Consumption of young child formulae in the Netherlands.

PURPOSE: Adequate micronutrient intakes are essential for young children. Special young child formulae (YCF) intended for children from 1 year old are available in the Dutch market. Since YCF are enriched with many micronutrients, it has the potential to have a beneficial effect on young children, or might pose a risk on excessive micronutrient intakes. The current study investigated the characteristics of YCF users, and the effect of YCF use on micronutrient intakes. METHODS: Data from the Dutch National Food Consumption Survey (2012-2016; n = 440 children aged 1-2 year old) and the Dutch Food Composition Database (NEVO version 2016) were used to assess micronutrient intakes. Habitual intakes of users and non-users of YCF were calculated using Statistical Program to Assess Dietary Exposure (SPADE) and compared. RESULTS: In the Netherlands, YCF was consumed by 21% of the 1-2-year-olds. YCF contributed mostly to total vitamin D intake (76%) and between 0 and 50% for other micronutrients. Higher vitamin A, B1, C, D, E, total folate, iron and zinc intakes were observed among users, and higher potassium and phosphorus intakes were found among non-users. Risk of inadequate intake was low among both users and non-users for most nutrients, and the only elevated risk of excessive intake found was for zinc among YCF users. CONCLUSION: YCF increased micronutrient intake, however, for most of the micronutrients there is already a low risk of inadequate intake. YCF increased the risk of excessive zinc intake. It is important that the addition of micronutrients to YCF is regulated, to prevent excessive intake.

Clusters of lifestyle behaviours and their associations with socio-demographic characteristics in Dutch toddlers.

PURPOSE: This study aimed to identify clusters of lifestyle behaviours in toddlers and assess associations with socio-demographic characteristics. METHODS: We used data from the Dutch National Food Consumption Survey 2012-2016 and included 646 children aged 1-3 years. Based on 24-h dietary recalls and a questionnaire, a two-step cluster analysis was conducted to identify clusters in the intake of fruit, vegetables, sugar-sweetened beverages and unhealthy snacks, physical activity and screen time. Logistic regression models assessed associations between socio-demographic characteristics and cluster allocation. RESULTS: Three clusters emerged from the data. The 'relatively healthy cluster' demonstrated a high intake of fruit and vegetables, low sugar-sweetened beverage and unhealthy snack intake and low screen time. The 'active snacking cluster' was characterised by high unhealthy snack intake and high physical activity, and the 'sedentary sweet beverage cluster' by high intake of sugar-sweetened beverages and high screen time. Children aged 1 year were most likely to be allocated to the 'relatively healthy cluster'. Compared to children of parents with a high education level, children of parents with a low or middle education level were less likely to be in the 'relatively healthy cluster', but more likely to be in the 'sedentary sweet beverage cluster'. CONCLUSION: Clusters of lifestyle behaviours can be distinguished already in children aged 1-3 years. To promote healthy lifestyle behaviour, efforts may focus on maintaining healthy behaviour in 1-year-olds and more on switching towards healthy behaviour in 2- and 3-year-olds.

Development and evaluation study of FLY-Kids: a new lifestyle screening tool for young children.

Evaluating, discussing, and advising on young children's lifestyles may contribute to timely modification of unhealthy behaviour and prevention of adverse health consequences. We aimed to develop and evaluate a new lifestyle screening tool for children aged 1-3 years. The lifestyle screening tool "FLY-Kids" was developed using data from lifestyle behaviour patterns of Dutch toddlers, age-specific lifestyle recommendations, target group analyses, and a Delphi process. Through 10 items, FLY-Kids generates a dashboard with an overview of the child's lifestyle that can be used as conversation aid. FLY-Kids was completed by parents of children aged 1-3 years attending a regular youth healthcare appointment. Youth healthcare professionals (YHCP) then used the FLY-Kids dashboard to discuss lifestyle with the parents and provided tailored advice. Parents as well as YHCP evaluated the tool after use. Descriptive and correlation statistics were used to determine the usability, feasibility, and preliminary effect of FLY-Kids. Parents (N = 201) scored an average of 3.2 (out of 9, SD 1.6) unfavourable lifestyle behaviours in their children, while 3.0% complied with all recommendations. Most unfavourable behaviours were reported in unhealthy food intake and electronic screen time behaviour. Parents and YHCP regarded FLY-Kids as usable and feasible. The number of items identified by FLY-Kids as requiring attention was associated with the number of items discussed during the appointment (r = 0.47, p < 0.001).     Conclusion: FLY-Kids can be used to identify unhealthy lifestyle behaviour in young children and guide the conversation about lifestyle in preventive healthcare settings. End-users rated FLY-Kids as helpful and user-friendly. What is Known: • A healthy lifestyle is important for optimal growth, development and overall health of young children (1-3 years). • Evaluating, discussing and advising on young children's lifestyles may contribute to timely modification of unhealthy behaviour and prevention of adverse health consequences. What is New: • The new lifestyle screening tool FLY-Kids generates a dashboard with an overview of young children's lifestyle that can be used as conversation aid between parents and youth healthcare professionals. • As parents and youth healthcare professionals rated FLY-Kids as helpful and user-friendly, and the number of items identified by FLY-Kids as requiring attention was associated with the number of items discussed during the appointment, FLY-Kids can be considered guiding the lifestyle discussion in preventive healthcare settings.

Contribution of voluntary fortified foods to micronutrient intake in The Netherlands.

PURPOSE: In the Netherlands, voluntary fortification of foods with micronutrients is allowed under strict regulations. This study investigates the impact of voluntary food fortification practices in the Netherlands on the frequency and type of fortified food consumption and on the micronutrient intakes of the Dutch population. METHODS: Data of the Dutch National Food Consumption Survey (2012-2016; N = 4314; 1-79 year) and the Dutch Food Composition Database (NEVO version 2016) was used. To determine if voluntary fortified foods could be classified as healthy foods, criteria of the Dutch Wheel of Five were used. Habitual intakes of users and non-users of voluntary food fortification were calculated using Statistical Program to Assess Dietary Exposure (SPADE) and compared. RESULTS: Within the Dutch population, 75% could be classified as user of voluntary fortified foods. Consumed voluntary fortified foods were mostly within food groups 'Fats and Oils', 'Non-alcoholic Beverages' and 'Dairy products and Substitutes' and fell mostly outside the Wheel of Five. Voluntary foods contributed between 9 and 78% to total micronutrient intake of users. Users had up to 64% higher habitual micronutrient intakes, compared to non-users. These higher intakes resulted into lower risks on inadequate intakes, and did not contribute to increased risks of excessive intakes. CONCLUSION: Although voluntary fortified foods increased micronutrient intakes, most of these foods cannot be classified as healthy foods. Future studies should study the association between higher micronutrient intakes and (potential) excessive intakes of e.g. saturated fat and sugar to better understand the role of voluntary fortified foods in a healthy food pattern.

Contribution of fortified margarines and other plant-based fats to micronutrient intake in the Netherlands.

PURPOSE: In the Netherlands, margarines and other plant-based fats (fortified fats) are encouraged to be fortified with vitamin A and D, by a covenant between the Ministry of Health and food manufacturers. Frequently, these types of fats are also voluntarily fortified with other micronutrients. The current study investigated the contribution of both encouraged as well as voluntary fortification of fortified fats on the micronutrient intakes in the Netherlands. METHODS: Data of the Dutch National Food Consumption Survey (2012-2016; N = 4, 314; 1-79 year.) and the Dutch Food Composition Database (NEVO version 2016) were used to estimate micronutrient intakes. Statistical Program to Assess Dietary Exposure (SPADE) was used to calculate habitual intakes and compared to dietary reference values, separate for users and non-users of fortified fats. RESULTS: Of the Dutch population, 84% could be considered as user of fortified fats. Users consumed mostly 1 fortified fat a day, and these fats contributed especially to the total micronutrient intake of the encouraged fortified micronutrients (vitamins D and A; 44% and 29%, respectively). The voluntary fortification also contributed to total micronutrient intakes: between 7 and 32%. Vitamin D and A intakes were up to almost double among users compared to non-users. Intakes were higher among users for almost all micronutrients voluntarily added to fats. Higher habitual intakes resulted into higher risks of excessive vitamin A-intakes among boys and adult women users. CONCLUSION: Consumption of fortified fats in the Netherlands resulted into higher vitamin A and D-intakes among users, compared to non-users of these products.

Neonatal heel prick screening TSH concentration in the Netherlands as indicator of iodine status.

BACKGROUND: Neonatal Thyroid Stimulating Hormone (nTSH) is proposed as indicator of iodine deficiency in a population. Population's iodine sufficiency is indicated by a proportion of the newborns less than 3% having nTSH above 5 mIU/L. The aim of this study was to explore the Dutch neonatal heel prick screening TSH data to assess iodine status in the Netherlands and identify determinants and potential confounders of this assessment. METHODS: All newborns born in the Netherlands between 2007 and 2015 with a heel prick collection at day 3-7 were included (n = 1,435,600), except preterm neonates and baby's with a low birth weight. Total T4 was measured for all children, nTSH was measured in the ~ 20% children with lowest total T4. RESULTS: The proportion with nTSH > 5mIU/L fluctuated between 0.6-1.3% in 2007-2015. nTSH was significantly associated with laboratory performing the nTSH assay and age of heel prick sampling. The overall increasing trend in proportion nTSH >1mIU/L was confounded by the laboratories with different and changed assays. CONCLUSIONS: The low proportion neonates with high nTSH suggests a sufficient iodine status in the Netherlands. Whether the increased proportion nTSH>1mIU/L over the years is an early indicator of deterioration of the iodine status remains unclear, due to differences and changes in analytical assays. nTSH might be a valuable and inexpensive way to get crude insight in the (trend in) iodine status, but more research is needed on the validity and potential conditions.

A Novel Approach to Optimize Vitamin D Intake in Belgium through Fortification Based on Representative Food Consumption Data.

BACKGROUND: Food fortification is a promising means to improve vitamin D intake of a population. Careful selection of food vehicles is needed to ensure that nearly all individuals within the population benefit from the fortification program. OBJECTIVES: The aim of the study was to develop and apply a model that simultaneously selects the optimal combination of food vehicles and defines the optimal fortification level that adequately increases vitamin D intake in the population without compromising safety. METHODS: Food consumption data from the Belgian Food Consumption Survey 2014 (n = 3200; age 3-64 y) were used. The optimization model included 63 combinations of 6 potential vehicles for food fortification, namely "bread," "breakfast cereals," "fats and oils," "fruit juices," "milk and milk beverages," and "yogurt and cream cheese." The optimization procedure was designed to minimize inadequate or excessive vitamin D intake in each of the food combinations. This allowed the relative ranking of the different combinations according to their fortification utility. The estimated average requirement and upper intake level were used as thresholds. An age-specific and population-based approach enabled the sensitivity of the population subgroups to adverse health effects to be taken into account. Feasibility, technical aspects, and healthiness of the food vehicles were used to select the optimal combination. RESULTS: Multiple combinations of food vehicles significantly reduced the prevalence of inadequate vitamin D intake within the Belgian population (from 92-96% to <2%). Taking other aforementioned criteria into account, the fortification of "milk and milk beverages" and "bread" with 6.9 µg vitamin D/100 kcal was proposed as an optimal fortification scenario. CONCLUSIONS: The optimization model allows identification of an effective fortification scenario to improve vitamin D intake within the Belgian population based on acceptable risks of inadequate and excessive intake. The model can be extended to other micronutrients and other populations.

Decreased, but still sufficient, iodine intake of children and adults in the Netherlands.

Sufficient I intake is important for the synthesis of thyroid hormones, which play an important role in normal growth and development. Our aim was to estimate habitual I intake for the Dutch population and the risk of inadequate or excessive intakes. Further, we aimed to provide an insight into the dietary sources of I and the association with socio-demographic factors. Data from the Dutch National Food Consumption Survey 2007-2010 (n 3819; 7-69 years), and from the Dutch food and supplement composition tables were used to estimate habitual I intake with a calculation model. Contribution of food groups to I intake were computed and multiple linear regression was used to examine associations of intakes with socio-demographic factors. A total of ≤2 % of the population had an intake below the estimated average requirement or above the upper level. The main sources of I were bread containing iodised salt (39 %), dairy products (14 %) and non-alcoholic drinks (6 %). I intake (natural sources only, excluding iodised salt and supplements) was positively associated with (parental) education, which could at least partly be attributed to a higher consumption of dairy products. Among children, the consumption of bread, often containing iodised bakery salt, was positively associated with parental education. The I intake of the Dutch population (7-69 years) seems adequate, although it has decreased since the period before 2008. With the current effort to reduce salt intake and changing dietary patterns (i.e. less bread, more organic foods) it is important to keep a close track on the I status, important sources and potential risk groups.

Vitamin D intake of Dutch infants from the combination of (fortified) foods, infant formula, and dietary supplements.

PURPOSE: Due to changes in the Dutch fortification policy for vitamin D and the vitamin D supplementation advice for infants (10-µg/d for 0-4 year olds), a partially virtual scenario study was conducted to evaluate the risk of excessive vitamin D intake assigning all infants to a 100 % adherence to the supplementation advice and considering the current fortification practice. METHODS: Food consumption data from the Nutrition Intake Study (2002; N = 941, 7-19 months) were combined with Dutch food composition data from 2011 to estimate vitamin D intake from (fortified) foods. For infants 0-6 months of age, the consumption volume infant formula was estimated from energy requirement and body weight. All subjects were assigned to take a daily 10 µg vitamin D supplement, according the Dutch supplementation advice for infants. Habitual vitamin D intake was estimated using the Statistical Program to Assess Dietary Exposure and compared with the tolerable upper intake levels (ULs) set by the European Food Safety Authority. RESULTS: The median habitual total vitamin D intake was 16-22 µg/day for infants aged 0-6 months (increasing with age) and 13-21 µg/day for infants aged 7-19 months (decreasing with age). About 4-12 % of infants aged 7-11 months exceeded the UL. At the 99th percentile, the intake was 2-4 µg above the UL, depending on age. Infants aged 0-6 and 12-19 months did not exceed the UL. CONCLUSIONS: In case of combined intake from infant formula, (fortified) foods, and supplements, vitamin D intakes above the UL are possible among some infants during a limited time period.

Are more environmentally sustainable diets with less meat and dairy nutritionally adequate?

OBJECTIVE: Our current food consumption patterns, and in particular our meat and dairy intakes, cause high environmental pressure. The present modelling study investigates the impact of diets with less or no meat and dairy foods on nutrient intakes and assesses nutritional adequacy by comparing these diets with dietary reference intakes. DESIGN: Environmental impact and nutrient intakes were assessed for the observed consumption pattern (reference) and two replacement scenarios. For the replacement scenarios, 30 % or 100 % of meat and dairy consumption (in grams) was replaced with plant-based alternatives and nutrient intakes, greenhouse gas emissions and land use were calculated. SETTING: The Netherlands. SUBJECTS: Dutch adults (n 2102) aged 19-69 years. RESULTS: Replacing 30 % of meat and dairy with plant-based alternatives did not substantially alter percentages below the Estimated Average Requirement (EAR) for all studied nutrients. In the 100 % replacement scenario, SFA intake decreased on average by ~35 % and Na intake by ~8 %. Median Ca intakes were below the Adequate Intake. Estimated habitual fibre, Fe and vitamin D intakes were higher; however, non-haem Fe had lower bioavailability. For Zn, thiamin and vitamin B12, 10-31 % and for vitamin A, 60 % of adults had intakes below the EAR. CONCLUSIONS: Diets with all meat and dairy replaced with plant-based foods lowered environmental impacts by >40 %. Estimated intakes of Zn, thiamin, vitamins A and B12, and probably Ca, were below recommendations. Replacing 30 % was beneficial for SFA, Na, fibre and vitamin D intakes, neutral for other nutrients, while reducing environmental impacts by 14 %.

How may a shift towards a more sustainable food consumption pattern affect nutrient intakes of Dutch children?

OBJECTIVE: Food has a considerable environmental impact. Diets with less meat and dairy reduce environmental impact but may pose nutritional challenges for children. The current modelling study investigates the impact of diets with less or no meat and dairy products on nutrient intakes. DESIGN: Energy and nutrient intakes were assessed for observed consumption patterns (reference) and two replacement scenarios with data from the Dutch National Food Consumption Survey - Young Children (2005-2006). In the replacement scenarios, 30 % or 100 % of the consumed dairy and meat (in grams) was replaced by plant-derived foods with similar use. SETTING: The Netherlands. SUBJECTS: Children (n 1279) aged 2-6 years. RESULTS: Partial and full replacement of meat and dairy foods by plant-derived foods reduced SFA intake by 9 % and 26 %, respectively, while fibre intake was 8 % and 29 % higher. With partial replacement, micronutrient intakes were similar, except for lower vitamin B12 intake. After full meat and dairy replacement, mean intakes of Ca, Zn and thiamin decreased by 5-13 %, and vitamin B12 intake by 49 %, while total intake of Fe was higher but of lower bioavailability. With full replacement, the proportion of girls aged 4-6 years with intakes below recommendations was 15 % for thiamin, 10 % for vitamin B12 and 6 % for Zn. CONCLUSIONS: Partial replacement of meat and dairy by plant-derived foods is beneficial for children's health by lowering SFA intake, increasing fibre content and maintaining similar micronutrient intakes. When full replacements are made, attention is recommended to ensure adequate thiamin, vitamin B12 and Zn intakes.

SPADE, a new statistical program to estimate habitual dietary intake from multiple food sources and dietary supplements.

BACKGROUND: For the evaluation of both the adequacy of intakes and the risk of excessive intakes of micronutrients, all potential sources should be included. In addition to micronutrients naturally present in foods, micronutrients can also be derived from fortified foods and dietary supplements. In the estimation of the habitual intake, this may cause specific challenges such as multimodal distributions and heterogeneous variances between the sources. OBJECTIVE: We present the Statistical Program to Assess Dietary Exposure (SPADE) that was developed to cope with these challenges in one single program. METHOD: Similar to other methods, SPADE can model habitual intake of daily and episodically consumed dietary components. In addition, SPADE has the option to model habitual intake from dietary supplements. Moreover, SPADE offers models to estimate habitual intake distributions from different sources (e.g., foods and dietary supplements) separately and adds these habitual intakes to get the overall habitual intake distribution. The habitual intake distribution is modeled as a function of age, and this distribution can directly be compared with cutoff values to estimate the proportion above or below. Uncertainty in the habitual intake distribution and in the proportion below or above a cutoff value is quantified with ready-for-use bootstrap and provides 95% CIs. RESULTS: SPADE is implemented in R and is freely available as an R package called SPADE.RIVM. The various features of SPADE are illustrated by the estimation of the habitual intake distribution of folate and folic acid for women by using data from the Dutch National Food Consumption Survey 2007-2010. The results correspond well with the results of existing programs. CONCLUSION: SPADE offers new features to existing programs to estimate the habitual intake distribution because it can handle many different types of modeling with the first-shrink-then-add approach.

Assessment of the prevalence of inadequate iron intakes in premenopausal females based on the reference values of the European Food Safety Authority using cross-sectional food consumption data.

BACKGROUND: The iron intake requirement distribution for premenopausal females is not symmetric, which invalidates the EAR cut-point approach for assessing the prevalence of iron inadequacy. Therefore, Beaton's Full Probability Approach (PA) must be used. Although the PA requires information on the entire iron intake requirement distribution, the European Food Safety Authority (EFSA) only provided the EAR (50th percentile), 90th, 95th (population reference intake), and 97.5th percentiles. OBJECTIVES: This study aimed to reliably estimate the prevalence of iron inadequacy in premenopausal females using the PA, based on the intake requirements established by EFSA, and compare the results with those obtained from the EAR cut-point method. METHODS: Habitual iron intakes were calculated using the statistical program to assess dietary exposure with data from 484 females (20-45 y) from the Dutch National Food Consumption Survey 2012-2016. Iron requirements of EFSA (including additionally obtained information) were applied. Results from the PA were compared to results obtained with the EAR cut-point method. Sensitivity analyses examined the impact of lower iron intake distributions on differences in estimated inadequate intakes between PA and EAR cut-point methods. RESULTS: A 2-fold higher prevalence of iron inadequacy among Dutch premenopausal females was observed when employing the PA compared to the EAR cut-point method, using EFSA's reference values. Sensitivity analysis showed that the EAR cut-point method could also result in large overestimations for populations with lower intake distributions. CONCLUSIONS: This study provided an example of using the PA method by using additionally derived information on the full requirement distribution underlying EFSA's reference values. Results showed once more the unsuitability of the EAR cut-point method to calculate the prevalence of iron inadequacy in premenopausal females. Hence, we recommend that institutions deriving dietary reference values provide all the information needed to use the correct method to determine inadequate intakes in the population.

Procedure to identify fortified foods in the Dutch branded food database.

Introduction: Information on fortified foods is needed for multiple purposes, including food consumption research and dietary advice. Branded food databases are a valuable source of food label data. European labeling legislation prescribes that food fortification should be indicated in the ingredient list, and nutrient values should be declared under certain conditions. This creates the potential to identify fortified foods in branded food databases, though it is not straightforward and labor-intensive. The aim of our study was to develop an automated approach to identify fortified foods in the Dutch branded food database called LEDA. Methods: An automated procedure, based on a stepwise approach conforming with European labeling legislation, using a list of rules and search terms, was developed to identify fortified foods. Fortification with calcium, folic acid, vitamin B12, and zinc was studied as an example. The results of a random stratified sample with fortified and not-fortified foods were validated by two experts. Results: The automated approach resulted in identifying 1,817 foods fortified with one or more of the selected nutrients in the LEDA dataset (0.94%). The proportions of fortified foods per nutrient were below 0.7%. The classification of fortified/non-fortified foods matched manual validation by experts for the majority of the foods in the sample, i.e., sensitivity and specificity indicating the probability of correctly identifying fortified and non-fortified foods was high (>94.0%). Conclusion: The automated approach is capable of easily and quickly identifying fortified foods in the Dutch branded food database with high accuracy, although some improvements to the automated procedure could be made. In addition, the completeness, correctness, and consistency of the LEDA database can be improved. To fully benefit from this automated approach, it needs to be expanded to cover all micronutrients that may be added to foods.

Replacement of meat and dairy by plant-derived foods: estimated effects on land use, iron and SFA intakes in young Dutch adult females.

OBJECTIVE: Reduction in the current high levels of meat and dairy consumption may contribute to environmental as well as human health. Since meat is a major source of Fe, effects on Fe intake need to be evaluated, especially in groups vulnerable to negative Fe status. In the present study we evaluated the effects of replacing meat and dairy foods with plant-based products on environmental sustainability (land requirement) and health (SFA and Fe intakes) in women. DESIGN: Data on land requirements were derived from existing calculation methods. Food composition data were derived from the Dutch Food Composition Table 2006. Data were linked to the food consumption of young Dutch women. Land requirements and nutrient intakes were evaluated at baseline and in two scenarios in which 30% (Scenario_30%) or 100% (Scenario_100%) of the dairy and meat consumption was randomly replaced by the same amount of plant-based dairy- and meat-replacing foods. SETTING: The Netherlands. SUBJECTS: Three hundred and ninety-eight young Dutch females. RESULTS: Replacement of meat and dairy by plant-based foods benefited the environment by decreasing land use. The intake of SFA decreased considerably compared with the baseline situation. On average, total Fe intake increased by 2.5 mg/d, although most of the Fe intake was from a less bioavailable source. CONCLUSIONS: Replacement of meat and dairy foods by plant-based foods reduced land use for consumption and SFA intake of young Dutch females and did not compromise total Fe intake.

An Evaluation of Food and Nutrient Intake among Pregnant Women in The Netherlands: A Systematic Review.

Nutritional deficiencies during pregnancy can have serious consequences for the health of the (unborn) child. This systematic review provides an updated overview of the available food and nutrient intake data for pregnant women in The Netherlands and an evaluation based on the current recommendations. Embase, MEDLINE, and national institute databases were used. Articles were selected if they had been published since 2008 and contained data on food consumption, nutrient intake, or the status of healthy pregnant women. A qualitative comparison was made with the 2021 Dutch Health Council recommendations and reference values. A total of 218 reports were included, representing 54 individual studies. Dietary assessments were primarily performed via food frequency questionnaires. Protein, vitamin A, thiamin, riboflavin, vitamin B6, folate, vitamin B12, vitamin C, iron, calcium, and magnesium intakes seemed to be adequate. For folate and vitamin D, supplements were needed to reach the recommended intake. The reasons for concern are the low intakes of fruits, vegetables, and (fatty) fish, and the intakes of alcohol, sugary drinks, and salt. For several foods and nutrients, no or limited intake data were found. High-quality, representative, and recent data are needed to evaluate the nutrient intake of pregnant women in order to make accurate assessments and evaluations, supporting scientific-based advice and national nutritional policies.

Estimating habitual iodine intake and prevalence of inadequacy from spot urine in cross-sectional studies: a modeling analysis to determine the required sample size.

BACKGROUND: The habitual/usual iodine intake and the prevalence of iodine inadequacy may be estimated from spot urinary iodine concentrations in cross-sectional studies by collecting a repeat spot urine in a subgroup of the study population and accounting for within-person variability in iodine intake. However, guidance on the required overall sample size (N) and the replicate rate (n) is lacking. OBJECTIVES: To determine the sample size (N) and replicate rate (n) needed to estimate the prevalence of iodine inadequacy in cross-sectional studies. METHODS: We used data from local observational studies conducted in women 17-49 y old in Switzerland (N = 308), South Africa (N = 154), and Tanzania (N = 190). All participants collected 2 spot urine samples. We calculated the iodine intake using urinary iodine concentrations and accounted for urine volume using urinary creatinine concentration. For each study population, we estimated the habitual iodine intake distribution and determined the prevalence of iodine intake below the average requirement using the Statistical Program to Assess habitual Dietary Exposure (SPADE). We used the obtained model parameters in power analyzes and estimated the prevalence of iodine inadequacy for different sample sizes (N = 400, 600, and 900) and replicate rates (n = 50, 100, 200, 400, 600, and 900). RESULTS: The estimated prevalence (95% CI) of inadequate iodine intake was 21% (15, 28%), 5.1% (1.3, 8.7%), and 8.2% (3.4, 13%) for Swiss, South African, and Tanzanian women, respectively. An N of 400 women, with a repeated measure (n) in 100 women, achieved a satisfactory precision of the prevalence estimate in all study populations. Increasing the replicate rate (n) improved the precision more effectively than increasing the N of the study. CONCLUSIONS: The sample size for cross-sectional studies aiming to assess the prevalence of inadequate iodine intake depend on the expected prevalence, the overall variance in intake, and the study design. However, an N of 400 participants with a repeated measure of 25% may be used as guidance when planning observational studies applying simple random sampling. This trial was registered at clinicaltrials.gov as NCT03731312.

Lifestyle Screening Tools for Children in the Community Setting: A Systematic Review.

Screening of children's lifestyle, including nutrition, may contribute to the prevention of lifestyle-related conditions in childhood and later in life. Screening tools can evaluate a wide variety of lifestyle factors, resulting in different (risk) scores and prospects of action. This systematic review aimed to summarise the design, psychometric properties and implementation of lifestyle screening tools for children in community settings. We searched the electronic databases of Embase, Medline (PubMed) and CINAHL to identify articles published between 2004 and July 2020 addressing lifestyle screening tools for children aged 0-18 years in the community setting. Independent screening and selection by two reviewers was followed by data extraction and the qualitative analysis of findings. We identified 41 unique lifestyle screening tools, with the majority addressing dietary and/or lifestyle behaviours and habits related to overweight and obesity. The domains mostly covered were nutrition, physical activity and sedentary behaviour/screen time. Tool validation was limited, and deliberate implementation features, such as the availability of clear prospects of actions following tool outcomes, were lacking. Despite the multitude of existing lifestyle screening tools for children in the community setting, there is a need for a validated easy-to-administer tool that enables risk classification and offers specific prospects of action to prevent children from adverse health outcomes.

A systematic review of iodine intake in children, adults, and pregnant women in Europe-comparison against dietary recommendations and evaluation of dietary iodine sources.

CONTEXT: Adequate iodine intake is essential throughout life. Key dietary sources are iodized salt and animal products, but dietary patterns in Europe are changing, for example toward lower salt intake and a more plant-based diet. OBJECTIVE: To review iodine intake (not status) in European populations (adults, children, and pregnant women) to identify at-risk groups and dietary sources. DATA SOURCES: PubMed, Embase, and Cochrane databases, as well as European national nutrition surveys were searched for data on had iodine intake (from dietary assessment) and sources of iodine, collected after 2006. DATA SELECTION: In total, 57 studies were included, comprising 22 national surveys and 35 sub-national studies. Iodine intake data were available from national surveys of children aged <10 years (n = 11), 11-17 years (n = 12), and adults (n = 15), but data from pregnancy were only available from sub-national studies. RESULTS: Iodine intake data are lacking-only 17 of 45 (38%) European countries had iodine-intake data from national surveys. Iodine intake reported from national surveys was below recommendations for: (1) children aged <10 years in 2 surveys (18%), (2) boys and girls aged 11-17 years in 6 (50%) and 8 (68%) surveys, respectively, and (3) adult men and women in 7 (47%) and 12 (80%) surveys, respectively. In pregnant women, intake was below recommendations except where women were taking iodine-containing supplements. Just 32% of national surveys (n = 7) included iodized salt when estimating iodine intake. Milk, dairy products, fish, and eggs were important contributors to intake in many countries, suggesting limited sources in plant-based diets. CONCLUSION: Results are limited by the challenges of dietary assessment for measuring iodine intake. Future national surveys should include iodine intake. Policy makers should consider dietary sources alongside any iodized salt policies when considering methods for improving population iodine intake. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2017 CRD42017075422.