Public Health Nutrition

Published by Cambridge University Press (CUP)
Online ISSN: 1475-2727
Print ISSN: 1368-9800
Distribution of BMI in the study population: men ( n 22 827; - - K - -) and women ( n 20 870; - - J - -) aged 18–45 years, Denmark, 2004–2005 (women) and 2006–2007 (men) 
Objective: The prevalence of obesity has increased in the last decades in the Western world. The aim of the present study was to examine the association between risk-taking behaviour in adolescence and adult obesity in men and women. Furthermore, we wished to describe social differences in obesity in Denmark. Design: Two population-based questionnaire studies (2004-2005 and 2006-2007) were used to collect information on weight and height, sociodemographic factors and factors regarding risk-taking behaviour during adolescence. Data were analysed using multivariate logistic regression. Setting: Denmark. Subjects: Individuals aged 18-45 years (men: n 22 827, participation rate 71·0%; women: n 20 870, participation rate 81·4%). Results: The prevalence of overweight and obesity was respectively 37·8% and 10·6% in men and 20·1% and 9·7% in women. In both sexes, obesity was found to be associated with older age, low level of schooling and living outside the capital centre. In relation to risk-taking behaviour, young age (≤13 years) at first intercourse significantly increased the odds of being obese in adulthood (men: OR = 1·34, 95% CI 1·04, 1·71; women: OR = 1·66, 95% CI 1·27, 1·99). In women specifically, young age at start drinking alcohol (≤12 years) was associated with obesity. Conclusions: Sociodemographic factors, in particular age, level of schooling and area of residence, are associated with obesity in both men and women. Risk-taking behaviour during adolescence seems to cluster in both obese men and obese women, however most convincingly in women.
(colour online) Tornado diagrams of the '10 000 Steps Ghent' intervention v. no intervention: results on costs for (a) men and (b) women (RR, relative risk) 
Parameters used for base case and sensitivity analyses 
(colour online) Results of the probabilistic sensitivity analysis whereby all variables are varied simultaneously assuming: (a) life-long intervention effects for men; (b) 5-year intervention effects for men; (c) 1-year intervention effects for men; (d) life-long intervention effects for women; (e) 5-year intervention effects for women; (f) 1-year intervention effects for women 
To evaluate the cost-effectiveness of the European community-based project '10 000 Steps Ghent', an intervention that resulted in a significant decrease in sedentary time and a significant increase in step counts (896 steps/d) and self-reported walking (66 min/week). An age- and gender-dependent Markov model, with a time horizon of 20 years and a cycle length of 1 year, estimating the development of diabetes, cardiovascular events and colorectal cancer. All individuals started in a health state free of events. The effect of the intervention was based on published risk reductions related to increased walking time. Costs and utility decrements related to events were obtained from published literature. The impact of the uncertainty of the parameters on incremental costs and quality-adjusted life years (QALY) were assessed with one-way sensitivity analyses and a Monte Carlo analysis. Cohort representing the population reached by the intervention (266 adults aged 25-75 years with a mean age of 48·2 (sd 13·1) years, 45·6 % men, 64·6 % highly educated, 70·0 % employed). Implementing the community-based programme increased average QALY by 0·16 and 0·11 for men and women, respectively. The total costs decreased by approximately 576€ and 427€, respectively. Hence, for both genders the intervention programme was dominant. The sensitivity analyses did not change the conclusion of dominance. The community-based '10 000 Steps Ghent' campaign is a dominant intervention. Sensitivity analyses have proved the robustness of the results; hence implementing this intervention on a population-based level could lead to improved health outcomes and reduced costs.
Receiver-operating characteristic curve for the studied sample (n 22 007) applying the Mini Nutritional Assessment (MNA) short form as compared with the full MNA. Area under the curve is 0?942  
Descriptive characteristics of the elderly Spanish population (n 22 007) participating in the present survey
Change of (a) BMI and (b) Mini Nutritional Assessment (MNA) total score with age for men (—E—) and women (—'—). Mean values were significantly different from those of women: *P , 0?05, **P , 0?001  
Proportion of total variability in the MNA score (R 2 ) explained by individual MNA questions (n 22 007)
Distribution of Mini Nutritional Assessment total score in Spain among ACNielsen regions. Values are means and their standard deviations. a,b,c,d,e,f Mean values with unlike superscript letters were significantly different (P , 0?05)  
To evaluate the prevalence of undernutrition among community-dwelling elderly people in Spain using the Mini Nutritional Assessment (MNA) and to analyse its distribution according to age, gender and residence region. Cross-sectional study assessing the nutritional status of elderly persons through both the short form and the full version of the MNA test. Pharmacy offices across the whole country (Spain) were enrolled to recruit participants. A total of 22 007 participants (8014 men and 13 993 women), aged >or=65 years, assessed during the last two months of 2005. According to MNA screening, 4.3 % subjects were classified as undernourished (MNA score <17) and 25.4 % were at risk of undernutrition (MNA score >or=17 to <or=23.5). The MNA short form correlated strongly with the full MNA version (r = 0.85). MNA total score was significantly higher in men than in women (25.4 (sd 3.7) v. 24.6 (sd 3.9); P < 0.001) and lower in the oldest than in the youngest subjects (P < 0.001) in both genders. According to regional distribution, the best nutritional status was found in elderly from the north of Spain excluding the north-west area. Female gender, older age and living in the south half or north-west of the country were associated with higher rates of undernutrition among community-dwelling elderly persons in Spain.
The current paper aims to present the main results of the Italian National Food Consumption Survey INRAN-SCAI 2005-06. A cross-sectional study was performed. Households were randomly selected after geographical stratification of the national territory. Food consumption was assessed on three consecutive days through individual estimated dietary records. Italy. The final study sample comprised 3323 subjects (1501 males and 1822 females) aged 0.1 to 97.7 years belonging to 1329 households: fifty-two infants (0-2.9 years), 193 children (3-9.9 years), 247 teenagers (10-17.9 years), 2313 adults (18-64.9 years) and 518 elderly (65 years and above). Participation rate was 33 %. The mean ratio of estimated energy intake to estimated BMR was 1.41 in adults. Indicators of mean and high individual consumption are presented for fifteen large categories and fifty-one subcategories of foods and beverages, in the total population and in consumers, by age and sex categories. The overall consumption of fruit and vegetables was 418 g/d. The consumption of red meat was approximately 700 g/week, expressed as raw weight. Some specific aspects of the Italian food consumption pattern were confirmed: a large contribution from bread, pasta and pizza to cereals, from olive oil to fats and from wine to alcoholic beverages. The database obtained from the survey will be the key reference for Italian food consumption during the coming years and will be utilized for a variety of purposes including the assessment of nutrient intakes and risk analysis.
Percentage of mixed dishes, not reported as recipes, within meat food groups consumed by adults aged 19 years and over in the 1997 National Nutrition Survey ( ; n 4339) and the 2008/09 New Zealand Adult Nutrition Survey ( ; n 3995) 
Difference in mean percentage of total energy, between the 1997 National Nutrition Survey (n 4339) and the 2008/09 New Zealand Adult Nutrition Survey (n 3995), consumed by males ( ) and females ( ) aged 19 years and over, for the ten food groups with the greatest change reported. Error bars indicate 95 % confidence intervals
Percentage of males reporting each food group in the 2008/09 NZANS and difference from the NNS97 by age group
Percentage of females reporting each food group in the 2008/09 NZANS and difference from NNS97 by age group
To examine changes in the food choices of New Zealand (NZ) adults, between the 1997 National Nutrition Survey (NNS97) and the 2008/09 NZ Adult Nutrition Survey (2008/09 NZANS). The 2008/09 NZANS and the NNS97 were cross-sectional surveys of NZ adults (aged 15 years and over). Dietary intake data were collected using a computer-based 24 h diet recall. Logistic regression models were used to examine changes over time in the percentage reporting each food group, with survey year, sex and age group (19-30 years, 31-50 years, 51-70 years, ≥71 years) as the variables. NZ households. Adults aged 19 years and over (NNS97, n 4339; 2008/09 NZANS, n 3995). In the 2008/09 NZANS compared with NNS97, males and females were less likely to report consuming bread, potatoes, beef, vegetables, breakfast cereal, milk, cheese, butter, pies, biscuits, cakes and puddings, and sugar/confectionery (all P<0·001). In contrast, there was an increase in the percentage reporting rice and rice dishes (P<0·001), and among females a reported increase in snacks and snack bars (e.g. crisps, extruded snacks, muesli bars; P=0·007) and pasta and pasta dishes (P=0·017). Although food choices were associated with sex and age group, there were few differential changes between the surveys by sex or age group. For all age groups there was a shift in the percentage who reported consuming the traditional NZ foods, namely bread, beef, potatoes and vegetables, towards more rice and rice dishes. Declines in the consumption of butter, pies, biscuits, cakes and puddings are congruent with current dietary guidelines.
This study examined the relationship between breakfast cereal consumption and non-milk extrinsic sugars (NMES) intake and the possible implications of this for caries in preschool children. Data from the 1995 UK National Diet and Nutrition Survey (NDNS) of children aged 1.5-4.5 years were reanalysed. Four-day weighed food records and dental examinations were available on 1450 children living in private households in Britain. Children were classified by tertiles (age-adjusted) according to the proportion of energy derived from breakfast cereals, and the amount of NME sugar from cereals. There were no significant differences in social class background between any of the groups. Children with diets high in breakfast cereals as a proportion of total energy (top third) had lower proportional intakes of NMES, compared with low consumers of cereals (lowest third). Consumption of sweetened cereals was positively associated with NMES intake. However, caries experience was unrelated to breakfast cereal consumption, whether presweetened or not. Although presweetened cereals are relatively high in NMES, their cariogenic potential is probably minimal in the circumstances in which they are normally consumed.
Categorized Framingham Heart Study Prediction Score Sheets 
Participant characteristics by race, sex and menopausal status, HANDLS study, Baltimore, MD, USA, 2001-2009 
Differences in iron status by race, sex and menopausal status, HANDLS study, Baltimore, MD, USA, 2001-2009 
Comparison of average 10-year risk and relative risk utilizing the Framingham Heart Study's CHD risk equations, across race by sex and menopausal status of women and within race for women by menopausal status, HANDLS study, Baltimore, MD, USA, 2001-2009 
Comparative 10-year risk between Framingham and the HANDLS study sample 
Objective: The present study examined the association of serum ferritin with CHD risk using the Framingham Heart Study's 10-year risk algorithm. Design: Ordinal logistic regression modelling was used to interpret risk. Proportional odds modelling assessed four divisions of ranked CHD risk (4, high; 3, increased; 2, slight; 1, minimal), separately by sex.
Race-specific validation of food intake obtained from a comprehensive food frequency questionnaire: Adventist Health Study-2 – Corrigendum - Volume 15 Issue 11 - Karen Jaceldo-Siegl, Jing Fan, Joan Sabaté, Synnove F Knutsen, Ella Haddad, W Lawrence Beeson, R Patti Herring, Terrence L Butler, Hannelore Bennett, Gary E Fraser
To compare the intake of key indicator foods at age 12 months and 18 months between infants of Pakistani and White British origin. Logistic regression was used to model associations between ethnicity and consumption of key indicator foods defined by high or low energy density using an FFQ at age 12 and 18 months. Born in Bradford 1000 study, Bradford, UK. Infants (n 1259; 38 % White British, 49 % Pakistani), mean age 12·7 (sd 1·0) months and toddlers (n 1257; 37 % White British, 49 % Pakistani), mean age 18·7 (sd1·0) months. At 12 months, Pakistani infants consumed more commercial sweet baby meals than White British infants, with greater odds for being above average consumers (adjusted OR (AOR)=1·90; 95 % CI 1·40, 2·56), more chips/roast potatoes (AOR=2·75; 95 % CI 2·09, 3·62), less processed meat products (AOR=0·11; 95 % CI 0·08, 0·15), more fruit (AOR=2·20; 95 % CI 1·70, 2·85) and more sugar-sweetened drinks (AOR=1·68; 95 % CI 1·29, 2·18). At 18 months these differences persisted, with Pakistani infants consuming more commercial sweet baby meals (AOR=4·57; 95 % CI 2·49, 8·39), more chips/roast potato shapes (AOR=2·26; 95 % CI 1·50, 3·43), more fruit (AOR=1·40; 95 % CI 1·08, 1·81), more sugar-sweetened drinks (AOR=2·03; 95 % CI 1·53, 2·70), more pure fruit juice (AOR=1·82; 95 % CI 1·40, 2·35), more water (AOR=3·24; 95 % CI 2·46, 4·25) and less processed meat (AOR=0·10; 95 % CI 0·06, 0·15) than White British infants. Dietary intake during infancy and the early toddlerhood period is associated with ethnicity, suggesting the importance of early and culturally adapted interventions aimed at establishing healthy eating behaviours.
The Forum on Mediterranean Food Cultures has the purpose to foster an interdisciplinary dialogue to acknowledge the underestimated role of the Mediterranean diet and of the Mediterranean food cultures for an effective sustainable development in the Mediterranean. It is addressed towards the achievement of food security and a broader nutritional well-being in the entire Mediterranean area. The Forum uses a creative approach for the development of community-based programmes to manage the emerging trend of childhood overweight and obesity, as well as to reduce the increasing erosion of the Mediterranean food cultural heritage.
Proportion of beverages in different nutritional categories (15) found at a metropolitan supermarket in Australia 
The macronutrient content of snacks found in an Australian supermarket. Values are given as median (interquartile range) 
Proportion of beverages in different categories complying with the nutritional criteria applying to drinks in the UK signposting recommendations (30) Percentage compliant with recommendation 
To estimate the proportion of snack food and beverage choices available to an Australian consumer. A survey of product Nutrition Information Panels (NIP) and product labels on snack foods and beverages offered for sale. Data on nutrient content were compared with criteria from different nutrient profile systems to estimate the proportion of items conforming to a choice. A large supermarket in metropolitan Melbourne, Australia. A consumer could choose from 1,070 different snack foods and 863 different drinks. Flavour variety was more common in snacks (maximum thirteen per product) while variation in container size was more common for drinks (up to ten per product). Recommended serving size for snacks varied greatly (1822 % of snack foods presented for sale could be deemed by multiple criteria. Similarly, only 14 healthy healthier' snack foods and beverages, e.g. by reformulation of many products by the food industry and their presentation in smaller, standardised portion-size packaging.
To provide an overview of research relevant to the Mediterranean diet. Personal perspectives.Setting: International.Subject: Populations in Europe, North America, Asia. Approximately 50 years ago, Keys and colleagues described strikingly low rates of coronary heart disease in the Mediterranean region, where fat intake was relatively high but largely from olive oil. Subsequent controlled feeding studies have shown that compared to carbohydrate, both monounsaturated and polyunsaturated fats reduce LDL and triglycerides and increase HDL cholesterol. Importantly, these beneficial metabolic effects are greater in the presence of underlying insulin resistance. In a detailed analysis within the Nurses' Health Study, trans fat from partially hydrogenated vegetable oils (absent in traditional Mediterranean diets) was most strongly related to risk of heart disease, and both polyunsaturated and monounsaturated fat were inversely associated with risk. Epidemiologic evidence has also supported beneficial effects of higher intakes of fruits and vegetables, whole grains, fish, and daily consumption of moderate amounts of alcohol. Together with regular physical activity and not smoking, our analyses suggest that over 80% of coronary heart disease, 70% of stroke, and 90% of type 2 diabetes can be avoided by healthy food choices that are consistent with the traditional Mediterranean diet. Both epidemiologic and metabolic studies suggest that individuals can benefit greatly by adopting elements of Mediterranean diets.
Body mass index (percentiles) of the cohort of 11– 12 year olds 
Mean weight, height and body mass index (BMI) of a subgroup of the Jamaican birth cohort aged 11-12 years
Height-for-age (percentiles) of the cohort of 11–12 year olds 
Household characteristics and housing amenities
Odds ratios for the likelihood of BMI , 5th percentile and BMI$85th percentile by social and demographic factors
To determine the nutritional status of a cohort of 11-12 year olds and ascertain social and demographic factors associated with under- and overweight in early adolescence. Cross-sectional. Subgroup (n = 1698) of the birth cohort (September-October 1986) of the Jamaican Perinatal Survey enrolled in schools in the Kingston Metropolitan area. One thousand and sixty-three parents or caregivers provided social and demographic information. Undernutrition and overnutrition are of public health significance among adolescent Jamaican children. Ten per cent of 11-12 year olds had body mass index (BMI) values below the 5th percentile (boys, 10.6%; girls, 7.1%) but this prevalence is relatively low compared with other developing countries. The prevalence of stunting was low (3%). The prevalence of overweight (BMI > or = 85th percentile) (19.3%) was approaching prevalence rates found in the USA. Similar social and demographic variables were associated with thinness and fatness in males. Birth weight predicted overweight in girls. Under- and overnutrition in early adolescence are important problems in Jamaica. There is a need to address both under- and overnutrition in adolescence in preventive and rehabilitative intervention programmes.
Consumption of various foods at home by 10-to 11-year-old Finnish schoolchildren by father's occupation category 
Factors associated with having many unhealthy food habits (.4) among 10-to 11-year-old Finnish schoolchildren 
patterns and food use among 10-to 11-year-old Finnish schoolchildren in Ylivieska during weekdays 
To describe the meal patterns and food use on weekdays among 10- to 11-year-old Finnish children and to analyse these in relation to family's socio-economic status and the child's behaviour. Cross-sectional study on a cohort of 404 children aged 10-11 years in the rural town of Ylivieska, mid-western Finland. A food-frequency questionnaire including questions on meal patterns and food use and the Child Behaviour Checklist (CBCL) completed by the parents and the child together. Practically all children (99%) ate breakfast regularly, 94% had a daily school lunch and 80% had dinner at home daily. Vegetables were consumed daily at home by 26% and fruits or berries by 21%, while 46% of the children had salad daily at school. Twenty-four per cent ate sweets daily or nearly so on weekdays. The children from families of high socio-economic status ate vegetables more often, and fewer of them used butter or high-fat milk. The children with no regular family dinner ate sweets and fast foods more often, and had higher total CBCL problem scores than those with a regular family dinner. Skipping meals appears not to be common among Finnish children aged 10-11 years, but a considerable proportion consume sweets frequently and vegetables infrequently. High family socio-economic status and a tendency to eat together are associated with healthy food choices among schoolchildren.
Patterns of the final cluster centres (expressed as standardised Z-values) of the selected lifestyle behaviour factors, identified using k-means cluster analysis; , Sporty media-oriented mixed eaters; , Academic healthy eaters; , Inactive healthy eaters; , Inactive media-oriented unhealthy eaters  
Mean absolute scores of the specific health-related behaviours by lifestyle cluster in 317 Flemish adolescents
Association between lifestyle clusters and gender, overweight prevalence and cardiorespiratory fitness (CRF) in 317 Flemish adolescents
The aim of the present study was to explore the existence of clusters in multiple lifestyle behaviours, including physical activity (PA), sedentariness and food habits, in young adolescents. The present study also investigated whether the identified groups could be characterised by gender and components of health-related physical fitness, especially weight status and cardiorespiratory fitness (CRF). A cross-sectional survey. Leisure-time PA, sedentary behaviour and food consumption were assessed by a questionnaire. Overweight prevalence was estimated using BMI (kg/m2) calculated from self-reported height and weight. CRF was measured using a 20 m shuttle-run test. The study was conducted in four middle schools in Flanders, Belgium. The sample size was 317 seventh grade students aged 11-12 years. Four reliable and meaningful lifestyle clusters could be identified, labelled as 'Sporty media-oriented mixed eaters' (boys: n 34; girls: n 16), 'Academic healthy eaters' (boys: n 30; girls: n 58), 'Inactive healthy eaters' (boys: n 38; girls: n 57) and 'Inactive media-oriented unhealthy eaters' (boys: n 35; girls: n 49). The lifestyle clusters could not be characterised by adolescents' weight status. Among boys, the 'Sporty media-oriented mixed eaters' group performed significantly better on the shuttle-run test than those in clusters with the lowest levels of PA (clusters 3 and 4). Our results showed that healthy and risk-related behaviours may coexist in some groups of young adolescents. Isolated unhealthy behaviours, such as high levels of screen-based media use or high consumption of energy-dense food items, are not necessarily related with negative health outcomes, on the condition that these risk-related behaviours co-occur with more health-enhancing behaviours such as PA.
Mean daily servings of fruit and juice (FJ) by availability according to high and low preference 
Frequency of demographic characteristics (n 5 473) 
Inter-correlations between psychosocial variables of fruit and juice (FJ) and vegetable (V) consumption 
Three-stage hierarchical regression analysis of fruit and juice (FJ) and vegetable (V) consumption 
Psychosocial and demographic correlates of fruit, juice and vegetable (FJV) consumption were investigated to guide how to increase FJV intake. Hierarchical multiple regression analysis of FJV consumption on demographics and psychosocial variables. Houston, Texas, USA. Boys aged 11-14 years (n = 473). FJV preference and availability were both significant predictors of FJV consumption, controlling for demographics and clustering of Boy Scout troops. Vegetable self-efficacy was associated with vegetable consumption. The interaction of preference by home availability was a significant predictor of FJV. The interaction of self-efficacy by home availability showed a trend towards significantly predicting vegetable consumption. No significant interactions were found between body mass index and the psychosocial variables. Findings suggest that future interventions emphasising an increase in preference, availability and efficacy may increase consumption of FJV in similar populations.
Summary of the study methodology (DGI-CA, Dietary Guideline Index for Children and Adolescents; SFS, Short Food Survey) 
Bland-Altman plot showing agreement between total DGI-CA scores calculated by the SFS and 24 h recalls.-represents the mean difference between the two methods;-represent the 95 % confidence interval (DGI-CA, Dietary Guideline Index for Children and Adolescents; SFS, Short Food Survey) 
To assess the reliability and relative validity of a diet index score derived from a Short Food Survey (SFS). The thirty-eight-item SFS was designed to assess recent dietary intake of 4-11-year-olds to enable calculation of the Dietary Guideline Index for Children and Adolescents. Reliability was assessed based on two online administrations of the SFS, one week apart. Relative validity was assessed by comparing intakes derived from the SFS with those from the mean of three 24 h recalls. Intra-class correlations, Bland-Altman plots and estimated biases were assessed. Cohen's κ coefficients were used to determine the level of agreement between the two methods. Adelaide, Australia. Sixty-three parents reported on their children's intake (mean age 7·1 (sd 2·1) years). The intra-class correlation for reliability ranged from 0·43 for dairy foods to 0·94 for beverages, and was 0·92 for total diet index score (all P < 0·01). The intra-class correlation for validity ranged from 0·04 for meat and alternatives to 0·41-0·44 for fruit, beverages and extra foods, and was 0·44 for the total diet index score. The SFS overestimated the mean diet index score by 16 %, and the bias was consistent across levels of compliance. The percentage agreement into tertiles of index scores was 84% between the administrations of the two SFS, but only 43 % when comparing the SFS with the mean of the recalls. The SFS can provide a consistent estimate of overall compliance to dietary guidelines for children aged 4-11 years, but overestimated the total diet index score by 16 % across all levels of compliance.
Percentage of children aged 6–11 years who frequently (at least 3 times per week) ate selected foods (five specific fruits) that are rich in provitamin A  
Plasma retinol concentrations in children (all regions) by sex and age
A nationwide study was performed in Cuba to assess vitamin A status and the intake of vitamin-A-providing foods in children aged 6-11 years. The sample comprised 1191 schoolchildren from first to sixth grade, both sexes, from municipalities randomly selected from the five eastern provinces of Cuba in 2002 (first semester) and from the four western and four central provinces in 2003 (first semester). A food-frequency questionnaire was completed by 2038 mother-and-child pairs. Mean (+/-standard deviation) plasma retinol concentrations were 1.77 +/- 0.48 micromol l-1 in the western, 2.01 +/- 0.56 micromol l-1 in the central and 1.40 +/- 0.41 micromol l-1 in the eastern region. No child had plasma retinol concentration below 0.35 micromol l-1, indicative of a high risk of clinical deficiency. Subclinical deficiency, plasma retinol concentration of 0.35-0.7 micromol l-1, was seen in 1.05 micromol l-1) was present in >90% of subjects in all western and central provinces, and in one of the eastern provinces (Holguín), whereas in the four remaining eastern provinces, adequate status was present in >75%. Only nine fruits and vegetables were consumed frequently (>3 times per week) by >50% of children. Thirty-seven per cent regularly consumed a supplement containing vitamin A. Most Cuban children aged 6-11 years had adequate vitamin A status. Consumption of foods rich in vitamin and provitamin A, especially vegetables, was frequent but limited to a small variety of foods.
between school-level deprivation and con- sumption of items from six food categories at breakfast and between attitudes towards breakfast and consumption of items from six food categories at breakfast (n ¼ 111) 
To examine school-level relationships between deprivation and breakfast eating behaviours (breakfast skipping and the healthfulness of foods consumed) in 9-11-year-old schoolchildren and to examine whether attitudes towards eating breakfast mediated these relationships. Cross-sectional survey. One hundred and eleven primary schools in Wales. Year 5 and 6 pupils within the 111 primary schools. Measures were completed by 4314 children. Analysis was conducted at the group (school) level, with each school representing one group. Deprivation was positively associated with breakfast skipping and consumption of 'unhealthy' items (i.e. sweet snacks, crisps) for breakfast. A significant negative association was found between deprivation and consumption of 'healthy' items (i.e. fruit, bread, cereal, milk). Deprivation was significantly inversely associated with attitudes towards eating breakfast. The relationships between deprivation and (1) breakfast skipping and (2) consumption of 'healthy' items for breakfast were mediated by attitudes towards eating breakfast. The hypothesis that attitudes mediated the relationship between deprivation and consumption of 'unhealthy' breakfast items was unsupported. Deprivation is associated with adverse breakfast eating behaviours amongst children aged 9-11 years, in terms of breakfast skipping and the quality of breakfasts consumed. Socio-economic differences in attitudes towards eating breakfast are apparent amongst this age group, and appear to relate to social gradients in breakfast eating behaviours. Research is needed to examine the causal nature of these trends and to elucidate factors underlying the development of socio-economic differences in eating-related cognitions.
Baseline characteristics of stratification variables by randomisation status: cluster-randomised controlled trial examin- ing the impact of the Primary School Free Breakfast Initiative in Wales on inequalities in children's dietary behaviours and cognitive functioning 
Universal interventions may widen or narrow inequalities if disproportionately effective among higher or lower socio-economic groups. The present paper examines impacts of the Primary School Free Breakfast Initiative in Wales on inequalities in children's dietary behaviours and cognitive functioning. Cluster-randomised controlled trial. Responses were linked to free school meal (FSM) entitlement via the Secure Anonymised Information Linkage databank. Impacts on inequalities were evaluated using weighted school-level regression models with interaction terms for intervention × whole-school percentage FSM entitlement and intervention × aggregated individual FSM entitlement. Individual-level regression models included interaction terms for intervention × individual FSM entitlement. Fifty-five intervention and fifty-six wait-list control primary schools. Approximately 4500 children completed measures of dietary behaviours and cognitive tests at baseline and 12-month follow-up. School-level models indicated that children in intervention schools ate a greater number of healthy items for breakfast than children in control schools (b = 0·25; 95 % CI 0·07, 0·44), with larger increases observed in more deprived schools (interaction term b = 1·76; 95 % CI 0·36, 3·16). An interaction between intervention and household-level deprivation was not significant. Despite no main effects on breakfast skipping, a significant interaction was observed, indicating declines in breakfast skipping in more deprived schools (interaction term b = -0·07; 95 % CI -0·15, -0·00) and households (OR = 0·67; 95 % CI 0·46, 0·98). No significant influence on inequality was observed for the remaining outcomes. Universal breakfast provision may reduce socio-economic inequalities in consumption of healthy breakfast items and breakfast skipping. There was no evidence of intervention-generated inequalities in any outcomes.
Neighbourhood characteristics of study participants: caregivers (n 25) of African-American children aged 3-11 years from six primarily African-American communities in metro Birmingham, AL, USA 
To assess caregivers' perceptions of the extent to which the food marketing environment influences food consumption among African-American children (aged 3-11 years) in order to generate potential strategies to make the marketing environment more favourable to healthier eating. Individual semi-structured interviews with caregivers were conducted by trained community leaders to ascertain their awareness of and perceptions about food marketing environments contributing to African-American children's food consumption. Six predominantly African-American communities in metro Birmingham, Alabama, USA with high proportions of school-age children and lower-income residents. Caregivers (n 25) were predominantly female (93 %) and either parents/guardians (64 %) or grandparents (28 %) of African-American children aged 3-11 years. Caregiver mean age was 43 years and 46 % had lived in their current residence for over 10 years. Caregivers reported all aspects of the food marketing matrix as supporting unhealthy eating among African-American youth. Child preference for foods higher in fat and sugar, lower pricing of less healthy foods, limited access to healthier food retailers and targeted advertisements were particularly influential on the food selection, acquisition and consumption of children. Company loyalty, corporate sponsorship of local events and conflicts over parental v. food company responsibility contributed to less consensus about the overall impact (positive or negative) of food companies in African-American communities. While caregivers perceived aspects of their food marketing environments as primarily contributing to unhealthy eating among African-American children, framing the demand for changes in the food marketing environments of African-American youth may be particularly challenging.
Standard scores of cluster centres on correlates in boys 
Standard scores of cluster centres on correlates in girls 
Involvement in school sports and sports outside school, frequency of moderate and vigorous physical activity (PA), activity levels during breaks and sedentary behaviour (mean score ^ standard deviation) in the four clusters of girls 
To evaluate gender differences for levels of physical activity, for sedentary behaviour and for psychosocial correlates in children, to evaluate whether psychosocial correlates cluster in meaningful ways and to examine whether physical activity and sedentary behaviour differ between children of clusters, differentiated by the level of perceived barriers and benefits, attitudes, social support and self-efficacy. Cross-sectional study using the Flemish Physical Activity Questionnaire. Questionnaires to be filled out by the children and one of their parents, contacted through the school system. A sample of 1124 10- to 11-year-olds (579 boys and 545 girls). Girls were found to be less active than boys, with boys scoring better for social support, perceived benefits and self-efficacy compared with girls. The way of clustering differed between boys and girls. Boys were allocated to three clusters: one cluster with positive correlates towards physical activity, labelled 'positives'; one with negative correlates, labelled 'negatives'; and one characterised mainly by high perceived barriers, labelled 'hindered'. In both genders the highest levels of physical activity were found in the 'positives', the lowest in the 'negatives'. In girls a fourth cluster was identified, characterised mainly by low perceived barriers and low social support. Physical activity levels in the girls of this cluster, labelled 'indifferents', were the second highest. More research is needed to further characterise these clusters. To prevent the physical activity decline during the transition from childhood to adulthood, novel interventions need to be explored that focus on children of the clusters with the most negative correlates.
In many studies it has been shown that breakfast is associated with normal weight in children and adolescents. Other meals, family meals and a regular meal pattern have been less studied. Therefore, the aim of the present study was to examine whether a regular meal pattern, or breakfast, lunch or dinner as separate regular meals, is associated with the BMI of children. A cross-sectional study conducted within the Helsinki region during 2006. Study participants were measured and weighed by research staff. Children filled in a study questionnaire on their health behaviour, including the frequency of consuming meals. A regular meal was defined as one usually eaten on every school day. A regular meal pattern was defined as one consisting of a usual consumption of breakfast, school lunch and dinner on every school day. Covariance analysis was used as the statistical analysis method. Capital region, Finland, 2006. A total of 604 schoolchildren (312 girls) aged 9-11 years. Irregular breakfast and an irregular meal pattern were associated with higher BMI. Regularity of school lunch, dinner or family dinner was not associated with BMI. A regular breakfast and meal pattern was associated with lower BMI in children, although breakfast was the only single meal associated with BMI. We conclude that, although the association between breakfast and weight status in children is fairly consistent, the role of other meals is less convincing.
To investigate the internal consistency of the scales and the test-retest reliability and predictive validity of behaviour theory-based constructs measuring personal, social and environmental correlates of fruit and vegetable intake in 10-11-year-old children. Test-retest with one-week interval. Five European countries: Norway, Spain, Denmark, Portugal, Belgium. Three hundred and twenty-six children completed the questionnaire during class hours. For the total sample across all countries, the test-retest reliability was good to very good (intra-class correlation coefficient (ICC) >0.60) for 12 out of the 15 fruit constructs and also for 12 out of the 15 vegetable constructs. Acceptable ICCs, ranging between 0.50 and 0.59, were found for the remaining constructs. Test-retest reliability was comparable across countries. Only in Portugal were some significantly lower ICCs found for some constructs (knowledge and barriers related to fruit, general self-efficacy related to fruit and vegetables) compared with the other countries. Cronbach's alpha values were moderate to high (range 0.52 to 0.89) with the exception of the general self-efficacy scale, which had a value below 0.50 for both fruit (alpha=0.42) and vegetables (alpha=0.49). Spearman correlations with intake ranged between -0.16 and 0.54 for personal determinants and between 0.05 and 0.38 for environmental determinants. Compared with other studies, predictive validity can be considered moderate to good. The questionnaire provides a reliable, valid and easy-to-administer tool for assessing personal, social and environmental factors of potential influence on fruit and vegetable intake in 10-11-year-olds.
Meals consumed 3-4 d/week or more often among balanced ( ) and imbalanced ( ) school lunch eaters on school days (percentage of balanced and imbalanced eaters; n 497-514). Frequencies were generated by cross-tabulations using the x 2 test for statistical significance (*P , 0?05, **P , 0?01, ***P , 0?001) 
Definition of a balanced school lunch according to the Finnish National Nutrition Council (2) and by the present study 
Descriptive characteristics of the study population 
Number of meals eaten during weekends among balanced (n 234-239) and imbalanced (n 263-274) school lunch eaters 
To explore how the quality of school lunch consumed reflected overall eating patterns in school-aged children. Children filled in an Internet-based questionnaire about their eating patterns. The children were then divided into balanced and imbalanced school lunch eaters on the basis of their responses in the questionnaire. A balanced school lunch consisted of, by the definition used in the present study, a main dish, salad and bread. Eleven primary schools and one middle school in eastern Finland. A total of 531 schoolchildren (247 boys and 284 girls) aged 11-16 years. The school lunch was balanced in 46·5 % of children. Eating a balanced school lunch was associated with overall healthier eating patterns outside school. Children who ate a balanced school lunch had more regular meal times and consumed healthier snacks. They ate fruit or berries and vegetables, dairy products and wholegrain foods more often, consumed fewer salty snacks, pizzas, meat pies and drank fewer soft drinks and energy drinks. Their eating patterns at home were also healthier, with vegetables being offered at every family dinner and fruit being offered daily, whereas soft drinks were offered seldom. The choices made by children in their school lunch reflect the overall eating patterns among school-aged children. Eating a balanced school lunch is associated with more regular meal patterns, the availability of healthier foods at home and an overall healthier diet, suggesting that healthy eating patterns are learnt at home.
To describe the eating habits of children in Liverpool and compare two age groups that bridge the transition from primary to secondary school. Two cross-sectional studies carried out one year apart using a food intake questionnaire that records whether or not each child claims to have eaten specific marker foods on the previous day. Primary and secondary schools in Liverpool. Six hundred and forty-nine children aged 11 or 12 years and 3556 children aged 9 or 10 years. Fewer older children ate breakfast (68-82%), especially the girls, and not eating breakfast was associated with eating on the way to school in the younger children. More of the older girls ate nothing at breakfast or on the way to school. Overall, the less desirable foods were reported to have been eaten by more children, of both ages, than the more desirable foods. Fruit, however, was mentioned by most children (69-77%) but the next 10 foods mentioned by most children were all less desirable ones. Only 31% of primary and 21% of secondary children ate both fruit and vegetables but 23% of primary and 26% of secondary children ate neither fruit nor vegetables. Overall, more of the girls of both age groups claimed to have eaten foods that would normally be encouraged. Food choice changes appreciably between primary and secondary school and, in some key respects, for the worse. In particular, far more children of both age groups need to be eating fruit and vegetables every day.
Percentages of parents in the four categories of parenting styles ( , authoritative; , authoritarian; , indulgent; , neglectful) in the four countries. Data were derived from the cross-sectional study of the Pro Children project, October-December 2003 
in fruit intake and social-environmental correlates of fruit intake between parenting style groups and the four countries (results of two-way ANOVA): data derived from the cross-sectional study of the Pro Children project, October-December 2003 
To investigate whether fruit and vegetable (F&V) intake in 11-year-olds, and social-environmental correlates of F&V intake such as parental modelling and encouragement, family food rules and home availability, differ according to general parenting styles in Belgium, The Netherlands, Portugal and Spain. Cross-sectional study. Primary schools in four countries. Pupils and one of their parents completed questionnaires to measure F&V intake, related social-environmental correlates and general parenting styles. The sample size was 4555 (49.3 % boys); 1180 for Belgium, 883 for The Netherlands, 1515 for Portugal and 977 for Spain. Parenting styles were divided into authoritative, authoritarian, indulgent and neglectful. No differences were found in F&V intake across parenting styles and only very few significant differences in social-environmental correlates. The authoritarian (more parental encouragement and more demands to eat fruit) and the authoritative (more availability of fruit and vegetables) parenting styles resulted in more favourable correlates. Despite earlier studies suggesting that general parenting styles are associated with health behaviours in children, the present study suggests that this association is weak to non-existent for F&V intakes in four different European countries.
To describe the meal patterns of Jena schoolchildren and their associations with children's weight status and parental characteristics. Cross-sectional study. Twenty schools in Jena (100,000 inhabitants), south-east Germany. A total of 2054 schoolchildren aged 7-14 years with information on BMI standard deviation score (BMI-SDS) and weight status (based on German reference values), of whom 1571 had additional information about their parents (parental education and employment status, weight status according to WHO guidelines) and meal patterns (school lunch participation rate, meal frequencies, breakfast consumption and frequency of family meals). Weight status of the children was associated with weight status, education and employment status of the parents. Meal patterns were strongly dependent on children's age and parental employment. As age increased, the frequency of meal consumption, participation rate in school lunches and the number of family meals decreased. Using linear regression analysis, a high inverse association between BMI-SDS and meal frequency was observed, in addition to relationships with parental weight status and paternal education. Age-specific prevention programmes should encourage greater meal frequency. The close involvement of parents is essential in any strategy for improving children's (families') diets.
List of countries that provided national HBS data in the context of the DAFNE I and II projects, and variables selected to be studied 
The DAFNE food classification system
The DAta Food NEtworking (DAFNE) initiative was conceived in the 1980s and aims at using data already collected in the context of household budget surveys (HBSs) for the assessment of dietary patterns across Europe. HBSs are country-representative surveys conducted, with similar methodology, at regular time intervals by the National Statistical Offices of almost all European countries. DAFNE focuses at the designation of comparable, between European countries, categories of food and socio-demographic data, and the estimation of daily per capita food availability. With food and socio-demographic data classified into common categories, comparisons of food habits between European countries become possible. Fifteen European countries with one or more HBS all undertaken during the period 1981-1999. Representative population samples in 15 European countries. DAFNE HBS data are comparable and allow a wide range of dietary analyses. Preliminary data document differences in food habits among European countries and provide insights into the socio-demographic determinants of food preferences. The DAFNE databank, if properly expanded and exploited, could become a valuable tool for national food and nutrition policy planning across Europe and for the identification of groups at higher risk for developing nutrition-related conditions.
To discuss present knowledge about Mediterranean diet and cardiovascular diseases. Review of existing literature. SETTING AND RESULTS: Epidemiological studies as well as randomised dietary trials suggest that Mediterranean diet may be important in relation to the pathogenesis (and prevention) of CHD. For instance, a striking protective effect of an ALA-rich Mediterranean diet was reported in the Lyon Diet Heart Study with a 50 to 70% reduction of the risk of recurrence after 4 years of follow-up in CHD patients. According to our current knowledge, dietary ALA should represent about 0.6 to 1% of total daily energy or about 2 g per day in patients following a Mediterranean diet, whereas the average intake in linoleic acid should not exceed 7 g per day. Supplementation with very-long-chain omega-3 fatty acids (about 1 g per day) in patients following a Mediterranean type of diet was shown to decrease the risk of cardiac death by 30% and of sudden cardiac death by 45% in the GISSI trial. In the context of a diet rich in oleic acid, poor in saturated fats and low in omega-6 fatty acids (a dietary pattern characterising the traditional Mediterranean diet), even small doses of omega-3 fatty acids (about 1 g EPA+DHA the form of fish oil capsules or 2 g alpha-linolenic acid in canola oil and margarine) might be very protective. These data underline the importance of the accompanying diet in any dietary strategy using fatty acid complements.
Percentage of children meeting RNIs/Department of Health recommendations for the five dietary indicators 
Frequency distribution of scores across the five dietary indicators 
Socio-economic variables and scores across the five dietary parameters 
Logistic regression model for meeting one or fewer RNIs/recommendations by a range of socio-economic measures 
To assess the proportion of pre-school children meeting reference nutrient intakes (RNIs) and recommendations for daily intakes of iron, zinc, vitamins C and A, and energy from non-milk extrinsic sugars. To assess whether meeting these five dietary requirements was related to a series of socio-economic variables. Secondary analysis of data on daily consumption of foods and drinks from the National Diet and Nutrition Survey (NDNS) of children aged 1.5-4.5 years based on 4-day weighed intakes. One thousand six hundred and seventy-five British pre-school children aged 1.5-4.5 years in 1993. Only 1% of children met all five RNIs/recommendations examined; 76% met only two or fewer. Very few children met the recommendations for intakes of zinc (aged over four years) and non-milk extrinsic sugars (all ages). The number of RNIs/recommendations met was related to measures of socio-economic class. Children from families in Scotland and the North of England, who had a manual head of household and whose mothers had fewest qualifications, met the least number of RNIs/recommendations. Very few pre-school children have diets that meet all the RNIs and recommendations for iron, zinc, vitamins C and A, and energy from non-milk extrinsic sugars. Dietary adequacy with respect to these five parameters is related to socio-economic factors. The findings emphasise the need for a range of public health policies that focus upon the social and economic determinants of food choice within families.
To assess the potential nutritional contribution of meals provided in a sample of community programmes for homeless individuals, to determine the effect of food donations on meal quality and to develop food-based guidance for meals that would meet adults' total nutrient needs. Toronto, Canada. An analysis of weighed meal records from eighteen programmes. The energy and nutrient contents of meals were compared to requirement estimates to assess contribution to total needs, given that homeless people have limited access to nutritious foods. Mixed linear modelling was applied to determine the relationship between the use of food donations and meal quality. The composition of meals that would meet adults' nutrient requirements was determined by constructing simulated meals, drawing on the selection of foods available to programmes. In all, seventy meals, sampled from eighteen programmes serving homeless individuals. On average, the meals contained 2.6 servings of grain products, 1.7 servings of meat and alternatives, 4.1 servings of vegetables and fruits and 0.4 servings of milk products. The energy and nutrient contents of most meals were below adults' average daily requirements. Most meals included both purchased and donated foods; the vitamin C content of meals was positively associated with the percentage of energy from donations. Increasing portion sizes improved the nutrient contribution of meals, but the provision of more milk products and fruits and vegetables was required to meet adults' nutrient requirements. The meals assessed were inadequate to meet adults' nutrient requirements. Improving the nutritional quality of meals requires additional resources.
Food groupings for construction of the dietary patterns 
Study characteristics of the urban adolescents (n 416), Gombak District, Selangor, Malaysia, July 2011- March 2012 
Factor-loading matrix-for the dietary patterns identified (n 416) 
The present study aimed to identify dietary patterns and determine the relationship between dietary patterns and cognitive ability among 12- to 13 year-old Malay adolescents in the urban areas of Gombak district in Selangor, Malaysia. Data on sociodemographic background were obtained from parents. Height and weight were measured and BMI-for-age was determined. Adolescents were interviewed on their habitual dietary intakes using a semi-quantitative FFQ. Cognitive ability was assessed using the Wechsler Nonverbal Scale of Ability in a one-to-one manner. Dietary patterns were constructed using principal component analysis based on thirty-eight food groups of the semi-quantitative FFQ. Urban secondary public schools in the district of Gombak in Selangor, Malaysia. Malay adolescents aged 12 to 13 years (n 416). The mean general cognitive ability score was 101·8 (sd 12·4). Four major dietary patterns were identified and labelled as 'refined-grain pattern', 'snack-food pattern', 'plant-based food pattern' and 'high-energy food pattern'. These dietary patterns explained 39·1 % of the variance in the habitual dietary intakes of the adolescents. The refined-grain pattern was negatively associated with processing speed, which is a construct of general cognitive ability. The high-energy food pattern was negatively associated with general cognitive ability, perceptual reasoning and processing speed. Monthly household income and parents' educational attainment were positively associated with all of the cognitive measures. In multivariate analysis, only the high-energy food pattern was found to contribute significantly towards general cognitive ability after controlling for socio-economic status. Consumption of foods in the high-energy food pattern contributed towards general cognitive ability after controlling for socio-economic status. However, the contribution was small.
Objective: To determine (i) the importance of parents’ motives for everyday family food choices; and (ii) the relationship between parental food choice motives and eating patterns of 12- to 13-year-old children. Design: Cross-sectional study. A modified version of the Food Choice Questionnaire was used to determine parental motives for food choices. The children’s food and drink intake was reported by their parents using a retrospective FFQ. Eating patterns were derived using principal component analysis. The association between food choice motives and eating patterns was examined using multiple linear regression analysis. Setting: Primary schools, Telemark County, Norway. Subjects: In total, 1095 children aged 12–13 years and their parents. Results: The parental motive ‘sensory appeal’ was the most important for food choice, followed by ‘health’, ‘convenience’, ‘natural content’ and ‘weight control’. The food choice motives were associated with the eating patterns of the children, independent of background variables. The motive ‘health’ was most strongly associated with a ‘varied Norwegian’ eating pattern, representing a diverse diet and regular meals, while the motive ‘convenience’ appeared to be the most important barrier to this eating pattern. ‘Weight control’ was not associated with the ‘varied Norwegian’ eating pattern. Conclusions: To encourage parents to make healthy food choices for their children, health promotion activities should focus on the health benefits of a diverse diet and regular meals, rather than weight control. Recommended food products should be made more convenient and easily available for families with children.
Characteristics of study participants: 12-13-year-old children and their parents (n 789)*, Telemark County, Norway, spring 2010 
Associations* (odds ratios and 95 % confidence intervals) between tertiles of eating pattern scores and mental health problems measured by the extended SDQ (SDQ symptom scores combined with impact scale scores) among 12-13-year-old children (n 789), Telemark County, Norway, spring 2010 
To investigate the association between eating patterns and mental health problems in young Norwegian adolescents (12-13 years of age). Cross-sectional study. Dietary information was reported by parents using a retrospective FFQ. Eating patterns were identified using principal component analysis. The Strengths and Difficulties Questionnaire was used to measure mental health problems. The association between eating patterns and mental health problems was examined using multiple logistic regression analysis. Primary schools, Telemark County, Norway. Children (n 1095) aged 12-13 years and their parents. Children with high scores on a 'varied Norwegian' eating pattern were less likely to have indications of any psychiatric disorders (adjusted OR = 0·5; 95 % CI 0·3, 1·0) and hyperactivity-inattention disorders (adjusted OR = 0·4; 95 % CI 0·2, 0·8) than children with low scores on this pattern. Children with high scores on a 'junk/convenient' eating pattern were more likely to have indications of hyperactivity-inattention disorders (adjusted OR = 3·4; 95 % CI 1·3, 8·6) than children with low scores on this pattern. Children with high scores on a 'snacking' eating pattern were more likely to have indications of conduct/oppositional disorders (adjusted OR = 3·8; 95 % CI 1·2, 11·5) than those with low scores on this eating pattern. We identified a significant association between eating patterns and mental health problems in young adolescents, independently of physical activity, sedentary activity and background variables. A diverse diet rich in unrefined plant foods, fish and regular meals was associated with better mental health, while energy-dense, nutrient-poor diets and irregular meals were associated with poorer mental health.
Mean BMI, BMI Z-score and daily intakes of energy and energy from beverages by gender: boys and girls aged 9-13 years, south- west London, UK 
Objective: Adequate fluid intake has been well documented as important for health but whether it has adverse effects on overall energy and sugar intakes remains under debate. Many dietary studies continue to refrain from reporting on beverage consumption, which the present study aimed to address. Design: A cross-sectional survey investigated self-reported measures of dietary intake and anthropometric measurements. Setting: Primary and secondary schools in south-west London, UK. Subjects: Boys and girls (n 248) aged 9–13 years. Results: Boys consumed 10 % and girls consumed 9 % of their daily energy intake from beverages and most children had total sugar intakes greater than recommended. Beverages contributed between a quarter and a third of all sugars consumed, with boys aged 11–13 years consuming 32 % of their total sugar from beverages. There was a strong relationship between consumption of beverages and energy intake; however, there was no relationship between beverage type and either BMI or BMI Z-score. Fruit juices and smoothies were consumed most frequently by all girls and 9–10-year-old boys; boys aged 11–13 years preferred soft drinks and consumed more of their daily energy from soft drinks. Milk and plain water as beverages were less popular. Conclusions: Although current health promotion campaigns in schools merit the attention being given to improving hydration and reducing soft drinks consumption, it may be also important to educate children on the energy and sugar contents of all beverages. These include soft drinks, as well as fruit juices and smoothies, which are both popular and consumed regularly.
Characteristics of the participants in study 1, study 2 and the nationwide survey 
Energy expenditure (EE), energy intake (EI), the relationship between EI and EE, physical activity level (PAL ¼ EE/basal meta- bolic rate) and underreporters in study 1 and study 2 
To validate energy intake (EI) estimated from pre-coded food diaries against energy expenditure (EE) measured with a validated position-and-movement monitor (ActiReg) in groups of 13-year-old Norwegian schoolchildren. Two studies were conducted. In study 1 the monitoring period was 4 days; participants recorded their food intake for four consecutive weekdays using food diaries and wore the ActiReg during the same period. In study 2 the monitoring period was 7 days; participants recorded their food intake for four consecutive days but wore the ActiReg for a whole week.Settings: Participants were recruited from grade 8 in a school in and one outside Oslo (Norway).Subjects: Forty-one and 31 participants from study 1 and 2, respectively, completed the study. The group average EI was 34% lower than the measured EE in study 1 and 24% lower in study 2. The width of the 95% confidence limits of agreement in a Bland-Altman plot for EI and EE varied from -0.2 MJ to 8.2 MJ in study 1 and from -2.3 MJ to 6.9 MJ in study 2. The Pearson correlation coefficients between reported energy intake and expenditure were 0.47 (P=0.002) in study 1 and 0.74 (P<0.001) in study 2. The data showed that there was substantial variability in the accuracy of the food diary at the individual level. Furthermore, the diary underestimated the average energy intake. The ability of the food diary to rank individuals according to energy intake was found to be good in one of the studies and moderate in the other.
Description and comparison of participants' characteristics, according to gender: 13-year-old adolescents, Porto, Portugal, 2003/2004 school year 
To identify food sources of nutrients in adolescents' diets and to identify differences in food sources according to individual characteristics. A cross-sectional evaluation was carried out in the 2003/2004 school year. Self-administered questionnaires were used and a physical examination was performed. Diet was evaluated using an FFQ. Public and private schools in Porto, Portugal. Adolescents aged 13 years (n 1522) enrolled at school. The main sources of energy were starchy foods (26·5 %), dairy (12·5 %) and meat (12·0 %). The major contributors to carbohydrate intake were starchy foods (38·2 %) and fruit (13·8 %) and to protein intake were meat (28·0 %), dairy products (20·3 %), starchy foods (15·3 %) and seafood (13·6 %). The main sources of total fat were meat (22·0 %), starchy foods (13·4 %) and dairy products (12·7 %). Sweets and pastries presented important contributions to energy (11·1 %), carbohydrate (12·4 %), total fat (13·3 %) and saturated fat (16·6 %) intakes. Parental education was inversely associated with the contribution of sweets and pastries to energy, carbohydrate and fat intakes and it was positively associated with the seafood contribution to protein intake. The major sources of carbohydrates were starchy foods, which also accounted for a quarter of energy intake. Dairy products plus meat accounted for another quarter of energy. Meat was a major source of protein and fats. Sweets and pastries contributed more than 10 % to energy, carbohydrates, total and saturated fat. Parental education was the strongest determinant of food sources and was positively associated with a healthier contribution of food groups.
Demographic characteristics, anthropometry and 24 h urinary sodium excretion of study participants by sex: primary-school children (n 238) attending nine independently funded schools, Victoria, Australia, June 2010-June 2011 
Discretionary salt use habits of study participants and their parents ( , 'yes, usually'; , 'yes, sometimes'; , 'no'). Primaryschool children (n 238) attending nine independently funded schools, Victoria, Australia, June 2010-June 2011 
Objective: To measure total daily salt intake using 24 h urinary Na excretion within a sample of Victorian schoolchildren aged 5-13 years and to assess discretionary salt use habits of children and parents. Design: Cross-sectional study. Setting: Completed within a convenience sample of independent primary schools (n 9) located in Victoria, Australia. Subjects: Two hundred and sixty children completed a 24 h urine collection over a school (34%) or non-school day (66%). Samples deemed incomplete (n 18), an over-collection (n 1) or that were incorrectly processed at the laboratory (n 3) were excluded. Results: The sample comprised 120 boys and 118 girls with a mean age of 9.8 (SD 1.7) years. The average 24 h urinary Na excretion (n 238) was 103 (SD 43) mmol/24 h (salt equivalent 6.0 (SD 2.5) g/d). Daily Na excretion did not differ by sex; boys 105 (SD 46) mmol/24 h (salt equivalent 6.1 (SD 2.7) g/d) and girls 100 (SD 41) mmol/24 h (salt equivalent 5.9 (SD 2.4) g/d; P=0.38). Sixty-nine per cent of children (n 164) exceeded the recommended daily Upper Limit for Na. Reported discretionary salt use was common: two-thirds of parents reported adding salt during cooking and almost half of children reported adding salt at the table. Conclusions: The majority of children had salt intakes exceeding the recommended daily Upper Limit. Strategies to lower salt intake in children are urgently required, and should include product reformulation of lower-sodium food products combined with interventions targeting discretionary salt use within the home.
The present study aimed to examine the impact of non-wear activities registered in diaries when using accelerometers to assess physical activity (PA) in young adolescents. Data arise from a large-scale cross-sectional study on PA. PA was objectively assessed using Actigraph™ accelerometers (Actigraph MTI, Manufacturing Technology Inc., Pensacola, FL, USA) during seven consecutive days. Non-wear time activity diaries were provided to register the activities for which the accelerometer was removed. After correction to deal with over-reporting, the registered minutes of PA were used to replace periods of non-wear time measured by the accelerometer. Between October 2008 and May 2009 adolescents were recruited by home visits in Ghent (Belgium). Young adolescents (n 513; 48·6 % boys) aged 13 to 15 years. Of the total sample, 49·9 % registered at least one activity of moderate to vigorous intensity in the non-wear time activity diary. More adolescents registered an activity performed on a weekday than on a weekend day and the registered mean number of minutes of moderate to vigorous PA were higher on weekend days. Repeated-measures (M)ANOVA tests revealed a significant difference between the mean minutes with and without non-wear activities for all PA intensities, regardless of adolescents' socio-economic status or gender. More adolescents achieved the PA recommendations after inclusion of the non-wear activities irrespective of accelerometer thresholds used. The collection of information regarding non-wear time by non-wear time activity diaries when using accelerometers in 13-15-year-old adolescents can lead to different PA outcomes at the individual level and therefore can improve the ability to accurately measure PA.
This exploratory study assessed how 8-13-year-old children categorised and labelled fruit and vegetables (FaV), and how these were influenced by child characteristics, to specify second-level categories in a hierarchical food search system for a computerised 24 h dietary recall (hdr). Two sets of food cards, sixty-seven for fruit (F) and sixty-four for vegetables (V), with pictures and names of FaV from ten professionally defined food categories were sorted, separately, by each child into piles of similar foods. Demographic data, BMI and 6-n-propylthiouracil (PROP) taster status were obtained. Participants attended the Children's Nutrition Research Center in the summer of 2006. In all, 152 8-13-year-old children, predominantly English-speaking, of whom sixteen were predominantly Spanish-speaking. Children created an average of 8.5 (5.3) piles with 7.9 (11.4) cards per pile for the F, and an average of 10.1 (4.8) piles with 6.2 (7.9) cards per pile for the V. No substantial differences in Robinson clustering were detected across subcategories for each of the demographic characteristics, BMI or PROP sensitivity. Children provided clusters names that were mostly 'Taxonomic - Professional' labels, such as salads, berries, peppers, for both F (51.8 %) and V (52.1 %). These categories should be tested to assess their ability to facilitate search of FaV items in a computerised 24 hdr for children in this age group.
Unlabelled: The Amsterdam Growth and Health Longitudinal Study is longitudinal co-hort study on 181 males and females initially aged 13 years, with follow-up measurements at ages 14, 15, 16, 21 and 27 years. Methods: Anthropometrical, biological and lifestyle parameters, and age 27 also bone mineral density (BMD) of the lumbar spine (L2-L4), were measured repeatedly. Adolescent dietary intake and physical activity was related to adult cardiovascular and bone health status indicators by MLR; longitudinal relationships between physical activity and dietary intake, and cardiovascular health status indicators were assessed hy GEE-analysis. Results: Adolescent physical activity was not related to most of the indicators of adult cardiovascular health status, with the exception of a positive relationship with the waist-to-hip in females; in males 'energetic' adolescent physical activity contributed significantly to adult BMD; both in males and females, when taking the entire longitudinal period into account, peak strain physical activity was a relatively more important predictor of adult BMD than 'energetic' physical activity; calcium intake during adolescence was not a significant predictor of bone health status measured at age 27, both in males and females; a consistent significant positive longitudinal relationship was found between physical activity and serum HDL-cholesterol and significant negative longitudinal relationships were found with the subscapular skinfold and with body fat mass; a positive longitudinal relationship was found between serum total cholesterol (TC) and cholesterol intake, saturated fat (SFA) intake and the Keys-score; a negative longitudinal relationship was found between TC and polyunsaturated fit and total energy intake; for HDL a positive longitudinal relationship was found with SFA intake; low tracking was found for physical (in-) activity and dietary intake variables.
Questionnaire items for variables assessed in the Child Nutrition Questionnaire and Computer-assisted Telephone Interview (n=395) 693 
Demographic characteristics of participants 704 
Moderation of predictors of non-core dietary outcomes by SEP using partial least squares structural equation modelling (n=395) 728
There is limited understanding as to why children of low socio-economic position (SEP) consume poorer diets than children of high SEP. Evidence suggests that determinants of dietary intake may differ between SEP groups. The present study aimed to determine if SEP moderated associations of personal and environmental predictors with children's non-core food and sweetened drink intakes and unhealthy dietary behaviours. Children completed online questionnaires and parents completed computer-assisted telephone interviews to assess intrapersonal and environmental dietary predictors. Dietary intake was measured using an FFQ. Parents reported demographic information for maternal education, occupation and employment, and household income. Twenty-six primary schools in South Australia, Australia. Children aged 9-13 years and their parents (n 395). Multiple personal and home environment factors predicted non-core food and sweetened drink intakes, and these associations were moderated by SEP. Maternal education moderated associations of girls' sweetened drink intake with self-efficacy, cooking skills and pressure to eat, and boys' non-core food intake with monitoring, parent's self-efficacy and home environment. Maternal occupation and employment moderated associations of sweetened drink intake with attitudes, self-efficacy, pressure to eat and food availability, and non-core food intake with parents' self-efficacy and monitoring. Income moderated associations with pressure to eat and home environment. Identifying differences in dietary predictors between socio-economic groups informs understanding of why socio-economic gradients in dietary intake may occur. Tailoring interventions and health promotion to the particular needs of socio-economically disadvantaged children may produce more successful outcomes and reduce socio-economic disparities in dietary intake.
To examine the relative contribution for the prediction of hypertension by waist circumference (WC), waist:stature ratio (WSR) or waist:hip ratio (WHR) with that by BMI, to ascertain if WC, WSR or WHR enhances the prediction of hypertension by BMI. Population-based, cross-sectional study. A change of >or=10 % in the prevalence ratio of BMI (PR) or the area under the receiver-operating characteristic curve (AUC) when WC, WSR or WHR was added to a model with BMI was used as the criterion for significant contribution to the prediction of hypertension by BMI. For greater contributions (>or=10 %) these waist measures were considered as better predictors. Nine provinces in China. Chinese adults aged 18 to 65 years (n 7336) who participated in the 2004 China Health and Nutrition Survey. The prevalence of hypertension (17 % and 23 % for women and men, respectively) was significantly related to increased BMI, WC, WSR and WHR (P for trend <0.001). Although there was a better model fit when WC, WSR or WHR was added to a model with BMI (P < 0.05; likelihood ratio test), the changes in PR and AUC were <10 % and <5 %, respectively. The sex-specific AUC for the prediction of hypertension by BMI (of 0.7-0.8) was similar to that by WC, WSR or WHR. The waist indices do not perform better than BMI or markedly enhance the prediction of increased hypertension risk by BMI in Chinese adults.
Definitions of breastfeeding, according to WHO 60,88
Comparison of official, national breastfeeding (BF) data collection and policy issues in European countries
List of breastfeeding co-ordinators
Prevalence of breastfeeding by age of child, UK 67 & Sweden 83 , 1990±1995/96 
Unlabelled: Recommendations suggest exclusive breast feeding for at least the first 4 to 6 months after birth. Paradoxically, an overwhelming proportion of breast feeding (BF) data in Europe refers to all BF, i.e. not only exclusive but also partial BF (including formula, juices, water, sweetened water etc). This makes it difficult to estimate to what extent the recommendations are met. There is currently strong evidence for recommending exclusive breast feeding for at least 6 months. Exclusive BF has progressively gained scientific support. Prevention of infections, allergies and chronic diseases and a favourable cognitive development are highlighted in the recent scientific literature. Further long-term studies on the effects of BF on prevention of chronic disease in the adult are needed. Great differences exist in BF prevalence and duration both within and between European countries. Trends point towards higher prevalence and duration, with some exceptions. Young mothers breast feed less than older mothers; single and/or less educated mothers breast feed less than married mothers with more education. However, inefficient and unreliable monitoring systems prevail, and the data are scarce, not only on exclusive BF but also on demographic, socio-economic, psychosocial and medical determinants of BF patterns. National BF coordinators have not been appointed in many countries, and only every second country has promotion of BF incorporated into their national plan of action for nutrition. Conclusions: Efficient surveillance systems, comparable across Europe and using common definitions and methodology, need to be developed. These should include determinants of breast feeding. A European consensus conference should urgently be organised, in which strategies for successful promotion of exclusive BF should be particularly considered. There is now strong evidence for a recommendation to breast feed exclusively for about 6 months, which is more than the duration recommended previously.
The �� 13C value of human blood is an emerging novel biomarker of added sugar (AS) intake for adults. However, no free-living, community-based assessments of comparative validity of this biomarker have been conducted. The purpose of the present investigation was to determine if Healthy Eating Index-2010 (HEI-2010) score, SoFAAS score (HEI-2010 sub-component for solid fat, alcohol and AS), AS and sugar-sweetened beverage (SSB) intakes were associated with �� 13C value of fingerstick blood in a community-based sample of adults, while controlling for relevant demographics. A cross-sectional analysis of data obtained from assessments of BMI, dietary intake using 24 h recalls and a fingerstick blood sample was completed. Statistical analyses included descriptive statistics, multiple linear regression and one-way ANOVA. Rural Southwest Virginia, USA. Adults (n 216) aged >18 years who consumed at least 837 kJ/d (200 kcal/d) from SSB. This sample of adult participants with low socio-economic status demonstrated a mean HEI-2010 score of 43��4 (sd 12��2), mean SoFAAS score of 10��2 (sd 5��7), mean AS intake of 93 (sd 65) g/d and mean blood �� 13C value of ���18��88 (sd 0��7) ���. In four separate regression models, HEI-2010 (R 2=0��16), SoFAAS (R 2=0��19), AS (R 2=0��15) and SSB (R 2=0��14) predicted �� 13C value (all P���0��001). Age was also predictive of �� 13C value, but not sex or race. These findings suggest that fingerstick �� 13C value has the potential to be a minimally invasive method for assessing AS and SSB intake and overall dietary quality in community-based settings. Strengths, limitations and future areas of research for using an objective �� 13C biomarker in diet-related public health studies are discussed.
of houses selected and the fraction of houses in rural and urban zones in each community 
To evaluate the association between overweight and wheezing in pre-school children in 14 small Brazilian communities. Cross-sectional epidemiological study, conducted between 2001 and 2002. A sample of 3453 children under 5 years of age was taken from nine communities in the state of Bahia and five in the state of São Paulo. Data on housing, family and children were obtained by applying structured questionnaires in loco. Weight and height for each child were also measured. The association between wheezing and overweight was assessed by unconditional logistic multivariate regression models. Overweight children had a greater frequency of wheezing and an odds ratio of 2.57 (95% confidence interval 1.51-4.37) was estimated after controlling for several potential confounding variables. The magnitude of the risk was not affected by several different model specifications. Excess weight is associated with increased risk for wheezing in this population of children below 5 years of age.
Developing countries are clearly facing a double burden of disease. The prevalences of overweight and obesity are rising among adults simultaneously with high rates of undernutrition among children 1-7 . Consequently, nutri- tion-related chronic diseases, such as cardiovascular disease and diabetes, are emerging as concerns in developing countries8. These concerns are combined with the continued need to address undernutrition and infectious disease. Overweight and obesity are increasing in Chile among low-income groups and poor commu- nities9. There is a triple burden of disease in South Africa, described by Vorster10. These are poverty-related infec- tious diseases, including HIV/AIDS, violence-related injuries and an increase in lifestyle-related non-commu- nicable diseases. The burden of obesity and cardiovas- cular disease in the more developed regions of Brazil is also emerging among the poor11. As nutrition-related chronic diseases become more prevalent, limited resources will be further strained by the simultaneous cost of addressing infectious disease and undernutrition, while treating nutrition-related chronic diseases. Early prevention is essential in order to prevent the epidemic. As Reddy8 states in this supplement, prevention is a necessary, cost-effective means of avoiding the high social, biological and economic costs of a treatment-based approach to nutrition-related chronic diseases. Thus, as a part of this meeting, we considered programmes in developing countries that have sought to intervene early to prevent obesity and nutrition-related chronic diseases.
Top-cited authors
Lluis Serra-Majem
  • Universidad de Las Palmas de Gran Canaria
Carlos Monteiro
  • University of São Paulo
James R Hebert
  • University of South Carolina
Anna Bach-Faig
  • Universitat Oberta de Catalunya
Nitin Shivappa
  • University of South Carolina