Adherence to Healthy and Sustainable Dietary Patterns and Long-Term Chronic Inflammation: Data from the EPIC-Potsdam Cohort.

OBJECTIVES: We explored the prospective associations between adherence to a priori chosen dietary patterns, including EAT-Lancet (EAT-L) and Mediterranean (tMDS) diet with long-term inflammatory responses in a German population sample. DESIGN AND SETTING: Prospective cohort study. PARTICIPANTS: A subsample of 636 predominantly healthy participants from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study who were on average 51-years old at baseline. MEASUREMENTS: Data was collected repeatedly between 1994/1998 - 2013. At baseline (1994/1998) and 6.8-years later (2001/2005), EAT-L and tMDS scores were derived from available food frequency questionnaires. Stable high, stable low, increasing, and decreasing adherence to EAT-L and tMDS were defined as scoring above/below baseline median at baseline and 6.8-years later. Long-term chronic inflammation was assessed based on the average values of repeated measurements of two inflammatory biomarkers - chemerin and high-sensitivity C-reactive protein (hs-CRP) - in plasma samples collected between 2010/2012 and 2013. Multivariable linear regression analysis adjusted for socio-demographic and lifestyle factors at baseline and in 2010/2012 was used to assess the association between diet adherence and long-term hs-CRP and chemerin concentrations. RESULTS: Stable high or increasing adherence to EAT-L diet compared to stable low adherence was associated with slight reduction of long-term chemerin concentrations on the long run (stable high: -4.4%; increasing: -4.0%), not reaching statistical significance. Increasing adherence to tMDS compared to stable low adherence was also associated with a minor reduction in chemerin concentrations (-3.6%). Decreasing adherence to tMDS compared stable high adherence was associated with 2.7% higher chemerin. The associations were even less pronounced when hs-CRP was used as an outcome. CONCLUSIONS: Adherence to healthy and sustainable dietary patterns defined using existing definitions for EAT-L and tMDS were associated with minor and not statistically significant reduction in the concentrations of inflammatory biomarkers on the long run. More research is needed to explore whether following these diets may represent a suitable approach for targeted prevention in the general population.

The effects of hypothetical behavioral interventions on the 13-year incidence of overweight/obesity in children and adolescents.

BACKGROUND: In view of the high burden of childhood overweight/obesity (OW/OB), it is important to identify targets for interventions that may have the greatest effects on preventing OW/OB in early life. Using methods of causal inference, we studied the effects of sustained behavioral interventions on the long-term risk of developing OW/OB based on a large European cohort. METHODS: Our sample comprised 10 877 children aged 2 to < 10 years at baseline who participated in the well-phenotyped IDEFICS/I.Family cohort. Children were followed from 2007/08 to 2020/21. Applying the parametric g-formula, the 13-year risk of developing OW/OB was estimated under various sustained hypothetical interventions on physical activity, screen time, dietary intake and sleep duration. Interventions imposing adherence to recommendations (e.g. maximum 2 h/day screen time) as well as interventions 'shifting' the behavior by a specified amount (e.g. decreasing screen time by 30 min/day) were compared to 'no intervention' (i.e. maintaining the usual or so-called natural behavior). Separately, the effectiveness of these interventions in vulnerable groups was assessed. RESULTS: The 13-year risk of developing OW/OB was 30.7% under no intervention and 25.4% when multiple interventions were imposed jointly. Meeting screen time and moderate-to-vigorous physical activity (MVPA) recommendations were found to be most effective, reducing the incidence of OW/OB by -2.2 [-4.4;-0.7] and -2.1 [-3.7;-0.8] percentage points (risk difference [95% confidence interval]), respectively. Meeting sleep recommendations (-0.6 [-1.1;-0.3]) had a similar effect as increasing sleep duration by 30 min/day (-0.6 [-0.9;-0.3]). The most effective intervention in children of parents with low/medium educational level was being member in a sports club; for children of mothers with OW/OB, meeting screen time recommendations and membership in a sports club had the largest effects. CONCLUSIONS: While the effects of single behavioral interventions sustained over 13 years were rather small, a joint intervention on multiple behaviors resulted in a relative reduction of the 13-year OW/OB risk by between 10 to 26%. Individually, meeting MVPA and screen time recommendations were most effective. Nevertheless, even under the joint intervention the absolute OW/OB risk remained at a high level of 25.4% suggesting that further strategies to better prevent OW/OB are required.

Potential selection effects when estimating associations between the infancy peak or adiposity rebound and later body mass index in children.

INTRODUCTION: This study aims to evaluate a potential selection effect caused by exclusion of children with non-identifiable infancy peak (IP) and adiposity rebound (AR) when estimating associations between age and body mass index (BMI) at IP and AR and later weight status. SUBJECTS AND METHODS: In 4744 children with at least 4 repeated measurements of height and weight in the age interval from 0 to 8 years (37 998 measurements) participating in the IDEFICS (Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants)/I.Family cohort study, fractional polynomial multilevel models were used to derive individual BMI trajectories. Based on these trajectories, age and BMI at IP and AR, BMI values and growth velocities at selected ages as well as the area under the BMI curve were estimated. The BMI growth measures were standardized and related to later BMI z-scores (mean age at outcome assessment: 9.2 years). RESULTS: Age and BMI at IP and AR were not identifiable in 5.4% and 7.8% of the children, respectively. These groups of children showed a significantly higher BMI growth during infancy and childhood. In the remaining sample, BMI at IP correlated almost perfectly (r⩾0.99) with BMI at ages 0.5, 1 and 1.5 years, whereas BMI at AR correlated perfectly with BMI at ages 4-6 years (r⩾0.98). In the total study group, BMI values in infancy and childhood were positively associated with later BMI z-scores where associations increased with age. Associations between BMI velocities and later BMI z-scores were largest at ages 5 and 6 years. Results differed for children with non-identifiable IP and AR, demonstrating a selection effect. CONCLUSIONS: IP and AR may not be estimable in children with higher-than-average BMI growth. Excluding these children from analyses may result in a selection bias that distorts effect estimates. BMI values at ages 1 and 5 years might be more appropriate to use as predictors for later weight status instead.

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.

Dietary energy density in young children across Europe.

OBJECTIVES: To describe energy density (ED; kcal g(-1)) of dietary intake of European children. METHODS: From 16, 228 children who participated in the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS) baseline examination, 8551 children with 24-h dietary recalls (24-HDR), with plausible reported energy intakes and complete covariate information were included in the present analysis. ED was calculated using two methods: (1) ED including solid foods (EDF) and (2) ED including solid foods and energy-containing beverages (EDF&B). Beverage energy was calculated in kcal per day. Dietary characteristics and body mass index (BMI) z-score of children aged 2 to <6 years and 6 to <10 years were compared between children with an overall EDF below the <25th percentile, between the 25th and 75th percentile as well as above the >75th percentile. Standardised regression coefficients were estimated to assess the association between dietary characteristics, BMI z-score and ED of the diet. RESULTS: Children with low EDF and EDF&B diets consumed less energy but higher quantity of food and beverages than children with high EDF and EDF&B diets. Consumption of caloric beverages decreased with increasing EDF&B of the diet owing to the relatively low ED of the beverages, in relation to solid foods. Generally, children with low EDF and EDF&B diets showed healthier food choices than peers with higher EDF and EDF&B diets. In this sample, EDF and EDF&B were not associated with BMI z-score. CONCLUSION: Health promotion strategies should proclaim lower ED diets by means of foods with high water and low fat content and mainly fruit and vegetable components. Excluding caloric beverages from EDF calculation is a useful method to avoid misinterpretation of true exposure to a high energy dense diet. We recommend excluding caloric beverages from EDF calculation when investigating the effect of ED on a certain (health) outcome.

Adherence to a Mediterranean-like dietary pattern in children from eight European countries. The IDEFICS study.

BACKGROUND: Despite documented benefits of a Mediterranean-like dietary pattern, there is a lack of knowledge about how children from different European countries compare with each other in relation to the adherence to this pattern. In response to this need, we calculated the Mediterranean diet score (MDS) in 2-9-year-old children from the Identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) eight-country study. SUBJECTS AND METHODS: Using 24 h dietary recall data obtained during the IDEFICS study (n=7940), an MDS score was calculated based on the age- and sex-specific population median intakes of six food groups (vegetables and legumes, fruit and nuts, cereal grains and potatoes, meat products and dairy products) and the ratio of unsaturated to saturated fats. For fish and seafood, which was consumed by 10% of the population, one point was given to consumers. The percentages of children with high MDS levels (>3) were calculated and stratified by sex, age and by having at least one migrant parent or both native parents. Demographic (sex and age) and socioeconomic characteristics (parental education and income) of children showing high (>3) vs low (⩽3) MDS levels were examined. RESULTS: The highest prevalence of children with MDS>3 was found among the Italian pre-school boys (55.9%) and the lowest among the Spanish school-aged girls (26.0%). Higher adherence to a Mediterranean-like dietary pattern was not associated with living in a Mediterranean country or in a highly educated or high-income family, although with some exceptions. Differences in adherence between boys and girls or age groups varied between countries without any general pattern. CONCLUSIONS: With the exception of Italian pre-schoolers, similar adherence levels to a Mediterranean-like dietary pattern have been observed among European children.

Validity of 24-h recalls in (pre-)school aged children: comparison of proxy-reported energy intakes with measured energy expenditure.

BACKGROUND & AIMS: Little is known about the validity of repeated 24-h dietary recalls (24-HDR) as a measure of total energy intake (EI) in young children. This study aimed to evaluate the validity of proxy-reported EI by comparison with total energy expenditure (TEE) measured by the doubly labeled water (DLW) technique. METHODS: The agreement between EI and TEE was investigated in 36 (47.2% boys) children aged 4-10 years from Belgium and Spain using subgroup analyses and Bland-Altman plots. Low-energy-reporters (LER), adequate-energy-reporters (AER) and high-energy-reporters (HER) were defined from the ratio of EI over TEE by application of age- and sex-specific cut-off values. RESULTS: There was good agreement between means of EI (1500 kcal/day) and TEE (1523 kcal/day) at group level though in single children, i.e. at the individual level, large differences were observed. Almost perfect agreement between EI and TEE was observed in thin/normal weight children (EI: 1511 kcal/day; TEE: 1513 kcal/day). Even in overweight/obese children the mean difference between EI and TEE was only -86 kcal/day. Among the participants, 28 (78%) were classified as AER, five (14%) as HER and three (8%) as LER. CONCLUSION: Two proxy-reported 24-HDRs were found to be a valid instrument to assess EI on group level but not on the individual level.

Associations between energy intake, daily food intake and energy density of foods and BMI z-score in 2-9-year-old European children.

PURPOSE: The aim of this study was to investigate the associations between proxy-reported energy intake, daily food intake and energy density of foods and body mass index (BMI) z-score in 2-9-year-old European children. METHODS: From 16,225 children who participated in the identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) baseline examination, 9,782 children with 24-h proxy dietary information and complete covariate information were included in the analysis. Participating children were classified according to adapted Goldberg cutoffs: underreports, plausible energy reports and overreports. Energy intake, daily food intake and energy density of foods excluding noncaloric beverages were calculated for all eating occasions. Effect of energy intake, daily food intake and energy density of foods on BMI z-score was investigated using multilevel regression models in the full sample and subsample of plausible energy reports. Exposure variables were included separately; daily food intake and energy intake were addressed in a combined model to check for interactions. RESULTS: In the group of plausible energy reports (N = 8,544), energy intake and daily food intake were significantly positively associated with BMI z-score. Energy density of foods was not associated with BMI z-score. In the model including energy intake, food intake and an interaction term, only energy intake showed a significantly positive effect on BMI z-score. In the full sample (N = 9,782), only energy intake was significantly but negatively associated with BMI z-score. CONCLUSION: Proxy-reporters are subject to misreporting, especially for children in the higher BMI levels. Energy intake is a more important predictor of unhealthy weight development in children than daily food intake.

Evaluation of food and nutrient intake assessment using concentration biomarkers in European adolescents from the Healthy Lifestyle in Europe by Nutrition in Adolescence study.

Accurate food and nutrient intake assessment is essential for investigating diet-disease relationships. In the present study, food and nutrient intake assessment among European adolescents using 24 h recalls (mean of two recalls) and a FFQ (separately and the combination of both) were evaluated using concentration biomarkers. Biomarkers included were vitamin C, ß-carotene, DHA+EPA, vitamin B12 (cobalamin and holo-transcobalamin) and folate (erythrocyte folate and plasma folate). For the evaluation of the food intake assessment 390 adolescents were included, while 697 were included for the nutrient intake assessment evaluation. Spearman rank and Pearson correlations, and validity coefficients, which are correlations between intake estimated and habitual true intake, were calculated. Correlations were higher between frequency of food consumption (from the FFQ) and concentration biomarkers than between mean food intake (from the recalls) and concentration biomarkers, especially for DHA+EPA (r 0·35 v. r 0·27). Most correlations were higher among girls than boys. For boys, the highest validity coefficients were found for frequency of fruit consumption (0·88) and for DHA+EPA biomarker (0·71). In girls, the highest validity coefficients were found for fruit consumption frequency (0·76), vegetable consumption frequency (0·74), mean fruit intake (0·90) and DHA+EPA biomarker (0·69). After exclusion of underreporters, correlations slightly improved. Correlations between usual food intakes, adjusted for food consumption frequency, and concentration biomarkers were higher than correlations between mean food intakes and concentration biomarkers. In conclusion, two non-consecutive 24 h recalls in combination with a FFQ seem to be appropriate to rank subjects according to their usual food intake.

Prevalence and determinants of misreporting among European children in proxy-reported 24 h dietary recalls.

Dietary assessment is strongly affected by misreporting (both under- and over-reporting), which results in measurement error. Knowledge about misreporting is essential to correctly interpret potentially biased associations between diet and health outcomes. In young children, dietary data mainly rely on proxy respondents but little is known about determinants of misreporting here. The present analysis was conducted within the framework of the multi-centre IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study and is based on 6101 children aged 2-9 years with 24 h dietary recall (24-HDR) and complete covariate information. Adapted Goldberg cut-offs were applied to classify the 24-HDR as 'over-report', 'plausible report' or 'under-report'. Backward elimination in the course of multi-level logistic regression analyses was conducted to identify factors significantly related to under- and over-reporting. Next to characteristics of the children and parents, social factors and parental concerns/perceptions concerning their child's weight status were considered. Further selective misreporting was addressed, investigating food group intakes commonly perceived as more or less socially desirable. Proportions of under-, plausible and over-reports were 8.0, 88.6 and 3.4 %, respectively. The risk of under-reporting increased with age (OR 1.19, 95 % CI 1.05, 1.83), BMI z-score of the child (OR 1.23, 95 % CI 1.10, 1.37) and household size (OR 1.12, 95 % CI 1.01, 1.25), and was higher in low/medium income groups (OR 1.45, 95 % CI 1.13, 1.86). Over-reporting was negatively associated with BMI z-scores of the child (OR 0.78, 95 % CI 0.69, 0.88) and higher in girls (OR 1.70, 95 % CI 1.27, 2.28). Further social desirability and parental concerns/perceptions seemed to influence the reporting behaviour. Future studies should involve these determinants of misreporting when investigating diet-disease relationships in children to correct for the differential reporting bias.

Food consumption and cardiovascular risk factors in European children: the IDEFICS study.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Few studies addressing the relationship between food consumption and cardiovascular disease or metabolic risk have been conducted in children. Previous findings have indicated greater metabolic risk in children with high intakes of solid hydrogenated fat and white bread, and low consumption of fruits, vegetables and dairy products. WHAT THIS STUDY ADDS: In a large multinational sample of 2 to 9 years old children, high consumption of sweetened beverages and low intake of nuts and seeds, sweets, breakfast cereals, jam and honey and chocolate and nut-based spreads were directly associated with increased clustered cardiovascular disease risk. These findings add new evidence to the limited literature available in young populations on the role that diet may play on cardiovascular health. OBJECTIVE: To investigate food consumption in relation to clustered cardiovascular disease (CVD) risk. METHODS: Children (n = 5548, 51.6% boys) from eight European countries participated in the IDEFICS study baseline survey (2007-2008). Z-scores of individual CVD risk factors were summed to compute sex- and age-specific (2-<6 years/6-9 years) clustered CVD risk scores A (all components, except cardiorespiratory fitness) and B (all components). The association of clustered CVD risk and tertiles of food group consumption was examined. RESULTS: Odds ratio (OR) of having clustered CVD risk A increased in older children with higher consumption of chocolate and nut-based spreads (boys: OR = 0.46; 95% CI = 0.32-0.69; girls: OR = 0.60; 95% CI = 0.42-0.86), jam and honey (girls: OR = 0.45; 95% CI = 0.26-0.78) and sweets (boys: OR = 0.69; 95% CI = 0.48-0.98). OR of being at risk significantly increased with the highest consumption of soft drinks (younger boys) and manufactured juices (older girls). Concerning CVD risk score B, older boys and girls in the highest tertile of consumption of breakfast cereals were 0.41 (95% CI = 0.21-0.79) and 0.45 (95% CI = 0.22-0.93) times, respectively, less likely to be at risk than those in tertile 1. CONCLUSIONS: High consumption of sugar-sweetened beverages and low intake of breakfast cereals, jam and honey, sweets and chocolate and nut-based spreads seem to adversely affect clustered CVD risk.

Evaluation of the Children's Eating Habits Questionnaire used in the IDEFICS study by relating urinary calcium and potassium to milk consumption frequencies among European children.

BACKGROUND: Measuring dietary intake in children is notoriously difficult. Therefore, it is crucial to evaluate the performance of dietary intake assessment methods in children. Given the important contribution of milk consumption to calcium (Ca) and potassium (K) intakes, urinary calcium (UCa) and potassium (UK) excretions in spot urine samples could be used for estimating correlations with milk consumption frequencies. OBJECTIVE: The aim of this study was to evaluate the assessment of milk consumption frequencies derived from the Food Frequency Questionnaire section of the Children's Eating Habits Questionnaire (CEHQ-FFQ) used in the IDEFICS (Identification and prevention of dietary- and lifestyle induced health effects in children and infants) study by comparing with UCa and UK excretions in spot urine samples. DESIGN: This study was conducted as a setting-based community-oriented intervention study and results from the first cross-sectional survey have been included in the analysis. SUBJECTS: A total of 10,309 children aged 2-10 years from eight European countries are included in this analysis. METHODS: UCa and UK excretions were measured in morning spot urine samples. Calcium and potassium urine concentrations were standardised for urinary creatinine (Cr) excretion. Ratios of UCa/Cr and UK/Cr were used for multivariate regression analyses after logarithmic transformation to obtain normal distributions of data. Milk consumption frequencies were obtained from the CEHQ-FFQ. Multivariate regression analyses were used to investigate the effect of milk consumption frequencies on UCa and UK concentrations, adjusting for age, gender, study centre, soft drink consumption and frequency of main meals consumed at home. RESULTS: A significant positive correlation was found between milk consumption frequencies and ratios of UK/Cr and a weaker but still significant positive correlation with ratios of UCa/Cr, when using crude or partial Spearman's correlations. Multivariate regression analyses showed that milk consumption frequencies were predictive of UCa/Cr and UK/Cr ratios, when adjusted for age, gender, study centre, soft drink consumption and frequency of main meals consumed at home. Mean ratios of UK/Cr for increasing milk consumption frequency tertiles showed a progressive increase in UK/Cr. Children consuming at least two milk servings per day had significantly higher mean UCa/Cr and UK/Cr ratios than children who did not. Large differences in correlations between milk consumption frequencies and ratios of UCa/Cr and UK/Cr were found between the different study centres. CONCLUSION: Higher milk consumption frequencies resulted in a progressive increase in UK/Cr and UCa/Cr ratios, reflecting the higher Ca and K intakes that coincide with increasing milk consumption, which constitutes a major K and Ca source in children's diet.