labeled foods and beverages. Semi-structured interviews were conducted with 133 schoolchildren aged 7 to 10 years old from a public school located in southern Brazil in 2015. A set of cards with pictures of 32 food and beverage items from the web-based Food Intake and Physical Activity of Schoolchildren tool (Web-CAAFE) were used. Participants identified each item, formed groups for them based on similarity, and assigned labels for those groups. Student's t-tests and analysis of variance (ANOVA) tests were used to verify the mean difference between the groups of items. K-means cluster analysis was applied to identify similar clusters. Schoolchildren made an average of 9.1 piles of foods and beverages that they thought were similar (±2.4) with 3.0 cards (±1.8) each. Five groups were identified: meats, snacks and pasta, sweets, milk and dairy products, and fruits and vegetables. The most frequently used nomenclature for labeling groups was taxonomic-professional (47.4%), followed by the specific food item name (16.4%), do not know/not sure (13.3%), and evaluative (health perception) (8.8%). The taxonomic-professional category could be applied to promote improvements in the identification process of food and beverage items by children in self-reported computerized dietary questionnaires.

Technological tools for assessing children's food intake: a scoping review

Technological innovations can standardise and minimise reporting errors in dietary assessment. This scoping review aimed to summarise the characteristics of technological tools used to assess children's food intake. The review followed the Joanna Briggs Institute's manual. The main inclusion criterion was studied that assessed the dietary intake of children 0-9 years of age using technology. We also considered articles on validation and calibration of technologies. We retrieved 15 119 studies and 279 articles were read in full, after which we selected 93 works that met the eligibility criteria. Forty-six technologies were identified, 37 % of which had been developed in Europe and 32⋅6 % in North America; 65⋅2 % were self-administered; 27 % were used exclusively at home; 37 % involved web-based software and more than 80 % were in children over 6 years of age. 24HR was the most widely used traditional method in the technologies (56⋅5 %), and 47⋅8 % of the tools were validated. The review summarised helpful information for studies on using existing tools or that intend to develop or validate tools with various innovations. It focused on places with a shortage of such technologies.

Dietary Effects of Introducing Salt-Reduced Bread with and without Dietary Counselling-A Cluster Randomized Controlled Trial

Successful strategies for policy makers and the food industry are required to reduce population salt intake. A 4-month cluster randomized controlled trial was conducted to evaluate whether the provision of salt-reduced bread with or without dietary counselling affected the dietary intake of selected food groups, energy, macronutrients, sodium, and potassium. Eighty-nine families (n = 309) consisting of minimum one parent and one child were assigned to receive bread gradually reduced in salt content alone (Intervention A), combined with dietary counselling (Intervention B), or bread with regular salt content (control). Food intake was recorded for seven consecutive days at baseline and follow-up. Salt intake was reduced in both Intervention A (−1.0 g salt/10 MJ, p = 0.027) and Intervention B (−1.0 g salt/10 MJ, p = 0.026) compared to the control. Consumption of bread and both total and salt-rich bread fillings remained similar between groups, while ‘cheese and cheese products’ were reduced in Intervention A (−38%, p = 0.011). Energy intake and macronutrient distribution were not affected in Intervention A, but Intervention B resulted in a higher energy intake (512 kJ, p = 0.019) and a lower energy % (E%) from saturated fat (−1.0 E%, p = 0.031) compared to the control. In conclusion, provision of salt-reduced bread both with and without dietary counselling successfully reduced dietary salt intake without adversely affecting the dietary nutritional quality.

Cumulative dietary risk assessment of pesticides in food for the Danish population for the period 2012-2017

The cumulative chronic dietary exposure for the Danish population were assessed using Danish food monitoring data for the period 2012-2017 and Danish food consumption data for the consumer groups children (age 1-2, age 4-6 and age 7-14 years), adults age 15-75, high consumers and consumers eating Danish produced fruit and vegetables whenever possible. Levels below the Limit of Reporting (LOR) were set to ½ LOR with correction. For risk assessment of the cumulative chronic dietary exposure we used the Hazard Index (HI) method where the Hazard Quotient (HQ) was calculated for each pesticide and summed up to a HI. The HI was calculated to be below 1 for all consumer groups; i.e. 0.36 for children age 4-6 years and 0.13 for adults, indicating that the cumulative chronic dietary pesticide exposure is unlikely to constitute a health risk for Danish consumers, even for high consumers eating 600 g or more of fruit and vegetables each day. By eating Danish produced commodities whenever possible, the HI was reduced by a factor of one third for both children and adults. 25 different commodities contributed to about 90% of the HI and to 84% of the exposure.

Development of a mobile application to assess Brazilian schoolchildren's diet: CADE – food consumption at home and at school

The development of technologies for children's dietary assessment shows important potential for reducing the occurrence of inherent errors in traditional methods. The present study aimed to describe the development of a mobile app for the dietary assessment of Brazilian schoolchildren. The mobile app assesses schoolchildren's diet with self-report by their parents or guardians in the home environment, through multiple-pass 24-hour recall coupled with a food propensity questionnaire; and by an adult in the school environment, through a food record. The tool presents a database of food items usually consumed by Brazilian schoolchildren, including modes of preparation, probing foods and types of food quantification such as digital photos of household measurements and food portions. The CADE app (food consumption at home and at school) contains 2125 food items, 9 options for preparation methods and 18 options for probing items. There are 75 options for household measurements, also including 26 digital photos of four types of household measurements and 440 photos of portion sizes of 90 foods from the Brazilian Manual of Child Food Portion Quantification. Some innovative features include an interface to take photos of the child's meals and report seconds and leftover food consumption, besides the possibility of receiving notifications on the mobile device to remember to report the diet. The CADE app can assist the standardisation and automation of dietary data collection from schoolchildren, support food and nutrition data in childhood and promote research in nutritional epidemiology while reducing data collection costs.

Effects of substitution dietary guidelines targeted at prevention of IHD on dietary intake and risk factors in middle-aged Danish adults: the Diet and Prevention of Ischemic Heart Disease: a Translational Approach (DIPI) randomised controlled trial

The objective was to investigate the effects of substitution (SUB) dietary guidelines (DG) targeted at the prevention of IHD on dietary intake and IHD risk factors in Danish adults with minimum one self-assessed IHD risk factor. A 6-month single-blinded parallel randomised controlled trial with a follow-up at month 12 included 219 subjects (median age 51 years, 59 % female, 73 % overweight or obese) randomised into an SUB DG, an official (OFF) DG or a control group following their habitual diet (HAB). Participants in the DG intervention groups received bi-weekly reminders of their DG and recipes for dishes and the HAB group received a greeting. Dietary intake and fasting blood, anthropometric and blood pressure measurements were obtained at baseline, month 6 and month 12. Linear regression analyses were applied. At month 6, when compared with the HAB, the SUB had a greater impact on the extent of dietary changes with increased intake of whole grains, dietary fibre and low fibre vegetables compared with the OFF DG, and both DG groups had similar decreased percentage of energy (E%) intake from SFA. The extent of dietary changes was similar at month 12. No overall significant changes from baseline were found in blood pressure, anthropometrics and IHD risk markers. In conclusion, both SUB and OFF DG resulted in cardioprotective dietary changes. However, neither the SUB nor the OFF DG resulted in any overall effects on the selected intermediate risk factors for IHD.

Development and Usability Study of an Open-Access Interviewer-Administered Automated 24-h Dietary Recall Tool in Argentina: MAR24

Background: Latin American countries show a fast-growing rate of non-communicable diseases (NCDs) and diet is a critical risk factor that must be properly assessed. Automated dietary assessment tools to collect 24-h dietary recalls (24HR) are lacking in Argentina.

Objective: This study aimed to develop an open-access automated tool (MAR24) for collecting 24HR using a multiple pass method and a database containing foods and recipes commonly consumed in Argentina.

Methods: MAR24 was developed based on data from 1,285 24HR provided by male and female participants aged 18 to 68 years from the six Argentinian geographical regions. The main structure and interface of the tool were designed using Visual Basic for Applications programming language in Excel Microsoft Office 365, integrating the five steps of the United States Department of Agriculture (USDA) Automated Multiple-Pass Method (AMPM) for the application of 24HR in Spanish. The tool underwent alpha testing and expert assessment to address structural and usability issues. Critical feedback and face validation from researchers and experienced dietitians, and repeated testing to collect 24HR were used to adjust and improve the tool.

Results: A total of 968 food items and 100 standard Argentinian recipes were added to its database. MAR24 allows the estimation of the nutrient profile of dietary intake. The analytic food composition includes energy and 50 nutrients including water, macronutrients, total dietary fiber, total sugar, 10 minerals, 19 vitamins, eight fatty acids, cholesterol, ethyl alcohol, caffeine, and theobromine. MAR24 includes a user manual and technical manual to guide users to apply changes (e.g., add foods or recipes, or change food designation according to local terms) to fit different research and clinical applications.

Conclusions: MAR24 is the first tool that uses the AMPM methodology for 24HR applications in Argentina. The tool may be used in clinical practice and clinical trials for monitoring purposes, and in validation of food frequency questionnaires (FFQ) for nutritional epidemiology studies addressing dietary-associated risk factors for NCDs.

A Web-Based Time-Use Application to Assess Diet and Movement Behavior in Asian Schoolchildren: Development and Usability Study of My E-Diary for Activities and Lifestyle (MEDAL)

Background

Web-based time-use diaries for schoolchildren are limited, and existing studies focus mostly on capturing physical activities and sedentary behaviors but less comprehensively on dietary behaviors.

Objective

This study aims to describe the development of My E-Diary for Activities and Lifestyle (MEDAL)—a self-administered, web-based time-use application to assess diet and movement behavior—and to evaluate its usability in schoolchildren in Singapore.

Methods

MEDAL was developed through formative research and an iterative user-centric design approach involving small groups of schoolchildren (ranging from n=5 to n=15, aged 7-13 years). To test the usability, children aged 10-11 years were recruited from 2 primary schools in Singapore to complete MEDAL for 2 weekdays and 2 weekend days and complete a 10-item usability questionnaire.

Results

The development process revealed that younger children (aged <9 years) were less able to complete MEDAL independently. Of the 204 participants (118/204, 57.8% boys, and 31/201, 15.4% overweight) in the usability study, 57.8% (118/204) completed 3 to 4 days of recording, whereas the rest recorded for 2 days or less. The median time taken to complete MEDAL was 14.2 minutes per day. The majority of participants agreed that instructions were clear (193/203, 95.1%), that MEDAL was easy to use (173/203, 85.2%), that they liked the application (172/202, 85.1%), and that they preferred recording their activities on the web than on paper (167/202, 82.7%). Among all the factors evaluated, recording for 4 days was the least satisfactory component reported. Compared with boys, girls reported better recall ability and agreed that the time spent on completing 1-day entry was appropriate.

Conclusions

MEDAL appears to be a feasible application to capture diet and movement behaviors in children aged 10-12 years, particularly in the Asian context. Some gender differences in usability performance were observed, but the majority of the participants had a positive experience using MEDAL. The validation of the data collected through the application is in progress.

Salt Reduction Intervention in Families Investigating Metabolic, Behavioral and Health Effects of Targeted Intake Reductions: Study Protocol for a Four Months Three-Armed, Randomized, Controlled "Real-Life" Trial

Reductions in salt intake have the potential to markedly improve population health at low cost. Real life interventions that explore the feasibility and health effects of a gradual salt reduction lasting at least four weeks are required. The randomized controlled SalT Reduction InterVEntion (STRIVE) trial was developed to investigate the metabolic, behavioral and health effects of four months of consuming gradually salt reduced bread alone or in combination with dietary counselling. This paper describes the rationale and methods of STRIVE. Aiming at 120 healthy families, participants were recruited in February 2018 from the Danish Capital Region and randomly allocated into: (A) Salt reduced bread; (B) Salt reduced bread and dietary counseling; (C) Standard bread. Participants were examined before the intervention and at four months follow-up. Primary outcome is change in salt intake measured by 24 h urine. Secondary outcomes are change in urine measures of potassium and sodium/ potassium ratio, blood pressure, plasma lipids, the renin-angiotensin system, the sympathetic nervous response, dietary intake as well as salt taste sensitivity and preferences. The results will qualify mechanisms affected during a gradual reduction in salt intake in compliance with the current public health recommendations.

Can Wearable Cameras be Used to Validate School-Aged Children's Lifestyle Behaviours?

Wearable cameras combined with accelerometers have been used to estimate the accuracy of children's self-report of physical activity, health-related behaviours, and the contexts in which they occur. There were two aims to this study; the first was to validate questions regarding self-reported health and lifestyle behaviours in 9⁻11-year-old children using the child's health and activity tool (CHAT), an accelerometer and a wearable camera. Second, the study sought to evaluate ethical challenges associated with taking regular photographs using a wearable camera through interviews with children and their families. Fourteen children wore an autographer and hip-worn triaxial accelerometer for the waking hours of one school and one weekend day. For both of these days, children self-reported their behaviours chronologically and sequentially using the CHAT. Data were examined using limits of agreement and percentage agreement to verify if reference methods aligned with self-reported behaviours. Six parent⁻child dyads participated in interviews. Seven, five, and nine items demonstrated good, acceptable, and poor validity, respectively. This demonstrates that the accuracy of children's recall varies according to the behaviour or item being measured. This is the first study to trial the use of wearable cameras in assessing the concurrent validity of children's physical activity and behaviour recall, as almost all other studies have used parent proxy reports alongside accelerometers. Wearable cameras carry some ethical and technical challenges, which were examined in this study. Parents and children reported that the autographer was burdensome and in a few cases invaded privacy. This study demonstrates the importance of adhering to an ethical framework.

Diet quality on days without breakfast or lunch - Identifying targets to improve adolescents' diet

Dietary intake in adolescents does often not align with the recommended dietary guidelines. Excess intakes of added sugar and saturated fat, and insufficient vegetable intake are among the identified challenges, which can affect future health negatively. Identifying targets to improve dietary practices is therefore essential. The current study aimed to examine the prevalence of meal skipping and if meal skipping days had a different diet quality than other days, using data from a recent Norwegian dietary survey in adolescents (n = 689, age 12-14 years). Their dietary intake was recorded for four days, using a web-based record system. Differences between days with, and without, breakfast or lunch were explored using mixed effect models, adjusting for correlated data and covariates, including weekday-weekend effect. In total, 8% and 11% were days without breakfast and lunch, respectively. Days with breakfast or lunch were associated with higher intake of fibre, and higher odds of consuming fruits and berries, juice and smoothie, than days without breakfast or lunch. Weekdays with lunch were also associated with lower intakes of added sugar and total fat (in % of energy), and discretionary foods, compared to weekdays without lunch. Skipping breakfast and lunch was associated with reduced diet quality in adolescents. Targeting these meals, and in particular school lunch, is a potential way forward to improve adolescents' dietary intake.

Evaluation of New Technology-Based Tools for Dietary Intake Assessment-An ILSI Europe Dietary Intake and Exposure Task Force Evaluation

BACKGROUND

New technology-based dietary assessment tools, including Web-based programs, mobile applications, and wearable devices, may improve accuracy and reduce costs of dietary data collection and processing. The International Life Sciences Institute (ILSI) Europe Dietary Intake and Exposure Task Force launched this project to evaluate new tools in order to recommend general quality standards for future applications.

METHODS

A comprehensive literature search identified technology-based dietary assessment tools, including those published in English from 01/2011 to 09/2017, and providing details on tool features, functions and uses. Each of the 43 tools identified (33 for research and 10 designed for consumer use) was rated on 25 attributes.

RESULTS

Most of the tools identified (79%) relied on self-reported dietary intakes. Most (91%) used text entry and 33% used digital images to help identify foods. Only 65% had integrated databases for estimating energy or nutrients. Fewer than 50% contained any features of customization and about half generated automatic reports. Most tools reported on usability or reported validity compared with another assessment method (77%). A set of Best Practice Guidelines was developed for reporting dietary assessment tools using new technology.

CONCLUSIONS

Dietary assessment methods that utilize technology offer many advantages for research and are often preferable to consumers over more traditional methods. In order to meet general quality standards, new technology tools require detailed publications describing tool development, food identification and quantification, customization, outputs, food composition tables used, and usability/validity testing.

What is the Validity of Questionnaires Assessing Fruit and Vegetable Consumption in Children when Compared with Blood Biomarkers? A Meta-Analysis

Fruit and vegetable consumption has been associated with improved health outcomes in children. As an extensive number of questionnaires are currently used to assess fruit and vegetable consumption, we performed a systematic review of the criterion validity of questionnaires used to estimate fruit and vegetable consumption in children, considering blood biomarkers as the reference method. Five electronic databases (MEDLINE, CINAHL, Scopus, PsycINFO, Web of Science) were searched from database inception to 23 July 2018. The search strategy used the following sets of descriptors: children; fruits and vegetables; dietary questionnaires; blood biomarkers; and validation coefficient. The search terms were adapted for use with other databases in combination with database-specific filters. Potentially eligible articles were selected independently by two reviewers, separately, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two articles meeting the inclusion criteria were included. The main reason for study exclusion was the sample age range, which included adolescents. The pooled correlation coefficient was 0.32 (95% confidence interval: 0.24–0.40).This review provided insights into assessment methods of fruit and vegetable consumption in children. Although further studies are required, questionnaires for assessing fruit and vegetable consumption have fair criterion validity in children.

New approaches in assessing food intake in epidemiology

PURPOSE OF REVIEW

A promising direction for improving dietary intake measurement in epidemiologic studies is the combination of short-term and long-term dietary assessment methods using statistical methods. Thereby, web-based instruments are particularly interesting as their application offers several potential advantages such as self-administration and a shorter completion time. The objective of this review is to provide an overview of new web-based short-term instruments and to describe their features.

RECENT FINDINGS

A number of web-based short-term dietary assessment tools for application in different countries and age-groups have been developed so far. Particular attention should be paid to the underlying database and the search function of the tool. Moreover, web-based instruments can improve the estimation of portion sizes by offering several options to the user.

SUMMARY

Web-based dietary assessment methods are associated with lower costs and reduced burden for participants and researchers, and show a comparable validity with traditional instruments. When there is a need for a web-based tool researcher should consider the adaptation of existing tools rather than developing new instruments. The combination of short-term and long-term instruments seems more feasible with the use of new technology.

Children and young people's participation in developing interventions in health and well-being: a scoping review

BACKGROUND

Greater interest is being shown in participatory approaches, especially in research on interventions that concern children and young people's health and well-being. Although participatory approaches have user involvement in common, they differ in terms of the explicit guidance on how to actually involve and engage children and young people in health research. The aim of this scoping review was to systematically map recent research involving children and young people in the development of interventions targeting issues of health and well-being.

METHODS

An interpretative scoping literature review based on: a scientific literature search in (health and social science) databases, reference lists, a manual search in key journals and contact with existing networks was conducted. A total of 4458 references were identified through the literature search, of which 41 studies published between 2000 and 2017 were included in the review. The target population was children and young people under 25 years old. Level of participation was categorized according to Shier's Pathways to Participation Model.

RESULTS

The review showed that participatory approaches were most often used in the development of interventions in school settings and in community and healthcare settings and on issues concerning support in lifestyle or in managing illness or disease. The level of participation varied from children and young people taking part just as active informants, through stages of greater participation both in quantitative and qualitative terms, to children and young people becoming an active agent involved as a co-researcher where the research process was shaped by views of a higher level of mutuality. Most of the studies were categorised at a medium level and only three studies were judged to involve the children and young people at the highest level.

CONCLUSIONS

This scoping review showed that work remains in enabling children and young people to influence the development of interventions targeting health and well-being. In relation to level of sustainability in the interventions, it is relevant that goals, strategies and processes are formulated by those who can gain from the interventions. Participatory approaches aiming for a higher level of participation where children and young people work together with the researchers in partnerships are thus warranted.

Associations between adherence to the Danish Food-Based Dietary Guidelines and cardiometabolic risk factors in a Danish adult population: the DIPI study

Diet is recognised as one modifiable lifestyle factor for ischaemic heart disease (IHD). We aimed at investigating the associations between adherence to the Danish Food-Based Dietary Guidelines (FBDG) indicated by a Dietary Quality Index (DQI) and selected cardiometabolic risk factors in a cross-sectional study with 219 Danish adult participants (59 %women; age 31–65years) with a minimum of one self-rated risk marker of IHD. Information regarding diet was obtained using web-based dietary assessment software and adherence to the Danish FBDG was expressed by a DQI calculated from 5 food and nutrient indicators (whole grain, fish, fruit and vegetables, energy from saturated fat and from added sugar). Background information, blood samples and anthropometrics were collected and blood pressure was measured. Linear regression analyses were used to evaluate the association between DQI and cardiometabolic risk factors. DQI was inversely associated with LDL:HDL ratio and TAG (−0·089 per unit; 95 % CI −0·177, −0·002 and −5 % per unit; 95 % CI −9, 0, respectively) and positively associated with HDL-cholesterol (0·047 mmol/l per unit; 95 % CI 0·007, 0·088). For men, DQI was inversely associated with BMI (−3 %per unit; 95 % CI −5, −1), trunk fat (−1 % per unit; 95 % CI −2, −1), high-sensitivity C-reactive protein (−30 % per unit; 95 % CI −41, −16 %), HbA1c(−0·09 % per unit; 95 % CI −0·14, −0·04), insulin (−13 % per unit; 95 % CI −19, −7) and homoeostatic model assessment-insulin resistance (−14 % per unit; 95 % CI −21, −7). In women, DQI was positively associated with systolic blood pressure (2·6 mmHg per unit; 95 % CI 0·6, 4·6). In conclusion, higher adherence to the current Danish FBDG was associated with a more beneficial cardiometabolic risk profile in a Danish adult population with a minimum of one self-rated risk factor for IHD.

Scaling up Dietary Data for Decision-Making in Low-Income Countries: New Technological Frontiers

Dietary surveys in low-income countries (LICs) are hindered by low investment in the necessary research infrastructure, including a lack of basic technology for data collection, links to food composition information, and data processing. The result has been a dearth of dietary data in many LICs because of the high cost and time burden associated with dietary surveys, which are typically carried out by interviewers using pencil and paper. This study reviewed innovative dietary assessment technologies and gauged their suitability to improve the quality and time required to collect dietary data in LICs. Predefined search terms were used to identify technologies from peer-reviewed and gray literature. A total of 78 technologies were identified and grouped into 6 categories: 1) computer- and tablet-based, 2) mobile-based, 3) camera-enabled, 4) scale-based, 5) wearable, and 6) handheld spectrometers. For each technology, information was extracted on a number of overarching factors, including the primary purpose, mode of administration, and data processing capabilities. Each technology was then assessed against predetermined criteria, including requirements for respondent literacy, battery life, requirements for connectivity, ability to measure macro- and micronutrients, and overall appropriateness for use in LICs. Few technologies reviewed met all the criteria, exhibiting both practical constraints and a lack of demonstrated feasibility for use in LICs, particularly for large-scale, population-based surveys. To increase collection of dietary data in LICs, development of a contextually adaptable, interviewer-administered dietary assessment platform is recommended. Additional investments in the research infrastructure are equally important to ensure time and cost savings for the user.

Validation of energy intake from a web-based food recall for children and adolescents

The purpose of this study was to validate estimated energy intake from a web-based food recall, designed for children and adolescents. We directly compared energy intake to estimates of total energy expenditure, calculated from accelerometer outputs, combined with data on weight and sex or resting energy expenditure prediction equations. Children (8–9 years) and adolescents (12–14 years) were recruited through schools in Norway in 2013 (N = 253). Results showed that more than one third (36–37%) were identified as under-reporters of energy. In contrast, only 2–4% were defined as over-reporters of energy. The mean energy intake was under-reported with -1.83 MJ/day for the entire study sample. Increased underestimation was observed for overweight and obese participants, the oldest age group (12–14 years), boys, those with parents/legal guardians with low educational level and those living in non-traditional families. In conclusion, energy intake from the web-based food recall is significantly underestimated compared with total energy expenditure, and should be used with caution in young people.

Common genetic variants are associated with lower serum 25-hydroxyvitamin D concentrations across the year among children at northern latitudes

In a longitudinal study including 642 healthy 8–11-year-old Danish children, we investigated associations between vitamin D dependent SNP and serum 25-hydroxyvitamin D (25(OH)D) concentrations across a school year (August–June). Serum 25(OH)D was measured three times for every child, which approximated measurements in three seasons (autumn, winter, spring). Dietary and supplement intake, physical activity, BMI and parathyroid hormone were likewise measured at each time point. In all, eleven SNP in four vitamin D-related genes: Cytochrome P450 subfamily IIR1 (CYP2R1); 7-dehydrocholesterol reductase/nicotinamide adenine dinucleotide synthetase-1(DHCR7/NADSYN1); group-specific complement (GC); and vitamin D receptor were genotyped. We found minor alleles of CYP2R1 rs10500804, and of GC rs4588 and rs7041 to be associated with lower serum 25(OH)D concentrations across the three seasons (all P<0·01), with estimated 25(OH)D differences of −5·8 to −10·6 nmol/l from major to minor alleles homozygosity. In contrast, minor alleles homozygosity of rs10741657 and rs1562902 in CYP2R1 was associated with higher serum 25(OH)D concentrations compared with major alleles homozygosity (all P<0·001). Interestingly, the association between season and serum 25(OH)D concentrations was modified by GC rs7041 (Pinteraction=0·044), observed as absence of increase in serum 25(OH)D from winter to spring among children with minor alleles homozygous genotypes compared with the two other genotypes of rs7041 (P<0·001). Our results suggest that common genetic variants are associated with lower serum 25(OH)D concentrations across a school year. Potentially due to modified serum 25(OH)D response to UVB sunlight exposure. Further confirmation and paediatric studies investigating vitamin D-related health outcomes of these genotypic differences are needed.

Overcoming Dietary Assessment Challenges in Low-Income Countries: Technological Solutions Proposed by the International Dietary Data Expansion (INDDEX) Project

An increasing number of low-income countries (LICs) exhibit high rates of malnutrition coincident with rising rates of overweight and obesity. Individual-level dietary data are needed to inform effective responses, yet dietary data from large-scale surveys conducted in LICs remain extremely limited. This discussion paper first seeks to highlight the barriers to collection and use of individual-level dietary data in LICs. Second, it introduces readers to new technological developments and research initiatives to remedy this situation, led by the International Dietary Data Expansion (INDDEX) Project. Constraints to conducting large-scale dietary assessments include significant costs, time burden, technical complexity, and limited investment in dietary research infrastructure, including the necessary tools and databases required to collect individual-level dietary data in large surveys. To address existing bottlenecks, the INDDEX Project is developing a dietary assessment platform for LICs, called INDDEX24, consisting of a mobile application integrated with a web database application, which is expected to facilitate seamless data collection and processing. These tools will be subject to rigorous testing including feasibility, validation, and cost studies. To scale up dietary data collection and use in LICs, the INDDEX Project will also invest in food composition databases, an individual-level dietary data dissemination platform, and capacity development activities. Although the INDDEX Project activities are expected to improve the ability of researchers and policymakers in low-income countries to collect, process, and use dietary data, the global nutrition community is urged to commit further significant investments in order to adequately address the range and scope of challenges described in this paper.

A review of the design and validation of web- and computer-based 24-h dietary recall tools

Technology-based dietary assessment offers solutions to many of the limitations of traditional dietary assessment methodologies including cost, participation rates and the accuracy of data collected. The 24-h dietary recall (24HDR) method is currently the most utilised method for the collection of dietary intake data at a national level. Recently there have been many developments using web-based platforms to collect food intake data using the principles of the 24HDR method. This review identifies web- and computer-based 24HDR tools that have been developed for both children and adult population groups, and examines common design features and the methods used to investigate the performance and validity of these tools. Overall, there is generally good to strong agreement between web-based 24HDR and respective reference measures for intakes of macro- and micronutrients.

Qualitative Analysis of Cognitive Interviews With School Children: A Web-Based Food Intake Questionnaire

Background

The use of computers to administer dietary assessment questionnaires has shown potential, particularly due to the variety of interactive features that can attract and sustain children’s attention. Cognitive interviews can help researchers to gain insights into how children understand and elaborate their response processes in this type of questionnaire.

Objective

To present the cognitive interview results of children who answered the WebCAAFE, a Web-based questionnaire, to obtain an in-depth understanding of children’s response processes.

Methods

Cognitive interviews were conducted with children (using a pretested interview script). Analyses were carried out using thematic analysis within a grounded theory framework of inductive coding.

Results

A total of 40 children participated in the study, and 4 themes were identified: (1) the meaning of words, (2) understanding instructions, (3) ways to resolve possible problems, and (4) suggestions for improving the questionnaire. Most children understood questions that assessed nutritional intake over the past 24 hours, although the structure of the questionnaire designed to facilitate recall of dietary intake was not always fully understood. Younger children (7 and 8 years old) had more difficulty relating the food images to mixed dishes and foods eaten with bread (eg, jam, cheese). Children were able to provide suggestions for improving future versions of the questionnaire.

Conclusions

More attention should be paid to children aged 8 years or below, as they had the greatest difficulty completing the WebCAAFE.

Comparison of a web-based food record tool and a food-frequency questionnaire and objective validation using the doubly labelled water technique in a Swedish middle-aged population

Two web-based dietary assessment tools have been developed for use in large-scale studies: the Riksmaten method (4-d food record) and MiniMeal-Q (food-frequency method). The aim of the present study was to examine the ability of these methods to capture energy intake against objectively measured total energy expenditure (TEE) with the doubly labelled water technique (TEEDLW), and to compare reported energy and macronutrient intake. This study was conducted within the pilot study of the Swedish CArdioPulmonary bioImage Study (SCAPIS), which included 1111 randomly selected men and women aged 50-64 years from the Gothenburg general population. Of these, 200 were enrolled in the SCAPIS diet substudy. TEEDLW was measured in a subsample (n 40). Compared with TEEDLW, both methods underestimated energy intake: -2·5 (sd  2·9) MJ with the Riksmaten method; -2·3 (sd 3·6) MJ with MiniMeal-Q. Mean reporting accuracy was 80 and 82 %, respectively. The correlation between reported energy intake and TEEDLW was r 0·4 for the Riksmaten method (P < 0·05) and r 0·28 (non-significant) for MiniMeal-Q. Women reported similar average intake of energy and macronutrients in both methods whereas men reported higher intakes with the Riksmaten method. Energy-adjusted correlations ranged from 0·14 (polyunsaturated fat) to 0·77 (alcohol). Bland-Altman plots showed acceptable agreement for energy and energy-adjusted protein and carbohydrate intake, whereas the agreement for fat intake was poorer. According to energy intake data, both methods displayed similar precision on energy intake reporting. However, MiniMeal-Q was less successful in ranking individuals than the Riksmaten method. The development of methods to achieve limited under-reporting is a major challenge for future research.

Associations between reported intakes of carotenoid-rich foods and concentrations of carotenoids in plasma: a validation study of a web-based food recall for children and adolescents

Objective

To validate estimated intakes of carotenoid-rich foods from a web-based food recall (WebFR) using carotenoids in blood as an objective reference method.

Design

Cross-sectional validation study using carotenoids in plasma to evaluate estimated intakes of selected carotenoid-rich foods. Participants recorded their food intake in the WebFR and plasma concentrations of β-carotene, α-carotene, β-cryptoxanthin, lycopene, lutein and zeaxanthin were measured.

Setting

Schools and homes of families in a suburb of the capital of Norway.

Subjects

A total of 261 participants in the age groups 8–9 and 12–14 years.

Results

Spearman’s rank correlation coefficients ranged from 0·30 to 0·44, and cross-classification showed that 71·6–76·6 % of the participants were correctly classified, when comparing the reported intakes of carotenoid-rich foods and concentrations of the corresponding carotenoids in plasma, not including lutein and zeaxanthin.

Conclusions

Correlations were acceptable and cross-classification analyses demonstrated that the WebFR was able to rank participants according to their reported intake of foods rich in α-carotene, β-carotene, β-cryptoxanthin and lycopene. The WebFR is a promising tool for dietary assessment among children and adolescents.

Differences in the effects of school meals on children's cognitive performance according to gender, household education and baseline reading skills

BACKGROUND/OBJECTIVES

We previously found that the OPUS School Meal Study improved reading and increased errors related to inattention and impulsivity. This study explored whether the cognitive effects differed according to gender, household education and reading proficiency at baseline.

SUBJECTS/METHODS

This is a cluster-randomised cross-over trial comparing Nordic school meals with packed lunch from home (control) for 3 months each among 834 children aged 8 to 11 years. At baseline and at the end of each dietary period, we assessed children's performance in reading, mathematics and the d2-test of attention. Interactions were evaluated using mixed models. Analyses included 739 children.

RESULTS

At baseline, boys and children from households without academic education were poorer readers and had a higher d2-error%. Effects on dietary intake were similar in subgroups. However, the effect of the intervention on test outcomes was stronger in boys, in children from households with academic education and in children with normal/good baseline reading proficiency. Overall, this resulted in increased socioeconomic inequality in reading performance and reduced inequality in impulsivity. Contrary to this, the gender difference decreased in reading and increased in impulsivity. Finally, the gap between poor and normal/good readers was increased in reading and decreased for d2-error%.

CONCLUSIONS

The effects of healthy school meals on reading, impulsivity and inattention were modified by gender, household education and baseline reading proficiency. The differential effects might be related to environmental aspects of the intervention and deserves to be investigated further in future school meal trials.

Socio-economic differences in cardiometabolic risk markers are mediated by diet and body fatness in 8- to 11-year-old Danish children: a cross-sectional study

OBJECTIVE

To explore whether socio-economic differences exist in cardiometabolic risk markers in children and whether lifestyle-related factors potentially mediate these differences.

DESIGN

Cross-sectional study including measurements of fasting blood lipids, glucose, homeostasis model assessment of insulin resistance (HOMA-IR), blood pressure and heart rate. Potential mediators examined were fat mass index (FMI); intakes of fruit, vegetables, dietary fibre and added sugar; whole-blood n-3 long-chain PUFA (LCPUFA) as a biomarker of fish intake; and physical activity and sedentary time.

SETTING

Nine primary schools in Denmark.

SUBJECTS

Children aged 8-11 years (n 715).

RESULTS

Children of parents with the shortest compared with longest education had higher TAG by 0·12 (95 % CI 0·04, 0·21) mmol/l and HOMA-IR by 0·36 (0·10, 0·62), whereas children of parents with a vocational education had higher total cholesterol by 0·14 (0·02, 0·27) mmol/l and LDL cholesterol by 0·14 (0·03, 0·25) mmol/l compared with children of parents with the longest education; all P<0·05. FMI explained 25 % of the difference in TAG, 64 % of the difference in HOMA-IR and 21-29 % of the differences in cholesterols. FMI and whole-blood n-3 LCPUFA combined explained 42 % of the difference in TAG, whereas FMI, whole-blood n-3 LCPUFA and dietary fibre explained 89 % of the difference in HOMA-IR.

CONCLUSIONS

Socio-economic differences were present in blood lipids and insulin resistance among 8- to 11-year-olds and were mediated by body fatness, whole-blood n-3 LCPUFA and dietary fibre. These lifestyle factors may be targets in public initiatives to reduce socio-economic differences. Confirmation in longitudinal studies and trials is warranted.

Validation of Reported Whole-Grain Intake from a Web-Based Dietary Record against Plasma Alkylresorcinol Concentrations in 8- to 11-Year-Olds Participating in a Randomized Controlled Trial

BACKGROUND

Whole-grain (WG) intake is important for human health, but accurate intake estimation is challenging. Use of a biomarker for WG intake provides a possible way to validate dietary assessment methods.

OBJECTIVE

Our aim was to validate WG intake from 2 diets reported by children, using plasma alkylresorcinol (AR) concentrations, and to investigate the 3-mo reproducibility of AR concentrations and reported WG intake.

METHODS

AR concentrations were analyzed in fasting blood plasma samples, and WG intake was estimated in a 7-d web-based diary by 750 participants aged 8-11 y in a 2 school meal × 3 mo crossover trial. Reported WG intake and plasma AR concentrations were compared when children ate their usual bread-based lunch (UBL) and when served a hot lunch meal (HLM). Correlations and cross-classification were used to rank subjects according to intake. The intraclass correlation coefficients (ICCs) between subjects' measurements at baseline and after the UBL were used to assess reproducibility.

RESULTS

Correlations between reported WG wheat + rye intake and plasma AR were 0.40 and 0.37 (P < 0.001) for the UBL and the HLM diets, and 78% and 77% were classified in the same or adjacent quartiles for the UBL and HLM diets, respectively. The ICC over 3 mo was 0.47 (95% CI: 0.38, 0.55) for plasma total ARs and 0.64 (95% CI: 0.58, 0.70) for reported WG intake. Correlations were higher when using the AR C17:0 homolog as a biomarker, reflecting rye intake instead of plasma total ARs [UBL: r = 0.47; HLM: r = 0.43, P < 0.001; ICC = 0.51 (95% CI: 0.43, 0.59)].

CONCLUSIONS

Self-reported WG wheat + rye intake among children showed moderate correlations with plasma AR concentrations. Substantial intraindividual variation was found in WG intake and plasma AR concentrations. The AR homolog C17:0 may be used as a biomarker for WG intake when the WG intake primarily comes from rye as in the present study. This trial was registered at clinicaltrials.gov as NCT01457794.

Sleep duration modifies effects of free ad libitum school meals on adiposity and blood pressure

Insufficient sleep can potentially affect both energy intake and energy expenditure, resulting in obesity and reduced cardiometabolic health. The objective of the study was to investigate if habitual sleep duration of 8- to 11-year-olds modifies the effect of free ad libitum school meals on cardiometabolic markers, body composition, dietary intake, and physical activity. For 2 consecutive 3-month periods, this cluster-randomized, controlled, cross-over trial provided 530 children with school meals or usual lunch brought from home. Dietary intake, activity, and sleep were measured simultaneously for 7 consecutive days using dietary records and accelerometers. Short- and long-sleeping children were defined as lower and upper tertile of sleep duration. Body composition, blood pressure, blood lipids, and homeostatic model assessment of insulin resistance (HOMAIR) were measured/calculated. Overall, school meals compared with lunch from home had positive effects on physical activity and blood pressure in long-sleeping children and negative effects on body fat in short-sleeping children. Short-sleeping children increased fat mass compared with long-sleeping children by 0.21 (95% confidence interval 0.03-0.38) kg, android fat mass by 0.02 (0.001-0.04) kg, waist circumference by 0.73 (0.23-1.24) cm, blood pressure by 1.5 (0.4-2.6) mm Hg, fat intake by 1.1 (0.2-2.0) percentage of energy, and decreased total physical activity by 7.2 (1.6-12.7) % (all P ≤ 0.04), while HOMAIR and blood lipids were not modified by sleep duration (all P ≥ 0.32). In conclusion, the susceptibility to increase abdominal adiposity and blood pressure when exposed to dietary changes can potentially be explained by too little sleep, which results in increased caloric intake and reduced physical activity.

Evaluation of a Web-Based Food Record for Children Using Direct Unobtrusive Lunch Observations: A Validation Study

Background

High-quality, Web-based dietary assessment tools for children are needed to reduce cost and improve user-friendliness when studying children’s dietary practices.

Objective

To evaluate the first Web-based dietary assessment tool for children in Norway, the Web-based Food Record (WebFR), by comparing children’s true school lunch intake with recordings in the WebFR, using direct unobtrusive observation as the reference method.

Methods

A total of 117 children, 8-9 years, from Bærum, Norway, were recruited from September to December 2013. Children completed 4 days of recordings in the WebFR, with parental assistance, and were observed during school lunch in the same period by 3 observers. Interobserver reliability assessments were satisfactory. Match, omission, and intrusion rates were calculated to assess the quality of the recordings in the WebFR for different food categories, and for all foods combined. Logistic regression analyses were used to investigate whether body mass index (BMI), parental educational level, parental ethnicity or family structure were associated with having a “low match rate” (≤70%).

Results

Bread and milk were recorded with less bias than spreads, fruits, and vegetables. Mean (SD) for match, omission, and intrusion rates for all foods combined were 73% (27%), 27% (27%), and 19% (26%), respectively. Match rates were statistically significantly associated with parental educational level (low education 52% [32%] versus high 77% [24%], P=.008) and parental ethnicity (non-Norwegian 57% [28%] versus others 75% [26%], P=.04). Only parental ethnicity remained statistically significant in the logistic regression model, showing an adjusted odds ratio of 6.9 and a 95% confidence interval between 1.3 and 36.4.

Conclusions

Compared with other similar studies, our results indicate that the WebFR is in line with, or better than most of other similar tools, yet enhancements could further improve the WebFR.

Vitamin D status and its determinants during autumn in children at northern latitudes: a cross-sectional analysis from the optimal well-being, development and health for Danish children through a healthy New Nordic Diet (OPUS) School Meal Study

Sufficient summer/autumn vitamin D status appears important to mitigate winter nadirs at northern latitudes. We conducted a cross-sectional study to evaluate autumn vitamin D status and its determinants in 782 Danish 8-11-year-old children (55°N) using baseline data from the Optimal well-being, development and health for Danish children through a healthy New Nordic Diet (OPUS) School Meal Study, a large randomised controlled trial. Blood samples and demographic and behavioural data, including 7-d dietary recordings, objectively measured physical activity, and time spent outdoors during school hours, were collected during September-November. Mean serum 25-hydroxyvitamin D (25(OH)D) was 60·8 (sd 18·7) nmol/l. Serum 25(OH)D levels ≤50 nmol/l were found in 28·4 % of the children and 2·4 % had concentrations <25 nmol/l. Upon multivariate adjustment, increasing age (per year) (β -2·9; 95 % CI -5·1, -0·7 nmol/l), female sex (β -3·3; 95 % CI -5·9, -0·7 nmol/l), sampling in October (β -5·2; 95 % CI -10·1, -0·4 nmol/l) and November (β -13·3; 95 % CI -17·7, -9·1), and non-white ethnicity (β -5·7; 95 % CI -11·1, -0·3 nmol/l) were negatively associated with 25(OH)D (all P<0·05). Likewise, immigrant/descendant background was negatively associated with 25(OH)D, particularly in females (β -16·3; 95 % CI -21·9, -10·7) (P<0·001) (P interaction=0·003). Moderate-to-vigorous physical activity (MVPA) (min/d) (β 0·06; 95 % CI 0·01, 0·12), outdoor walking during school hours (min/week) (β 0·4; 95 % CI 0·1, 0·6) and intake of vitamin D-containing supplements ≥3 d/week (β 8·7; 95 % CI 6·4, 11·0) were positively associated with 25(OH)D (all P<0·05). The high proportion of children with vitamin D status below the recommended sufficiency level of 50 nmol/l raises concern as levels expectedly drop further during winter months. Frequent intake of vitamin D supplements was strongly associated with status. MVPA and outdoor activity during school hours should be investigated further in interventions to improve autumn vitamin D status in children at northern latitudes.

Effects of school meals with weekly fish servings on vitamin D status in Danish children: secondary outcomes from the OPUS (Optimal well-being, development and health for Danish children through a healthy New Nordic Diet) School Meal Study

Children's vitamin D intake and status can be optimised to meet recommendations. We investigated if nutritionally balanced school meals with weekly fish servings affected serum 25-hydroxyvitamin D (25(OH)D) and markers related to bone in 8- to 11-year-old Danish children. We conducted an explorative secondary outcome analysis on data from 784 children from the OPUS School Meal Study, a cluster-randomised cross-over trial where children received school meals for 3 months and habitual lunch for 3 months. At baseline, and at the end of each dietary period, 25(OH)D, parathyroid hormone (PTH), osteocalcin (OC), insulin-like growth factor-1 (IGF-1), bone mineral content (BMC), bone area (BA), bone mineral density (BMD), dietary intake and physical activity were assessed. School meals increased vitamin D intake by 0·9 (95 % CI 0·7, 1·1) μg/d. No consistent effects were found on 25(OH)D, BMC, BA, BMD, IGF-1 or OC. However, season-modified effects were observed with 25(OH)D, i.e. children completing the school meal period in January/February had higher 25(OH)D status (5·5 (95 % CI 1·8, 9·2) nmol/l; P = 0·004) than children completing the control period in these months. A similar tendency was indicated in November/December (4·1 (95 % CI –0·12, 8·3) nmol/l; P = 0·057). However, the effect was opposite in March/April (–4·0 (95 % CI –7·0, –0·9) nmol/l; P = 0·010), and no difference was found in May/June (P = 0·214). Unexpectedly, the school meals slightly increased PTH (0·18 (95 % CI 0·07, 0·29) pmol/l) compared with habitual lunch. Small increases in dietary vitamin D might hold potential to mitigate the winter nadir in Danish children's 25(OH)D status while higher increases appear necessary to affect status throughout the year. More trials on effects of vitamin D intake from natural foods are needed.

Vitamin D status is associated with cardiometabolic markers in 8-11-year-old children, independently of body fat and physical activity

Vitamin D status has been associated with cardiometabolic markers even in children, but the associations may be confounded by fat mass and physical activity behaviour. This study investigated associations between vitamin D status and cardiometabolic risk profile, as well as the impact of fat mass and physical activity in Danish 8-11-year-old children, using baseline data from 782 children participating in the Optimal well-being, development and health for Danish children through a healthy New Nordic Diet (OPUS) School Meal Study. We assessed vitamin D status as serum 25-hydroxyvitamin D (25(OH)D) and measured blood pressure, fasting plasma glucose, homoeostasis model of assessment-insulin resistance, plasma lipids, inflammatory markers, anthropometry and fat mass by dual-energy X-ray absorptiometry, and physical activity by 7 d accelerometry during August-November. Mean serum 25(OH)D was 60·8 (sd 18·7) nmol/l. Each 10 mmol/l 25(OH)D increase was associated with lower diastolic blood pressure (-0·3 mmHg, 95 % CI -0·6, -0·0) (P=0·02), total cholesterol (-0·07 mmol/l, 95 % CI -0·10, -0·05), LDL-cholesterol (-0·05 mmol/l, 95 % CI -0·08, -0·03), TAG (-0·02 mmol/l, 95 % CI -0·03, -0·01) (P≤0·001 for all lipids) and lower metabolic syndrome (MetS) score (P=0·01). Adjustment for fat mass index did not change the associations, but the association with blood pressure became borderline significant after adjustment for physical activity (P=0·06). In conclusion, vitamin D status was negatively associated with blood pressure, plasma lipids and a MetS score in Danish school children with low prevalence of vitamin D deficiency, and apart from blood pressure the associations were independent of body fat and physical activity. The potential underlying cause-effect relationship and possible long-term implications should be investigated in randomised controlled trials.

A changing landscape: web-based methods for dietary assessment in adolescents

PURPOSE OF REVIEW

Adolescents' dietary intake is an important determinant of health and well-being and is influenced by a complex interaction of environmental, social, psychological, and physiological factors. The complexity of the adolescent diet makes its assessment prone to error, which has prompted researchers and clinicians to turn to technology to reduce this error. Previous reviews have been conducted regarding the use of technology in dietary assessment for adults; however, there are no known reviews for adolescents. Therefore, the purpose of this review is to describe the practical considerations for web-based dietary assessment methods and to evaluate recent evidence on their validity and implications.

RECENT FINDINGS

There are numerous web-based dietary assessment methods that are available, valid, and reliable for use in the adolescent population. Web-based methods include both native and web-based applications (or 'apps'), and have been developed for use as food records, 24-h dietary recalls, and food frequency questionnaires.

SUMMARY

Web-based methods provide an efficient, cost-effective and practical solution to assess dietary intake; they are less burdensome to respondents and reduce errors and bias. Furthermore, adolescents are technologically savvy and often prefer the use of technology. Web-based methods should be considered when assessing adolescents' dietary intake.

What do Danish children eat, and does the diet meet the recommendations? Baseline data from the OPUS School Meal Study

A child's diet is an important determinant for later health, growth and development. In Denmark, most children in primary school bring their own packed lunch from home and attend an after-school care institution. The aim of the present study was to evaluate the food, energy and nutrient intake of Danish school children in relation to dietary guidelines and nutrient recommendations, and to assess the food intake during and outside school hours. In total, 834 children from nine public schools located in the eastern part of Denmark were included in this cross-sectional study and 798 children (95·7 %) completed the dietary assessment sufficiently (August–November 2011). The whole diet was recorded during seven consecutive days using the Web-based Dietary Assessment Software for Children (WebDASC). Compared with the food-based dietary guidelines and nutrient recommendations, 85 % of the children consumed excess amounts of red meat, 89 % consumed too much saturated fat, and 56 % consumed too much added sugar. Additionally 35 or 91 % of the children (depending on age group) consumed insufficient amounts of fruits and vegetables, 85 % consumed insufficient amounts of fish, 86 % consumed insufficient amounts of dietary fibre, 60 or 84 % had an insufficient Fe intake (depending on age group), and 96 % had an insufficient vitamin D intake. The study also showed that there is a higher intake of fruits and bread during school hours than outside school hours; this is not the case with, for example, fish and vegetables, and future studies should investigate strategies to increase fish and vegetable intake during school hours.

Effects of school meals based on the New Nordic Diet on intake of signature foods: a randomised controlled trial. The OPUS School Meal Study

A New Nordic Diet (NND) was developed in the context of the Danish OPUS Study (Optimal well-being, development and health for Danish children through a healthy New Nordic Diet). Health, gastronomic potential, sustainability and Nordic identity were crucial principles of the NND. The aim of the present study was to investigate the effects of serving NND school meals compared with the usual packed lunches on the dietary intake of NND signature foods. For two 3-month periods, 834 Danish children aged 8-11 years received NND school meals or their usual packed lunches brought from home (control) in random order. The entire diet was recorded over 7 consecutive days using a validated Web-based Dietary Assessment Software for Children. The NND resulted in higher intakes during the entire week (% increase) of root vegetables (116 (95 % CI 1·93, 2·42)), cabbage (26 (95 % CI 1·08, 1·47)), legumes (22 (95 % CI 1·06, 1·40)), herbs (175 (95 % CI 2·36, 3·20)), fresh berries (48 (95 % CI 1·13, 1·94)), nuts and seeds (18 (95 % CI 1·02, 1·38)), lean fish and fish products (47 (95 % CI 1·31, 1·66)), fat fish and fish products (18 (95 % CI 1·02, 1·37)) and potatoes (129 (95 % CI 2·05, 2·56)). Furthermore, there was a decrease in the number of children with zero intakes when their habitual packed lunches were replaced by NND school meals. In conclusion, this study showed that the children increased their intake of NND signature foods, and, furthermore, there was a decrease in the number of children with zero intakes of NND signature foods when their habitual packed lunches were replaced by school meals following the NND principles.

Accuracy of self-reported intake of signature foods in a school meal intervention study: comparison between control and intervention period

Bias in self-reported dietary intake is important when evaluating the effect of dietary interventions, particularly for intervention foods. However, few have investigated this in children, and none have investigated the reporting accuracy of fish intake in children using biomarkers. In a Danish school meal study, 8- to 11-year-old children (n 834) were served the New Nordic Diet (NND) for lunch. The present study examined the accuracy of self-reported intake of signature foods (berries, cabbage, root vegetables, legumes, herbs, potatoes, wild plants, mushrooms, nuts and fish) characterising the NND. Children, assisted by parents, self-reported their diet in a Web-based Dietary Assessment Software for Children during the intervention and control (packed lunch) periods. The reported fish intake by children was compared with their ranking according to fasting whole-blood EPA and DHA concentration and weight percentage using the Spearman correlations and cross-classification. Direct observation of school lunch intake (n 193) was used to score the accuracy of food-reporting as matches, intrusions, omissions and faults. The reporting of all lunch foods had higher percentage of matches compared with the reporting of signature foods in both periods, and the accuracy was higher during the control period compared with the intervention period. Both Spearman's rank correlations and linear mixed models demonstrated positive associations between EPA+DHA and reported fish intake. The direct observations showed that both reported and real intake of signature foods did increase during the intervention period. In conclusion, the self-reported data represented a true increase in the intake of signature foods and can be used to examine dietary intervention effects.

Personalised nutrition: the role of new dietary assessment methods

Food records or diaries, dietary recalls and FFQ are methods traditionally used to measure dietary intake; however, advancing technologies and growing awareness in personalised health have heightened interest in the application of new technologies to assess dietary intake. Dietary intake data can be used in epidemiology, dietary interventions and in the delivery of personalised nutrition advice. Compared with traditional dietary assessment methods, new technologies have many advantages, including their ability to automatically process data and provide personalised dietary feedback advice. This review examines the new technologies presently under development for the assessment of dietary intakes, and their utilisation and efficacy for personalising dietary advice. New technology-based methods of dietary assessment can broadly be categorised into three key areas: online (web-based) methods, mobile methods and sensor technologies. Several studies have demonstrated that utilising new technologies to provide tailored advice can result in positive dietary changes and have a significant impact on selected nutrient and food group intakes. However, comparison across studies indicates that the magnitude of change is variable and may be influenced by several factors, including the frequency and type of feedback provided. Future work should establish the most effective combinations of these factors in facilitating dietary changes across different population groups.

Provision of healthy school meals does not affect the metabolic syndrome score in 8-11-year-old children, but reduces cardiometabolic risk markers despite increasing waist circumference

An increasing number of children are exhibiting features of the metabolic syndrome (MetS) including abdominal fatness, hypertension, adverse lipid profile and insulin resistance. Healthy eating practices during school hours may improve the cardiometabolic profile, but there is a lack of evidence. In the present study, the effect of provision of school meals rich in fish, vegetables and fibre on a MetS score (primary outcome) and on individual cardiometabolic markers and body composition (secondary outcomes) was investigated in 834 Danish school children. The study was carried out as a cluster-randomised, controlled, non-blinded, cross-over trial at nine schools. Children aged 8-11 years received freshly prepared school lunch and snacks or usual packed lunch from home (control) each for 3 months. Dietary intake, physical activity, cardiometabolic markers and body composition were measured at baseline and after each dietary period. The school meals did not affect the MetS score (P= 1.00). However, it was found that mean arterial pressure was reduced by 0.4 (95% CI 0.0, 0.8) mmHg (P= 0.04), fasting total cholesterol concentrations by 0.05 (95% CI 0.02, 0.08) mmol/l (P= 0.001), HDL-cholesterol concentrations by 0.02 (95% CI 0.00, 0.03) mmol/l, TAG concentrations by 0.02 (95% CI 0.00, 0.04) mmol/l (both P< 0.05), and homeostasis model of assessment-insulin resistance by 0.10 (95% CI 0.04, 0.16) points (P= 0.001) compared with the control diet in the intention-to-treat analyses. Waist circumference increased 0.5 (95% CI 0.3, 0.7) cm (P< 0.001), but BMI z-score remained unaffected. Complete-case analyses and analyses adjusted for household educational level, pubertal status and physical activity confirmed the results. In conclusion, the school meals did not affect the MetS score in 8-11-year-olds, as small improvements in blood pressure, TAG concentrations and insulin resistance were counterbalanced by slight undesired effects on waist circumference and HDL-cholesterol concentrations.

Eicosapentaenoic acid and docosahexaenoic acid in whole blood are differentially and sex-specifically associated with cardiometabolic risk markers in 8-11-year-old danish children

n-3 long-chain polyunsaturated fatty acids improve cardiovascular risk markers in adults. These effects may differ between eicosapentaenoic acid (EPA, 20∶5n-3) and docosahexaenoic acid (DHA, 22∶6n-3), but we lack evidence in children. Using baseline data from the OPUS School Meal Study we 1) investigated associations between EPA and DHA in whole blood and early cardiometabolic risk markers in 713 children aged 8-11 years and 2) explored potential mediation through waist circumference and physical activity and potential dietary confounding. We collected data on parental education, pubertal stage, 7-day dietary records, physical activity by accelerometry and measured anthropometry, blood pressure, and heart rate. Blood samples were analyzed for whole blood fatty acid composition, cholesterols, triacylglycerol, insulin resistance by the homeostatic model of assessment (HOMA-IR), and inflammatory markers. Whole blood EPA was associated with a 2.7 mmHg (95% CI 0.4; 5.1) higher diastolic blood pressure per weight% EPA, but only in boys. Heart rate was negatively associated with both EPA and DHA status (P = 0.02 and P = 0.002, respectively). Whole blood EPA was negatively associated with triacylglycerol (P = 0.003) and positively with total cholesterol, low density and high density lipoprotein (HDL) cholesterol and HDL:triacylglycerol (all P<0.01) whereas DHA was negatively associated with insulin and HOMA-IR (P = 0.003) and tended to be negatively associated with a metabolic syndrome-score (P = 0.05). Adjustment for waist circumference and physical activity did not change the associations. The association between DHA and HOMA-IR was attenuated but remained after adjustment for fiber intake and none of the other associations were confounded by dietary fat, protein, fiber or energy intake. This study showed that EPA status was negatively associated with triacylglycerol and positively with cholesterols whereas DHA was negatively associated with insulin resistance, and both were inversely associated with heart rate in children. The sex-specific associations with blood pressure confirm our previous findings and warrant further investigation.

Low physical activity level and short sleep duration are associated with an increased cardio-metabolic risk profile: a longitudinal study in 8-11 year old Danish children

Background

As cardio-metabolic risk tracks from childhood to adulthood, a better understanding of the relationship between movement behaviors (physical activity, sedentary behavior and sleep) and cardio-metabolic risk in childhood may aid in preventing metabolic syndrome (MetS) in adulthood.

Objective

To examine independent and combined cross-sectional and longitudinal associations between movement behaviors and the MetS score in 8-11 year old Danish children.

Design

Physical activity, sedentary time and sleep duration (seven days and eight nights) were assessed by accelerometer and fat mass index (fat mass/height²) was assessed using Dual-energy X-ray absorptiometry. The MetS-score was based on z-scores of waist circumference, mean arterial blood pressure, homeostatic model assessment of insulin resistance, triglycerides and high density lipoprotein cholesterol. All measurements were taken at three time points separated by 100 days. Average of the three measurements was used as habitual behavior in the cross-sectional analysis and changes from first to third measurement was used in the longitudinal analysis.

Results

723 children were included. In the cross-sectional analysis, physical activity was negatively associated with the MetS-score (P<0.03). In the longitudinal analysis, low physical activity and high sedentary time were associated with an increased MetS-score (all P<0.005); however, after mutual adjustments for movement behaviors, physical activity and sleep duration, but not sedentary time, were associated with the MetS-score (all P<0.03). Further adjusting for fat mass index while removing waist circumference from the MetS-score rendered the associations no longer statistically significant (all P>0.17). Children in the most favorable tertiles of changes in moderate-to-vigorous physical activity, sleep duration and sedentary time during the 200-day follow-up period had an improved MetS-score relative to children in the opposite tertiles (P = 0.005).

Conclusion

The present findings indicate that physical activity, sedentary time and sleep duration should all be targeted to improve cardio-metabolic risk markers in childhood; this is possibly mediated by adiposity.

Dietary effects of introducing school meals based on the New Nordic Diet - a randomised controlled trial in Danish children. The OPUS School Meal Study

The OPUS (Optimal well-being, development and health for Danish children through a healthy New Nordic Diet (NND)) School Meal Study investigated the effects on the intake of foods and nutrients of introducing school meals based on the principles of the NND covering lunch and all snacks during the school day in a cluster-randomised cross-over design. For two 3-month periods, 834 Danish children aged 8-11 years from forty-six school classes at nine schools received NND school meals or their usual packed lunches brought from home (control) in random order. The whole diet of the children was recorded over seven consecutive days using a validated Web-based Dietary Assessment Software for Children. The NND resulted in higher intakes of potatoes (130 %, 95 % CI 2·07, 2·58), fish (48 %, 95 % CI 1·33, 1·65), cheese (25 %, 95 % CI 1·15, 1·36), vegetables (16 %, 95 % CI 1·10, 1·21), eggs (10 %, 95 % CI 1·01, 1·19) and beverages (6 %, 95 % CI 1·02, 1·09), and lower intakes of bread (13 %, 95 % CI 0·84, 0·89) and fats (6 %, 95 % CI 0·90, 0·98) were found among the children during the NND period than in the control period (all, P< 0·05). No difference was found in mean energy intake (P= 0·4), but on average children reported 0·9 % less energy intake from fat and 0·9 % higher energy intake from protein during the NND period than in the control period. For micronutrient intakes, the largest differences were found for vitamin D (42 %, 95 % CI 1·32, 1·53) and iodine (11 %, 95 % CI 1·08, 1·15) due to the higher fish intake. In conclusion, the present study showed that the overall dietary intake at the food and nutrient levels was improved among children aged 8-11 years when their habitual packed lunches were replaced by school meals following the principles of the NND.

Challenges involved in measuring intake in early life: focus on methods

Assessing dietary intake in people of any age is challenging but measuring the diet of infants and children can be particularly problematic. Young children may lack the cognitive skills, writing skills and food knowledge to record their own food intake. Multiple people may be responsible for the care of the child and to collect an accurate picture of intake it may be necessary to combine parental reports with observation in school or nursery. Where interviews are conducted with the child themselves questions may need to focus on aspects of the diet which children are likely to attend to. For example, children may not be familiar with food names or brands but may be able to describe their texture, colour and images on packaging. Adolescents are likely to be more aware of the foods they consume and have the cognitive and writing skills to record their own food intake but may lack the interest or motivation. Research has focused on reducing the burden of recording intake on the participant. Developments include food photographs for assessment of portion size which remove the need for weighing each food item, and, in recent years, computer-based methods have been developed for self-completion by young people with the aim of motivating them to participate in studies by making dietary reporting more engaging. The present paper discusses methods and challenges in assessing food intake in children followed by details of two such tools developed at Newcastle University, UK, the Young Person's Food Atlas and INTAKE24.

Qualitative analysis of the contributions of nutritionists to the development of an online instrument for monitoring the food intake of schoolchildren

BACKGROUND

The Consumo Alimentar e Atividade Fisica de Escolares (CAAFE) questionnaire is an online research tool that has been developed to enable the self-report of physical activity and diet by Brazilian schoolchildren aged 7-10 years. Formative research was conducted with nutritionists during the development of the web-based questionnaire. The suggestions and insights obtained were used to design a tool to monitor schoolchildren's food consumption based on the concept of healthy and unhealthy food indicators. The present study aimed to report the focus group discussions conducted with nutritionists concerning the CAAFE questionnaire.

METHODS

Focus group discussions were conducted using a semi-structured questionnaire, and these were then analysed thematically.

RESULTS

Twenty-four nutritionists participated (four focus groups; average per group: six people); the majority (n = 22) had experience with 7-10-year-old children. Four themes emerged: (i) healthy and unhealthy food indicators; (ii) suggestions for the online instrument; (iii) potential applications; and (iv) challenges for its construction.

CONCLUSIONS

Comments made by nutritionists enabled the construction of an instrument that is able to answer questions related to food consumption in schools and at home.