Food composition database harmonization for between-country comparisons of nutrient data in the TEDDY Study.

The Environmental Determinants of Diabetes in the Young Study (TEDDY) aims at examining the associations between islet autoimmunity and various environmental exposures, (e.g. diet) in Finland, Germany, Sweden and the United States (US). In order to produce comparable results from dietary assessments, the national food composition databases (FCDB) must contain mutually comparable food composition data. Systematic comparison (definition, unit of measurement, and method of analysis) of energy, protein, fats, carbohydrates, cholesterol, fiber, 13 vitamins, and 8 minerals was carried out among the FCDB of the four countries. Total fat, cholesterol, vitamin A: retinol equivalents and beta-carotene, thiamin, riboflavin, pyridoxine, vitamin B(12), calcium, phosphorus, potassium, magnesium, iron, and zinc are comparable across all four databases. Carbohydrates, fiber, sugars, fatty acids, vitamin D, vitamin E: alpha-tocopherol, vitamin K, vitamin C, pantothenic acid, niacin, manganese, and copper are comparable or can be converted comparable at least across three of the databases. Vitamin E: alpha-tocopherol equivalents, will be comparable across all databases after Finland and Germany subtract tocotrienols from their values. Nitrogen values were added to the Swedish and US databases. After recalculation of protein from nitrogen (Sweden and US), and subtraction of fiber from the total carbohydrate (Finland) followed by recalculations of energy, these values will be comparable across the countries. Starch and folate are not comparable.

Nutritional knowledge in European adolescents: results from the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) study.

OBJECTIVE: To build up sufficient knowledge of a 'healthy diet'. Here, we report on the assessment of nutritional knowledge using a uniform method in a large sample of adolescents across Europe. DESIGN: A cross-sectional study. SETTING: The European multicentre HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) study conducted in 2006-2007 in ten cities in Austria, Belgium, France, Germany, Greece (one inland and one island city), Hungary, Italy, Spain and Sweden. SUBJECTS: A total of 3546 adolescents (aged 12·5-17·5 years) completed a validated nutritional knowledge test (NKT). Socio-economic variables and anthropometric data were considered as potential confounders. RESULTS: NKT scores increased with age and girls had higher scores compared with boys (62% v. 59%; P < 0·0001). Scores were approximately 10% lower in 'immigrant' adolescents or in adolescents with 'immigrant' mothers. Misconceptions with respect to the sugar content in food or in beverages were found. Overall, there was no correlation between BMI values and NKT scores. After categorization according to BMI, scores increased significantly with BMI group only in boys. These differences disappeared after controlling for socio-economic status (SES). Smoking status and educational level of the mother influenced the NKT scores significantly in boys, as well as the educational levels of both parents in girls. CONCLUSIONS: Nutritional knowledge was modest in our sample. Interventions should be focused on the lower SES segments of the population. They should be initiated at a younger age and should be combined with environmental prevention (e.g. healthy meals in school canteens).

Validation of energy requirement equations for estimation of breast milk consumption in infants.

OBJECTIVE: To test equations for calculating infants' energy requirements as a simple and reliable instrument for estimating the amount of breast milk consumed in epidemiological studies where test-weighing is not possible. DESIGN: Infants' energy requirements were calculated using three different equations based on reference data and compared with actual energy intakes assessed using the 3 d weighed dietary records of breast-fed infants from the DOrtmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. SETTING: A sub-sample of 323 infants from the German DONALD Study who were predominantly breast-fed for at least the first four months of life, and who had 3 d weighed dietary records and repeated body weight measurements within the first year of life. SUBJECTS: Healthy, term infants breast-fed for at least 4 months, 0-12 months of age. RESULTS: The overall differences between measured energy intake and calculated energy requirements were quite small, never more than 10 % of total energy intake, and smaller than the mean variance of energy intake between the three days of recording. The equation of best fit incorporated body weight and recent growth, while the worst fit was found for the equation not considering body weight. CONCLUSIONS: Breast milk consumption in fully and partially breast-fed infants can be reasonably quantified by calculating the infants' individual energy requirements via simple equations. This provides a feasible approach for estimating infant energy intake in epidemiological studies where test-weighing of breast milk is not possible.

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

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

Breastfeeding duration in families with type 1 diabetes compared to non-affected families: results from BABYDIAB and DONALD studies in Germany.

BACKGROUND: There are only a few small studies that compare breastfeeding rates in mothers with and without type 1 diabetes (T1D). STUDY DESIGN: We studied breastfeeding duration in 665 German infants whose mother and/or father had T1D from the BABYDIAB Study (data collected between 1992 and 2000) and compared it with data from 268 German infants of unaffected parents from the DONALD Study. RESULTS: Infants with a parent who had T1D were less likely to be breastfed and breastfed for shorter lengths of time than infants from unaffected families. Mothers with T1D showed a positive long-term breastfeeding time trend, but did not reach the rates of the DONALD Study. CONCLUSIONS: This study identified minor secular trends influencing the differences in breastfeeding initiation and duration between families affected with T1D and those without.

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

In the present study the relationship between the consumption of different beverage groups and body-weight status in 5 years of study participation in German adolescents was investigated. We used anthropometric and dietary data from 3 d weighed records of 244 subjects between 9 and 18 years of age participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study. Only subjects with at least four out of six possible weighed dietary records were considered. A repeated-measures regression model (PROC MIXED) was used to analyse the effect of beverage consumption on body-weight status. BMI standard deviation scores (BMI-SDS) and body fat percentage (%BF) were chosen as the dependent variables. In boys, energetic beverage consumption was not associated with BMI-SDS or %BF, neither cross-sectionally nor prospectively. In girls, baseline consumption of energetic beverages did not predict baseline BMI-SDS, baseline %BF, or change in either variable over the study period. However, an increase in energetic beverage consumption over the study period was associated with an increase in BMI-SDS (+0.070 SDS/MJ increase in energetic beverage consumption; P = 0.01). Separate consideration of regular soft drinks and fruit juices revealed that, in girls, BMI-SDS increased with increased fruit juice consumption (+0.096 SDS/MJ increase in fruit juice consumption; P = 0.01), and to a lesser extent with regular soft drink consumption (+0.055 SDS/MJ increase in regular soft drink consumption; P = 0.08). In conclusion, these results suggest that an increase in energetic beverage consumption may result in weight gain, at least in adolescent girls.

Convenience food in the diet of children and adolescents: consumption and composition.

Despite an increasing trend towards the use of convenience food, there is to date little debate on it in the nutritional sciences. In the present study, we present and evaluate data on consumption frequencies and composition of savoury convenience food in German families using data from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. The DONALD Study is an ongoing, longitudinal (open cohort) study (started 1985), collecting detailed data on diet, development, and metabolism in infants, children and adolescents. Dietary intake was measured by yearly repeated 3 d weighed dietary records (n 1558) in 554 subjects (278 boys; 276 girls), 3-18 years old, between 2003 and 2006. A total of 1345 (86%) 3 d dietary records mentioned consumption of at least one convenience food. Convenience food consumption (percentage of total food intake, g/d) increased with age from approximately 3% in the 3-8 year olds to 7% in 14-18-year-old boys and 5% in 14-18-year-old girls (P < 0.0001) but remained constant during the study period. Convenience foods contributed more to total fat (g/d) (P < 0.001) and less to total carbohydrate (P < 0.0001) than to total energy (kJ/d) intake. The 700 convenience-food products recorded by our sample had on average fourteen ingredients; 4% were flavourings and 16% were food additives. In conclusion, convenience foods were widely consumed by our sample of German children and adolescents and their consumption increased with age. The composition of convenience food was characterised by a high fat content and a high number of flavourings and food additives.

Measuring the effects of nutritional counseling on total infant diet in a randomized controlled intervention trial.

OBJECTIVES: To examine the effects of nutritional counseling for the infant diet focused on complementary feeding and total diet by use of dietary scores. PATIENTS AND METHODS: In a randomized controlled intervention trial, 183 mothers of full-term infants were allocated to 4 intervention groups (IG0-IG3). Intervention consisted of dietary counseling based on the food-based guidelines for infant nutrition in Germany. Counseling was done in 3 different forms: a telephone hotline (IG1), then written information (IG2), followed by additional personal telephone counseling (IG3). The IG0 group was not counseled at all. The actual diet of the infants was assessed by telephone interviews when the infants were 2, 4, 6, 9, and 12 months old and evaluated by food-based and meal-based dietary scores. RESULTS: Plausible, although often not statistically significant, effects of counseling were found for several single scores at various age points. Total diet during the first year of life was significantly closer to the recommendations in the most intensively counseled group than in the non-counseled and lowest-counseled groups. Telephone counseling proved to be more effective than distribution of written material. CONCLUSIONS: The measured effects of the innovative approach of personal telephone counseling point to the advantages of giving dietary advice to mothers of infants by means of personal contacts and suggest that positive effects on dietary habits may even be greater by face-to-face talks between mothers and experts.

Vitamin intakes from supplements and fortified food in German children and adolescents: results from the DONALD study.

Frequent consumption of supplements is a common behavior in adults, as well as children and adolescents. We report on vitamin intake from consuming supplements, taking into account the vitamin intake from fortified and usual foods. A total of 5990 3-d weighed dietary records from 931 German subjects (452 males, 479 females, 2-18 y of age) between 1986 and 2003 from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study were evaluated. We identified 133 different vitamin-containing supplements in 451 records (7.5%). Slightly more males (8.0%) than females (7.1%) consumed supplements, with highest frequencies found between ages 15 and 18 y. For the majority (10 of 13) of vitamins (vitamin A, vitamin E, vitamin K, thiamin, riboflavin, vitamin B-6, vitamin B-12, niacin, biotin, and vitamin C), intake from usual and fortified food already reached or exceeded 80% of the recommended dietary allowances in all age groups. In the case of folate and pantothenic acid, intake from supplements was necessary to achieve at least 80% of recommended dietary allowances for half of the age groups, especially in females. Supplements with vitamin D considerably helped increase vitamin intake but failed to achieve 80% of references in almost all age groups. Intakes of vitamin A and folic acid exceeded the tolerable upper level most frequently in many age groups and were most pronounced in up to 32% and 13% of children aged 2-3 y. Intake of vitamin D, vitamin E, and vitamin C exceeded the tolerable upper level in single age groups only (<7% of subjects). For the other vitamins, no exceeded limits were identified. The ubiquitous availability of supplements might indicate that even healthy children and adolescents profit by taking them. However, it is difficult to evaluate whether consumers receive more benefits or risks from the unrestricted consumption of supplements as they are marketed today.

Fortifying food with folic acid improves folate intake in German infants, children, and adolescents.

Folate is a critical nutrient and programs to enhance folate intake have been established or are under consideration. We investigated to what extent consumers (C) profit from folic acid-fortified food and dietary supplements compared to nonconsumers (NC) of these products. A total of 6135 weighed records from 861 subjects (47% males, 53% females, age 6 mo to 18 y) from the Dortmund Nutritional and Anthropometric Longitudinally Designed Study between 1990 and 2001 were evaluated. In 61% of the records, at least 1 item fortified with folic acid was reported, and in total 644 different items with a wide range of fortification levels were found. These were primarily commercial infant food (i.e., infant formula, weaning food) (44%), breakfast cereals (20%), and soft drinks (11%). Median dietary folate equivalents (DFEs) in NC increased from 65 and 62 microg/d in boys and girls at 6-12 mo of age, respectively, to 184 and 143 microg/d in adolescents 15-18 y of age. In C, DFEs increased from 109 and 100 microg/d in boys and girls at 6-12 mo of age, respectively, to 370 and 276 microg/d in adolescents 15-18 y of age. Irrespective of gender, NC had 50-70% the DFE intakes of C with a tendency for higher percentages in younger than in older children and adolescents. Folate intakes by male and female consumers of fortified food or supplements exceeded the upper levels in 1.7 and 1.2% of subjects, respectively. Currently, a fortification program for staple foods (e.g., grain products) does not seem necessary in Germany if children and adolescents consume food already fortified with folic acid.

The DONALD Study. History, current status and future perspectives.

Nutrition during childhood and adolescence is an important determinant of development and health, both for the child and the later adult. In industrialised countries as well as in many countries of economic transition, emphasis has moved from combating nutrient deficiencies to research on the effects of overnutrition and food selection. Prevention of chronic diseases including obesity have become a major focus in research. However, the complex relation between infant growth and its related endocrine and metabolic changes on the one hand and the influence of nutrition and nutritional status on the other hand still need to be understood in detail. Studies aiming to elucidate this have to follow children and adolescents during their growth period. The following pages display the features of the German DONALD Study ( DOrtmund Nutritional and Anthropometric Longitudinally Designed Study) which was specifically designed to address these complex research questions. Finally, comparisons to other studies are made and the specific strength and weaknesses of this study are discussed. As the DONALD study offers unique research opportunities and due to its long follow-up an abundance of data, collaborative research is encouraged.

Vitamin and mineral supplements use in German children and adolescents between 1986 and 2003: results of the DONALD Study.

BACKGROUND/AIMS: Dietary supplements may contribute to a considerable proportion to micronutrient intake. However, little is known about the consumption of supplements in children and adolescents, especially in Germany. We therefore examined patterns and time trends in supplement consumption in healthy children and adolescents. METHODS: A total of 5,990 3-day records from 931 subjects 2-18 years of age from the DONALD Study between 1986 and 2003 were examined. RESULTS: (a) Supplement type: A total of 166 different supplements were reported: 49% vitamin-mineral combinations, 31% vitamin, 13% mineral, 7% fluorine supplements. 12% (vitamin) and 13% (mineral) were single nutrient supplements. Vitamin C (72%), B(1) (57%), B(2) (54%), calcium (44%), magnesium (31%) and phosphorus (20%) were the most frequent added nutrients. (b) Users: In 25.8% (males 13.2%, females 12.6%) of the records, supplement usage was documented. Fluorine supplements were by far the most often consumed items (18.1%) followed by vitamins (4.5%), vitamin-mineral combinations (3.6%), minerals (2.4%), and multiple usage (2.6%). (c) Time trend: We found a marked time trend in supplement consumption in the past 18 years with a peak between 1994 and 1996 and lower usage before and after that time (independent of age and gender). (d) Associated factors: Supplement usage was influenced by age, year of study, season, smoking and number of persons in families, education level and employment of mothers, whereas gender or the number of children per family failed to have any effect. CONCLUSION: Supplement usage is a common behaviour in German children and adolescents and changing with time. Type and frequency of supplement usage is age dependent. Those nutrients found mostly in supplements are not the critical ones. In evaluations of children's diet it is mandatory to separate fluorine from other supplements.

Trends in dietary intake of vitamins A, C, and E in German children and adolescents--results of the DONALD Study.

Intake of vitamins A, C, and E was evaluated and age and time trends were assessed on the basis of 3-day weighed dietary records (n = 5121) of 2- to 18-year old boys (n = 417) and girls (n = 425) enrolled in the DONALD Study (Dortmund Nutritional and Anthropometric Longitudinally Designed Study) 1986-2001. Intake of vitamin A remains stable over time, intake of vitamin C increases linearly, and intake of vitamin E follows a nonlinear trend. Age trends of vitamins A and C (per MJ) were nonlinear with a minimum at the beginning adolescence, while intake of vitamin E (per MJ) increased linearly. Girls had higher nutrient densities but lower intakes expressed as percent of reference values. Fortified food in total had a higher impact on time trends of nutrient intake than other single food groups defined here. Our results point to the impact of the food industry on long-term nutrient intake, but also underline the necessity of nutrition education even in young age groups to improve vitamin intake.

Associations between intake of added sugars and intakes of nutrients and food groups in the diets of German children and adolescents.

The aim of the present analysis was to evaluate the effect of intake of added sugars on intakes of nutrients and food groups. We used a mixed linear model (PROC MIXED) to analyse data from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study (an ongoing longitudinal cohort study between infancy and adulthood). Between July 1985 and August 2001, 3 d weighed dietary records (n 4993) from 849 children and adolescents (416 male, 433 female) aged 2-18 years were collected and evaluated. Overall mean intake of added sugars was 12.4 (SD 5.3) (median 12.0) % energy. Fat intake (% energy) and intake of all analysed nutrients (as % reference values for nutrient intakes) fell across quintiles 1-5 of energy intake from added sugars (P<0.001). With the exception of 'Sugary foods' and 'Beverages' (significant increase, P<0.0001) and 'Dairy' (NS), intake of all other food groups decreased with increasing intake of added sugars (P<0.0001). In conclusion, we found a slight, but statistically significant, nutrient-dilution effect of added sugars and a significant reduction in intake of important nutrient-bearing food groups. However, the DONALD study gives no clear indicator on grounds of micronutrient dilution for a quantitative limit on intake of added sugars.

The most essential nutrient: defining the adequate intake of water.

Although water is quantitatively the most import nutrient, there are no recommended dietary allowances (RDA) or adequate intake (AI) values. Based on 718 assessments of 24-hour total water intake, urine volume, and urine osmolality, individual hydration status was characterized in 479 healthy boys and girls of the DONALD study aged 4.0 to 6.9 years and 7.0 to 10.9 years. Mean 24-hour total water intake ranged from 0.90 mL/kcal to 0.96 mL/kcal, and median 24-hour urine osmolality ranged from 683 mosm/kg to 854 mosm/kg. A maximum urine osmolality of 830 mosm/kg (mean - 2 SD) in healthy children with a typical affluent Western-type diet was the physiologic criterion of the upper limit of euhydration. "Water reserve" (24-hour urine volume - hypothetical urine volume to excrete 24 urine solutes at a concentration of 830 mosm/kg) was a quantitative measure of individual 24-hour hydration status and ensuring euhydration in 97% of the subjects in each group; AI values of total water in the 4 age and sex groups ranged from 1.01 mL/kcal to 1.05 mL/kcal. These procedures to quantify 24-hour hydration status may prove valuable in investigating the effects on health of different states of euhydration.

Fortification masks nutrient dilution due to added sugars in the diet of children and adolescents.

High intakes of added sugars have often been suspected of lowering nutrient density, especially in the diet of children and adolescents. Because fortified foods, which currently contribute considerably to the intake of vitamins and minerals, are often also sweetened with added sugars, they could counteract this nutrient dilution. Data from the DOrtmund Nutritional and Anthropometric Longitudinally Designed (DONALD)-Study were used to assess the effects of added sugars, fortified food and energy intakes, time and age on nutrient densities. A total of 4993 3-d weighed dietary records from 849 children and adolescents 2-18 y old, collected between 1985 and 2001 were analyzed using a mixed linear model, in which the means of the data and the covariance structure specific to the DONALD-Study was modeled. In general, nutrient densities in the diets of children and adolescents were above recommended nutrient densities. Added sugars intake [in percentage of energy intake (E%)] was positively associated with energy intake (MJ/d; P < 0.05) and intake of fortified food (E%; P < 0.0001). Positive effects of fortification on nutrient densities (usually P < 0.0001) exceeded the negative effects of added sugars intake (usually P < 0.01) for most nutrients, in some cases even twofold. Associations between energy intake and nutrient densities were negative and, with the exception of thiamin in 2- to 3-y-olds, statistically significant. Time and age trends were heterogeneous. Our data did not show significant nutrient dilution because of added sugars. The positive effect of fortification on nutrient densities was greater than the negative effect of added sugars. Therefore, fortification should more often be considered in dietary analyses.

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

The DONALD study (Dortmund Nutritional and Anthropometric Longitudinally Designed study) gives the opportunity to evaluate long-term food and nutrient intake data on the basis of 3 d weighed dietary records of infants, children and adolescents since 1985. In this paper, we examine changes in energy and macronutrient intakes (protein, fat, saturated, mono- and polyunsaturated fatty acids, carbohydrates and added sugars) of 795 2-18-year-old subjects between 1985 and 2000 (4483 records). No significant changes in intakes of energy and of protein, polyunsaturated fatty acids and added sugars (as % energy intake, E %) were found. Fat intake decreased significantly in all age groups (between -0.20 and -0.26 E %/year), as well as intake of saturated fatty acids (between -0.11 and -0.14 E %/year) and monounsaturated fatty acids (between -0.07 and -0.014 E %/year). This decline was compensated for by a significant increase in carbohydrate intake (between +0.18 and +0.27 E %/year). The changes in macronutrient intake were mainly due to a decreased consumption of fats-oils (between -0.29 and -1.26 g/year) and meat-fish-eggs (between -0.21 and -2.92 g/year), whereas consumption of bread-cereals (between +0.12 and +2.42 g/year) and potatoes-pasta-rice (between +0.15 and +2.26 g/year) increased slightly. However, since recommended fat intake and fatty acid composition was not reached at the end of the study period by far, further efforts will be necessary to improve macronutrient composition and to stabilize favourable dietary habits.