Content uploaded by Hans Georg Butschalowsky
Author content
All content in this area was uploaded by Hans Georg Butschalowsky on Nov 19, 2018
Content may be subject to copyright.
Journal of Health Monitoring CONCEPTS & METHODS
EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2Journal of Health Monitoring
Journal of Health Monitoring (S)
Journal of Health Monitoring
Journal of Health Monitoring · (S)
DOI ./RKI-GBE--
Robert Koch Institute, Berlin
Authors:
Gert B.M. Mensink, Marjolein Haftenberger,
Anna-Kristin Brettschneider,
Clarissa Lage Barbosa, Hanna Perlitz,
Eleni Patelakis, Karoline Heide,
Melanie Frank, Franziska Lehmann,
Laura Krause, Robin Houben,
Hans Butschalowsky, Almut Richter,
Panagiotis Kamtsiuris
Journal of Health Monitoring
EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Abstract
Nutrition plays an important role for health, in particular of children and adolescents. In addition to the baseline
German Health Interview and Examination Survey for Children and Adolescents (KiGGS, 2003-2006), the nutrition
survey EsKiMo (Eating study as a KiGGS Module) assessed the dietary habits of children and adolescents aged
6 to 17 in detail. In KiGGS Wave 2 (2014-2017) the corresponding module is EsKiMo II. Between June 2015 and
September 2017, specially trained nutritionists will visit EsKiMo II participants at their homes. The parents of
6-to 11-year-olds are instructed on how to complete food records on four randomly chosen days - three consecutive
days, followed later by an additional day. Participants aged 12 to 17 are interviewed personally on their food intake
during the past four weeks with the dietary interview programme DISHES. Further information, for example, regarding
dietary supplements is also recorded. EsKiMo II will provide an up-to-date and representative overview of the current
nutrition status of 6-to 17-year-olds living in Germany, and it allows analysing changes in dietary behaviour over
time. EsKiMo II can identify shortcomings in the nutrition of children and adolescents and thus may contribute
with important information to nutrition and health policy.
NUTRITION · FOOD CONSUMPTION · NUTRIENT SUPPLY · HEALTH MONITORING · KIGGS
1. Background and objective
Eating and drinking are essential for our life, and indi
-
vidual dietary habits have great influence on our physical
and mental health. An adequate diet is particularly impor-
tant for the growth and health development of children
and adolescents. Compared to adults, children require
a higher amount of nutrients per kilogramme of body
weight. Due to their lower body weight and an immune
system which is still developing over the first years of
their life, children constitute a particularly vulnerable
group for the health implications of food contaminated
with pathogens or other harmful substances. Addition-
ally, dietary habits generally develop during childhood
and have implications for people’s dietary behaviour at
adult age [1]. Monitoring potential health risks related to
food intake and improving dietary habits are important
tasks of nutrition and health policy. Keeping track of pop-
ulation dietary behaviour on a regular basis is therefore
necessary.
In the context of the German Health Interview and
Examination Survey for Children and Adolescents
(KiGGS) of the Robert Koch Institute (RKI), a food fre-
quency questionnaire is used for participants aged 3 and
older to obtain both the frequency and the respective
portion size of certain food groups that were consumed
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2 CONCEPTS & METHODS
may be subject to change over time. Data for EsKiMo II
will be collected between June 2015 and September 2017.
EsKiMo II aims to provide an up-to-date overview of the
dietary habits of children and adolescents aged 6 to 17
living in Germany.
2. Methodology
2.1 Study design and sampling
Participants of EsKiMo II are sampled from the cross-sec-
tional study population of KiGGS Wave 2 (aged 6 to 17),
mostly those who took also part in the physical exami-
nation of KiGGS Wave 2, and partly those who only
answered the KiGGS questionnaire. The target popula-
tion and sampling for KiGGS Wave 2 is described in
detail in the article New data for action. Data collection
for KiGGS Wave 2 has been completed in this issue of
the Journal of Health Monitoring. Participants receive a
written invitation to EsKiMo II three to six months after
taking part in KiGGS Wave 2 and about six weeks prior
to the scheduled date of the nutrition survey in their
locality (routes). Participation and appointments for
EsKiMo II are arranged by telephone (Figure 1). During
a route, participants are visited at their homes in paral-
lel at several KiGGS Wave 2 sample points (Figure 2) by
specially trained nutritionists. Like in KiGGS Wave 2, the
order of routes ensures a broad distribution of the
regions visited across Germany within seasons, to
account for seasonal dierences. The survey aims for a
net sample of at least 2,400 children and adolescents.
EsKiMo II received an approval from the ethics com-
mittee of the Hannover School of Medicine (number
during the past four weeks [2, 3]. While this information
does provide an impression of respondents’ regular die-
tary behaviour, it cannot, however, answer more complex
questions, for example to identify deficits in respondents’
nutrient supply.
This led, in the context of the RKI’s KiGGS baseline
study (2003-2006), to the implementation of EsKiMo
(Eating study as a KiGGS Module, referred to as
EsKiMo I in the following), the first representative sur-
vey of the dietary behaviour of children and adolescents
aged 6 to 17 in Germany [4, 5]. Funding was provided by
the Federal Ministry for Consumer Protection, Food and
Agriculture, which today is the Federal Ministry of Food
and Agriculture (BMEL). Given that data collection for
EsKiMo I took place ten years ago, KiGGS Wave 2 (2014-
2017) will include the EsKiMo II module, funded by the
BMEL. The Federal Institute for Risk Assessment (BfR)
will conduct in addition to EsKiMo II a further module
on nutrition (KiESEL – the children’s nutrition survey
module in KiGGS Wave 2), assessing the dietary habits
of children below six years [6].
As a module of the KiGGS study, EsKiMo II will pro-
vide the basis for dierentiated analyses for example of
the relation between dietary habits, socio-demographic
criteria (such as size of town, social status, and educa-
tion), behavioural factors (such as levels of physical activ-
ity, use of media or smoking), as well as a diverse set of
health parameters (biochemical and physiological meas-
urements) and diseases. Some of the planned analyses
will require data collection on food intake to take place
as soon as possible after data collection for KiGGS
Wave 2, since certain parameters (such as blood values)
EsKiMo II
Second Wave of the Eating study as a KiGGS
Module, -
Acronym: EsKiMo - Eating study as a KiGGS
Module
Implementation: Robert Koch Institute
Aim: Providing an up-to-date representative
overview of the dietary habits of children and
adolescents aged to in Germany.
Study design: Cross-sectional study based
on a modified diet history interview and food
records
Population: Children and adolescents with
permanent residence in Germany
Sampling: EsKiMo II participants are randomly
selected from the cross-sectional sample of
KiGGS Wave (registry oce sample). Being
invited to EsKiMo II requires participation in
KiGGS Wave .
Age range: to years
Sample size: at least , participants
Survey period: June - September
More information in German is available at
www.rki.de/eskimo
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Journal of Health Monitoring 2017 2(S3)
CONCEPTS & METHODS
2275-2015). Germany’s Federal Commissioner for Data
Protection and Freedom of Information has been
informed about and has also approved the survey. Par-
ents and guardians of all participants as well as adoles-
cents aged 14 and older have provided their informed
consent to participate in the survey.
2.2 Assessment methods and testing instruments
As in EsKiMo I, dierent assessment instruments are
used for the specific age groups. For children aged 6 to
11, the parents (or guardians) are asked to use weight-
ed food records to record children’s food intake on three
consecutive days, followed by an additional 1-day weight-
ed food record at a later point in time. A randomisation
process is used to determine the recording days. The
minimum timespan between the 3-day-weighted food
record and the 1-day-weighted food record should be
two weeks, the maximum timespan three months. The
parents (or guardians) are instructed on how to record
their children’s food intake. Entries are to include an
exact description of the foods consumed as well as
information on the brand, product name, fat content
Figure
Organisational process of EsKiMo II
field phases
Own figure
Figure
Sample points of EsKiMo II
Source: RKI Sample points
Preparatory phase
(- weeks)
Field phase
(- weeks)
Post-processing phase
(- months)
Ages - Invitations
sent out to
participants
Appoint-
ments
arranged
Instructions for the
use of weighted food
records
-day food records
and -day food
record
Data processing and
quality assurance Personal nutrition
analyses
Ages - DISHES interview Data processing and
quality assurance
Adequate nutrition is
essential in ensuring the
healthy development of
children and adolescents.
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Journal of Health Monitoring 2017 2(S3)
CONCEPTS & METHODS
food record requires participants to describe meals as
precisely as possible. Parents are asked to discuss the
entries with their children at home. The amounts con-
sumed are estimated based on the picture book or
household measures. The picture book aims to improve
the accuracy of participants’ estimates. It was adapted
for EsKiMo II and contains pictures provided by the
International Agency for Research on Cancer (IARC) and
the Pilot study for the Assessment of Nutrient intake
and food Consumption Among Kids in Europe (PAN-
CAKE) [7, 8]. Parents (or guardians) are also asked to
weigh and record in advance the food and beverages
that children take with them to school, as well as any
leftovers. For children who have school meals, parents
(for example of cheese), the actual amount of food on
the plate, and leftovers (Figure 3). Details on the time
of consumption, place of food preparation/consump-
tion, the state when purchased (for example raw), on
how the meal was prepared, and what type of packag-
ing it came in (for example plastic) are to be recorded
as well. In addition, participants are asked to provide
the recipes of self-prepared meals. Participants are giv-
en kitchen scales and instructions on how to use them,
as well as a picture book showing portion sizes. A sim-
plified version of the food record that children can fill
out themselves is provided for situations where partic-
ipants cannot weigh meals (for example in school can-
teens and/or restaurants). The simplified version of the
Wochentag: (bitte ankreuzen) Mo Di Mi Do Fr Sa So
. Tag
Beim Verzehr Marken name
(Firma) des
Produkts
Produktbeschreibung
(Fettgehalt, zugesetzte
Vitamine u. Mineral-
stoe)
Verpackung
bei Verkauf
Zustand
bei
Einkauf
Zubereitung Mengenangabe
Uhrzeit Ort Art Ort verzehrs-
fertige Menge
(Waage/
Fotobuch)
Restmenge/
Abfall
(Waage)
7:00 z. H. Dr. Oetker Vitalis Knusper Schoko K getr - z. H. 63 g -
+ Arla Friche BioWeidemilch
1,5 % Fett
V gek X - z. H. 127 g -
Becker's Bester Orangensaft G kons - z. H. 211 g 12 g
10:00 K Demeter Apfel, Sorte Elstar - fr X gew,
geschä,
geschn
z. H. 67 g -
12:30 z. H. Barilla Spaghetti aus
Hartweizengrieß
P getr geko z. H. 112 g -
+ Tomatensoße mit Gemüse*
(s. Rezept)
- - geko z. H. 68 g -
Leibniz Keks, Choco Vollmilch K - - - 15 g -
Beispiel Ernährungstagebuch
Figure
Sample food record page (in German)
Source: RKI
EsKiMo II provides an
up-to-date overview of the
dietary behaviour of
6-to 17-year-olds in Germany.
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Journal of Health Monitoring 2017 2(S3)
CONCEPTS & METHODS
lope. On the scheduled date they receive the 1-day-
weighted food record, which is also to be sent back after
completion. After completion, survey participants receive
a personal nutrition analysis and a voucher. The infor-
mation provided in the food records is processed with
(or guardians) are asked to provide the menu where
possible.
Telephone support is available to respond to any pos-
sible question of participants. Participants return the
completed food record to the RKI via a post-paid enve-
Figure
Example of a DISHES interview mask
(in German)
Source: RKI
The data provide the basis for
comprehensive analyses of
trends in dietary habits over
time of 6-to 17-year-olds.
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2 CONCEPTS & METHODS
3. Discussion and outlook
EsKiMo II will provide again up-to-date representative data
for Germany on the dietary behaviour and nutrient intake
of children and adolescents aged 6 to 17. This overview is
complemented by data on even younger children collect-
ed in the KiESEL survey. This means that a comprehensive
data set on the dietary behaviour of children and adoles-
cents of all ages will be available. For nutrition research,
food and health policy, as well as for the implementation
and evaluation of prevention measures, this data consti-
tutes an important source of information. Besides the
Federal Ministry of Food and Agriculture (BMEL) and the
Robert Koch Institute, further ministries including the
Federal Ministry of Health (BMG), the Federal Ministry for
the Environment, Nature Conservation, Building and
Nuclear Safety (BMUB), and subordinated institutes such
as the Federal Institute for Risk Assessment (BfR), the
German Environment Agency (UBA), as well as the Euro-
pean Food Safety Authority (EFSA) are greatly interested
in up-to-date data on the dietary behaviour of children and
adolescents in Germany. This is because this data helps
to identify deficits in the nutrition situation and to develop
corresponding consumer protection measures.
Because food supply and therefore also dietary be -
haviour are changing constantly, surveys on dietary be -
haviour should be conducted at regular intervals. During
the past years, for example, the number of gluten-free,
vegetarian, and vegan products on oer has increased
significantly. The contents of products such as breakfast
cereals are also regularly modified. Consumption of exotic
products in Germany has increased as a result of the
version 5.3 of the EAT software (Paderborn University)
using the codes of the German Nutrient Database ver-
sion 3.02 [9]. If necessary, discrepancies or missing infor-
mation is clarified by telephone.
With participants aged 12 to 17 a personal dietary inter-
view is conducted during the home visit using the DISHES
software (Dietary Interview Software for Health Examina-
tion Studies). Developed at the RKI, DISHES is a tool to
record regular dietary habits based on a modified diet his-
tory method. This method documents the frequency and
portion size of meals during the past four weeks (Figure 4),
the collected data are internally coded according to the
German Nutrient Database version 3.02 [9]. Portion sizes
are estimated using tableware and the picture book men-
tioned above. The instrument has been validated for
adults [10]. Provided respondents give their consent,
DISHES interviews are recorded digitally to allow sta to
clarify cases where the data provided by participants does
not seem plausible. In exchange, adolescents are remu-
nerated and receive a personal nutrition analysis.
For both age groups, the survey also records details
on school meals, diets, consumption of dietary supple-
ments, as well as information including height and
weight. This final item is important, because height and
weight may be subject to change in the interval between
data collection of KiGGS Wave 2 and EsKiMo II. EsKiMo II
also includes participants who were not previously exam-
ined in the context of KiGGS Wave 2. The participants’
current weight is required to evaluate their diet.
KiGGS Wave
Second follow-up to the German Health
Interview and Examination Survey for Children
and Adolescents
Data owner: Robert Koch Institute
Aim: Providing reliable information on health
status, health-related behaviour, living condi-
tions, protective and risk factors, and health
care among children, adolescents and young
adults living in Germany, with the possibility
of trend and longitudinal analyses.
Study design: Combined cross-sectional and
cohort study conducted as an examination
and interview survey
KiGGS cross-sec tional study
Population: Children and adolescents with
permanent residence in Germany
Sampling: Samples from ocial residency
registries - randomly selected children and
adolescents from the cities and municipal-
ities covered by the KiGGS baseline study
Age range: - years
Sample size: Approximately , participants
KiGGS cohort study
Sampling: Re-invitation of everyone who took
part in the KiGGS baseline study (-;
aged between and at that time) and who
was willing to participate in a follow-up
Age range: - years
Sample size: Approximately , follow-up
participants
Survey period: September - August
Modules: BELLA, EsKiMo, GerES, KiESEL,
MoMo
More information is available at
www.kiggs-studie.de/english
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Journal of Health Monitoring 2017 2(S3)
CONCEPTS & METHODS
dren. Moreover, adolescents in particular spend a lot of
time outside of their homes, which could make filling
out a food record dicult. This is why for this group the
DISHES interview was used.
Home visits will be concluded in September 2017.
A more detailled description of the study design and
methods is available elsewhere [13]. First results for
EsKiMo II will be available in 2018. EsKiMo II results will
be made available to policy-makers, science, and the
interested public. Corresponding publication formats
are being considered, such as project reports, press
releases, and German and English language publications
in academic journals.
Acknowledgement
We would like to thank all participants of EsKiMo II, their
parents, and the entire KiGGS study sta.
References
1. Birch LL (1999) Development of food preferences. Annu Rev
Nutr 19:41-62
2. Mensink GBM, Burger M (2004) Was isst du? Ein Verzehrshäu-
figkeitsfragebogen für Kinder und Jugendliche. Bundesgesund-
heitsbl Gesundheitsforsch Gesundheitsschutz 47(3):219-226
edoc.rki.de/oa/articles/rexKPi8f0KZ3E/PDF/25okAR8peLJI.pdf
(As at 31.07.2017)
3. Truthmann J, Mensink GBM, Richter A (2011) Relative validation
of the KiGGS Food Frequency Questionnaire among adolescents
in Germany. Nutr J 10:133
4. Mensink GBM, Bauch A, Vohmann C et al. (2007) EsKiMo – Das
Ernährungsmodul im Kinder- und Jugendgesundheitssurvey
(KiGGS). Bundesgesundheitsbl Gesundheitsforsch Gesundheits-
schutz 50(5-6):902-908
edoc.rki.de/oa/articles/reEzagAaWOvY/PDF/26r8LhAfE99Dc.pdf
(As at 31.07.2017)
globalisation of trade. This steadily expanding and chang-
ing supply of foods increases the diculties of recording
data on food consumption. Therefore, within EsKiMo II,
food composition information on foods not yet included
in the German Nutrient Database as well as dietary
supplements is continually gathered.
The combination of EsKiMo I (2006) and EsKiMo II
(2015-2017) for the first time enables a comprehensive
analysis of changes in the dietary habits of children and
adolescents in Germany over the past ten years. This is
facilitated by the largely identical design and methods
used in both surveys. The most important dierences
between both surveys are that in EsKiMo II data collec-
tion was one year longer and that food amounts are
weighed instead of estimated. Both of these aspects
ought to be considered when interpreting the results. To
improve diet-related risk assessment, EsKiMo II uses a
3-day-weighted food record and an independent 1-day
food record. EsKiMo is therefore now in line with the
standards of other institutions such as EFSA [11]. All of
the instruments used in EsKiMo II were developed in
close collaboration with the KiESEL study team, a step
that will ensure a high degree of comparability between
both nutrition surveys.
The food record method produces a detailed and com-
plete appraisal of consumed foods. Frequently, however,
food consumption changes while conducting a record.
This method is used for young children, in particular,
because they cannot be interviewed on their dietary
behaviour yet [12]. With adolescents, the willingness to
keep such a diary for three consecutive days is probably
significantly lower than among parents of younger chil-
EsKiMo II is an important
source of information for
nutrition and health policy.
Journal of Health Monitoring EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Journal of Health Monitoring 2017 2(S3)
CONCEPTS & METHODS
5. Stahl A, Vohmann C, Richter A et al. (2009) Changes in food and
nutrient intake of 6- to 17-year-old Germans between the 1980s
and 2006. Public Health Nutr 12(10):1912-1923
6. Schweter A, Parreidt N, Lähnwitz C et al. (2015) Kinder-
Ernährungsstudie zur Erfassung des Lebensmittelverzehrs
(KiESEL). UMID 2(2):57-63
7. Ocké M, de Boer E, Brants H et al. (2012) PANCAKE - Pilot study
for the Assessment of Nutrient intake and food Consumption
Among Kids in Europe. European Food Safety Authority. Support-
ing Publications 2012:EN-339
8. Van Kappel A, Amoyel J, Slimani N et al. (1995) EPIC-SOFT pic-
ture book for the estimation of food portion sizes. International
Agency for Research on Cancer, Lyon
9. Hartmann BM, Vásquez-Caicedo AL, Bell S et al. (2008) The Ger-
man nutrient database: Basis for analysis of the nutritional status
of the German population. J Food Compost Anal 21, Supple-
ment:P115-P118
10. Mensink GBM, Haftenberger M, Thamm M (2001) Validity of
DISHES 98, a computerised dietary history interview: energy and
macronutrient intake. Eur J Clin Nutr 55(6):409-417
11. European Food Safety Authority (2009) General principles for the
collection of national food consumption data in the view of a
pan-European dietary survey. EFSA Journal 7(12):1435
12. Livingstone MB, Robson PJ (2000) Measurement of dietary
intake in children. Proc Nutr Soc 59(2):279-293
13. Lage Barbosa C, Brettschneider AK, Haftenberger M et al. (2017)
Comprehensive assessment of food and nutrient intake of
children and adolescents in Germany: EsKiMo II - the Eating
Study as a KiGGS Module. BMC Nutrition 3:75
Journal of Health Monitoring CONCEPTS & METHODS
Publisher
Robert Koch Institute
Nordufer 20
D-13353 Berlin, Germany
Editors
Susanne Bartig, Johanna Gutsche, Dr Franziska Prütz,
Martina Rabenberg, Alexander Rommel, Dr Anke-Christine Saß,
Stefanie Seeling, Martin Thißen, Dr Thomas Ziese
Robert Koch Institute
Department of Epidemiology and Health Monitoring
General-Pape-Str. 62-66
D-12101 Berlin, Germany
Phone: +49 (0)30-18 754-3400
E-mail: healthmonitoring@rki.de
www.rki.de/journalhealthmonitoring-en
Typesetting
Gisela Dugnus, Alexander Krönke, Kerstin Möllerke
Translation
Simon Phillips/Tim Jack
Please cite this publication as
Mensink GBM, Haftenberger M, Brettschneider AK et al. (2017)
EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2.
Journal of Health Monitoring 2(S3):36–44.
DOI 10.17886/RKI-GBE-2017-107
ISSN 2511-2708
Imprint
Journal of Health Monitoring
Author details
Robert Koch Institute
Department of Epidemiology and Health Monitoring, Berlin
Corresponding author
Dr Gert B.M. Mensink
Robert Koch Institute
Department of Epidemiology and Health Monitoring
General-Pape-Str. 62-66
D-12101 Berlin, Germany
E-mail: MensinkG@rki.de
Conflicts of interest
The authors declared no conflicts of interest.
Funding
According to a German Bundestag decision, EsKiMo II was financially
supported by the German Federal Ministry of Food and Agriculture
(BMEL) through the Federal Oce for Agriculture and Food (BLE),
grant number 2814HS004.
Note
External contributions do not necessarily reflect the opinions of the
Robert Koch Institute.
EsKiMo II – the Eating study as a KiGGS Module in KiGGS Wave 2
Journal of Health Monitoring (S)
The Robert Koch Institute is a Federal Institute within
the portfolio of the German Federal Ministry of Health
This work is licensed under a
Creative Commons Attribution .
International License.