Protein intake and cancer: an umbrella review of systematic reviews for the evidence-based guideline of the German Nutrition Society.

PURPOSE: It has been proposed that a higher habitual protein intake may increase cancer risk, possibly via upregulated insulin-like growth factor signalling. Since a systematic evaluation of human studies on protein intake and cancer risk based on a standardised assessment of systematic reviews (SRs) is lacking, we carried out an umbrella review of SRs on protein intake in relation to risks of different types of cancer. METHODS: Following a pre-specified protocol (PROSPERO: CRD42018082395), we retrieved SRs on protein intake and cancer risk published before January 22th 2024, and assessed the methodological quality and outcome-specific certainty of the evidence using a modified version of AMSTAR 2 and NutriGrade, respectively. The overall certainty of evidence was rated according to predefined criteria. RESULTS: Ten SRs were identified, of which eight included meta-analyses. Higher total protein intake was not associated with risks of breast, prostate, colorectal, ovarian, or pancreatic cancer incidence. The methodological quality of the included SRs ranged from critically low (kidney cancer), low (pancreatic, ovarian and prostate cancer) and moderate (breast and prostate cancer) to high (colorectal cancer). The outcome-specific certainty of the evidence underlying the reported findings on protein intake and cancer risk ranged from very low (pancreatic, ovarian and prostate cancer) to low (colorectal, ovarian, prostate, and breast cancer). Animal and plant protein intakes were not associated with cancer risks either at a low (breast and prostate cancer) or very low (pancreatic and prostate cancer) outcome-specific certainty of the evidence. Overall, the evidence for the lack of an association between protein intake and (i) colorectal cancer risk and (ii) breast cancer risk was rated as possible. By contrast, the evidence underlying the other reported results was rated as insufficient. CONCLUSION: The present findings suggest that higher total protein intake may not be associated with the risk of colorectal and breast cancer, while conclusions on protein intake in relation to risks of other types of cancer are restricted due to insufficient evidence.

Dietary protein and blood pressure: an umbrella review of systematic reviews and evaluation of the evidence.

INTRODUCTION: This umbrella review aimed to investigate the evidence of an effect of dietary intake of total protein, animal and plant protein on blood pressure (BP), and hypertension (PROSPERO: CRD42018082395). METHODS: PubMed, Embase and Cochrane Database were systematically searched for systematic reviews (SRs) of prospective studies with or without meta-analysis published between 05/2007 and 10/2022. The methodological quality and outcome-specific certainty of evidence were assessed by the AMSTAR 2 and NutriGrade tools, followed by an assessment of the overall certainty of evidence. SRs investigating specific protein sources are described in this review, but not included in the assessment of the overall certainty of evidence. RESULTS: Sixteen SRs were considered eligible for the umbrella review. Ten of the SRs investigated total protein intake, six animal protein, six plant protein and four animal vs. plant protein. The majority of the SRs reported no associations or effects of total, animal and plant protein on BP (all "possible" evidence), whereby the uncertainty regarding the effects on BP was particularly high for plant protein. Two SRs addressing milk-derived protein showed a reduction in BP; in contrast, SRs investigating soy protein found no effect on BP. The outcome-specific certainty of evidence of the SRs was mostly rated as low. DISCUSSION/CONCLUSION: This umbrella review showed uncertainties whether there are any effects on BP from the intake of total protein, or animal or plant proteins, specifically. Based on data from two SRs with milk protein, it cannot be excluded that certain types of protein could favourably influence BP.

Protein intake and type 2 diabetes mellitus: an umbrella review of systematic reviews for the evidence-based guideline for protein intake of the German Nutrition Society.

PURPOSE: Protein-rich foods show heterogeneous associations with the risk of type 2 diabetes (T2D) and it remains unclear whether habitual protein intake is related to T2D risk. We carried out an umbrella review of systematic reviews (SR) of randomised trials and/or cohort studies on protein intake in relation to risks of T2D. METHODS: Following a pre-specified protocol (PROSPERO: CRD42018082395), we retrieved SRs on protein intake and T2D risk published between July 1st 2009 and May 22nd 2022, and assessed the methodological quality and outcome-specific certainty of the evidence using a modified version of AMSTAR 2 and NutriGrade, respectively. The overall certainty of evidence was rated according to predefined criteria. RESULTS: Eight SRs were identified of which six contained meta-analyses. The majority of SRs on total protein intake had moderate or high methodological quality and moderate outcome-specific certainty of evidence according to NutriGrade, however, the latter was low for the majority of SRs on animal and plant protein. Six of the eight SRs reported risk increases with both total and animal protein. According to one SR, total protein intake in studies was ~ 21 energy percentage (%E) in the highest intake category and 15%E in the lowest intake category. Relative Risks comparing high versus low intake in most recent SRs ranged from 1.09 (two SRs, 95% CIs 1.02-1.15 and 1.06-1.13) to 1.11 (1.05-1.16) for total protein (between 8 and 12 cohort studies included) and from 1.13 (1.08-1.19) to 1.19 (two SRs, 1.11-1.28 and 1.11-1.28) (8-9 cohort studies) for animal protein. However, SRs on RCTs examining major glycaemic traits (HbA1c, fasting glucose, fasting insulin) do not support a clear biological link with T2D risk. For plant protein, some recent SRs pointed towards risk decreases and non-linear associations, however, the majority did not support an association with T2D risk. CONCLUSION: Higher total protein intake was possibly associated with higher T2D risk, while there is insufficient evidence for a risk increase with higher intakes of animal protein and a risk decrease with plant protein intake. Given that most SRs on plant protein did not indicate an association, there is possibly a lack of an effect.

Protein intake and body weight, fat mass and waist circumference: an umbrella review of systematic reviews for the evidence-based guideline on protein intake of the German Nutrition Society.

PURPOSE: This umbrella review aimed to assess whether dietary protein intake with regard to quantitative (higher vs. lower dietary protein intake) and qualitative considerations (total, plant-based or animal-based protein intake) affects body weight (BW), fat mass (FM) and waist circumference (WC). METHODS: A systematic literature search was conducted in PubMed, Embase and Cochrane Database of Systematic Reviews for systematic reviews (SRs) with and without meta-analyses of prospective studies published between 04 October 2007 and 04 January 2022. Methodological quality and outcome-specific certainty of evidence of the retrieved SRs were assessed by using AMSTAR 2 and NutriGrade, respectively, in order to rate the overall certainty of evidence using predefined criteria. RESULTS: Thirty-three SRs were included in this umbrella review; 29 were based on randomised controlled trials, a few included cohort studies. In studies without energy restriction, a high-protein diet did not modulate BW, FM and WC in adults in general (all "possible" evidence); for older adults, overall certainty of evidence was "insufficient" for all parameters. Under hypoenergetic diets, a high-protein diet mostly decreased BW and FM, but evidence was "insufficient" due to low methodological quality. Evidence regarding an influence of the protein type on BW, FM and WC was "insufficient". CONCLUSION: "Possible" evidence exists that the amount of protein does not affect BW, FM and WC in adults under isoenergetic conditions. Its impact on the reduction in BW and FM under hypoenergetic conditions remains unclear; evidence for an influence of protein type on BW, FM and WC is "insufficient".

Protein intake and bone health: an umbrella review of systematic reviews for the evidence-based guideline of the German Nutrition Society.

This umbrella review aimed at assessing whether a protein intake exceeding the current recommendation for younger (0.8 g/kg body weight [BW]/day) and older (1.0 g/kg BW/day) adults affects bone mineral density and fracture risk. Moreover, the effect of animal or plant protein was evaluated. A systematic literature search was conducted in PubMed, Embase, and Cochrane Database of Systematic Reviews for systematic reviews (SRs) with or without meta-analysis of prospective studies published between 11/2008 and 08/2021. Methodological quality, outcome-specific certainty of evidence, and overall certainty of evidence of the retrieved SRs were assessed using established tools and predefined criteria. Eleven SRs of randomized controlled trials (RCTs) and/or cohort studies were included. In SRs of cohort studies and RCTs, protein intake/kg BW/day ranged between 0.21-0.95 g (low intake) and > 1.24 g (high intake), respectively, and between 0.67-1.1 g (control groups) and 1.01-1.69 g (intervention groups), respectively. The vast majority of outcome-specific certainty of evidence was rated "low" or "very low." The overall certainty of evidence for an association (cohort studies) or effect (RCTs) of total, animal or plant protein intake on each of the investigated outcomes was rated "insufficient," with the exception of possible evidence for a reduced hip fracture risk by high vs. low protein intake. Since protein intakes in low/control and high/intervention groups were very heterogeneous and with low certainty of evidence, it remains unclear whether a dose above the current recommendation or type of protein intake (animal or plant protein) affects bone health overall. However, there is possible evidence for reduced hip fracture risk with high versus low protein intake.

Protein intake and risk of urolithiasis and kidney diseases: an umbrella review of systematic reviews for the evidence-based guideline of the German Nutrition Society.

PURPOSE: Changes in dietary protein intake metabolically affect kidney functions. However, knowledge on potential adverse consequences of long-term higher protein intake (HPI) for kidney health is lacking. To summarise and evaluate the available evidence for a relation between HPI and kidney diseases, an umbrella review of systematic reviews (SR) was conducted. METHODS: PubMed, Embase and Cochrane Database of SRs published until 12/2022 were searched for the respective SRs with and without meta-analyses (MA) of randomised controlled trials or cohort studies. For assessments of methodological quality and of outcome-specific certainty of evidence, a modified version of AMSTAR 2 and the NutriGrade scoring tool were used, respectively. The overall certainty of evidence was assessed according to predefined criteria. RESULTS: Six SRs with MA and three SRs without MA on various kidney-related outcomes were identified. Outcomes were chronic kidney disease, kidney stones and kidney function-related parameters: albuminuria, glomerular filtration rate, serum urea, urinary pH and urinary calcium excretion. Overall certainty of evidence was graded as 'possible' for stone risk not to be associated with HPI and albuminuria not to be elevated through HPI (above recommendations (> 0.8 g/kg body weight/day)) and graded as 'probable' or 'possible' for most other kidney function-related parameters to be physiologically increased with HPI. CONCLUSION: Changes of the assessed outcomes may have reflected mostly physiological (regulatory), but not pathometabolic responses to higher protein loads. For none of the outcomes, evidence was found that HPI does specifically trigger kidney stones or diseases. However, for potential recommendations long-term data, also over decades, are required.

Work-related stressors and coping behaviors among leaders in small and medium-sized IT and technological services enterprises.

BACKGROUND: Occupational health interventions for leaders are underrepresented in small and medium-sized enterprises (SMEs). When creating and developing effective occupational health interventions, identification of the specific needs of the target group is regarded as an essential step before planning an intervention. Therefore, the aim of this study was (1) to examine the subjectively experienced work-related stressors of leaders in small and medium-sized IT and technological services enterprises, (2) to explore coping behaviors leaders use to deal with the experienced work-related stressors, (3) to investigate resources supporting the coping process and (4) to identify potentially self-perceived consequences resulting from the experienced stressors. METHODS: Ten semi-structured interviews with leaders in small and medium-sized IT and technological services enterprises were conducted. The interviews were transcribed and analyzed with content-structuring qualitative content analysis in accordance to Kuckartz. RESULTS: Leaders in small and medium-sized IT and technological services enterprises experience various stressors caused by work organization as well as industry-related stressors and other work-related stressors. To address the experienced stressors, leaders apply problem focused coping behaviors (e.g. performing changes on structural and personal level), emotional focused coping behaviors (e.g. balancing activities, cognitive restructuring) as well as the utilization of social support. Helpful resources for the coping process include organizational, social and personal resources. As a result of the experienced work-related stressors, interviewees stated to experience different health impairments, negative effects on work quality as well as neglect of leisure activities and lack of time for family and friends. CONCLUSION: The identified experienced work-related stressors, applied coping behaviors, utilized resources and emerging consequences underpin the urgent need for the development and performance of health-oriented leadership interventions for leaders in small and medium- sized IT and technological services. The results of this study can be used when designing a target-oriented intervention for the examined target group.

Dietary protein intake and health-related outcomes: a methodological protocol for the evidence evaluation and the outline of an evidence to decision framework underlying the evidence-based guideline of the German Nutrition Society.

PURPOSE: The present work aimed to delineate (i) a revised protocol according to recent methodological developments in evidence generation, to (ii) describe its interpretation, the assessment of the overall certainty of evidence and to (iii) outline an Evidence to Decision framework for deriving an evidence-based guideline on quantitative and qualitative aspects of dietary protein intake. METHODS: A methodological protocol to systematically investigate the association between dietary protein intake and several health outcomes and for deriving dietary protein intake recommendations for the primary prevention of various non-communicable diseases in the general adult population was developed. RESULTS: The developed methodological protocol relies on umbrella reviews including systematic reviews with or without meta-analyses. Systematic literature searches in three databases will be performed for each health-related outcome. The methodological quality of all selected systematic reviews will be evaluated using a modified version of AMSTAR 2, and the outcome-specific certainty of evidence for systematic reviews with or without meta-analysis will be assessed with NutriGrade. The general outline of the Evidence to Decision framework foresees that recommendations in the derived guideline will be given based on the overall certainty of evidence as well as on additional criteria such as sustainability. CONCLUSION: The methodological protocol permits a systematic evaluation of published systematic reviews on dietary protein intake and its association with selected health-related outcomes. An Evidence to Decision framework will be the basis for the overall conclusions and the resulting recommendations for dietary protein intake.

Maternal pregnancy weight or gestational weight gain and offspring's blood pressure: A systematic review.

AIMS: An increasing number of studies suggest that maternal weight parameters in pregnancy are associated with offspring's blood pressure (BP). The aim of this systematic review - following the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement - was to assess and judge the evidence for an association between maternal pregnancy weight/body mass index (BMI) or gestational weight gain (GWG) with offspring's BP in later life. DATA SYNTHESIS: MEDLINE, EMBASE, Cochrane Library, CINAHL and Web of Science were searched without limits. Risk of bias was assessed using the "US National Heart, Lung and Blood Institute"-tool, and an evidence grade was allocated following the "World Cancer Research Fund" criteria. Of 7,124 publications retrieved, 16 studies (all cohort studies) were included in the systematic review. Overall data from 52,606 participants (0 years [newborns] to 32 years) were enclosed. Association between maternal pregnancy BMI and offspring's BP were analyzed in 2 (both "good-quality" rated) studies, without consistent results. GWG and offspring's BP was analyzed in 14 studies (2 "good-quality", 9 "fair-quality", 3 "poor-quality" rated). Of these, 3 "fair-quality" studies described significant positive results for systolic BP and significant results, but partly with varying directions of effect estimates for diastolic BP. Mean arterial pressure (MAP) was analyzed in 1 "poor-quality" congress paper. Overall, based on the small number of "good-quality"-rated studies and the inconsistency of effect direction, no firm conclusion can be drawn. CONCLUSION: Evidence for an association of maternal pregnancy weight determinants with offspring's BP was overall graded as "limited - no conclusion".

Fast food consumption among 12- to 17-year-olds in Germany - Results of EsKiMo II.

Consuming high amounts of fast food can lead to an excessive intake of energy and subsequently promote obesity. Obesity increases a person's risk for diabetes and cardiovascular diseases. The second wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017) included the Eating study as a KiGGS Module (EsKiMo II, 2015-2017) which assessed the self-reported dietary habits of children and adolescents in Germany. The analysis of the data permits an overview of the fast food consumption of 12- to 17-year-olds (n=1,353). Girls consume 57.5 grams and boys 86.3 grams of fast food per day on average (around 400 grams and 600 grams per week, respectively). Pizza is the most consumed fast food product, followed by filled pita and sausage/meat products such as curry sausage. Adolescent girls on average get 6.5% and boys 7.8% of total daily energy intake from fast food. 23% of 12- to 17-year-olds get at least 10% of their daily energy intake from fast food (high consumers). Significant differences between the proportion of high consumers exist regarding sex, age, socioeconomic status, community size, type of school and media consumption. Compared to EsKiMo I (2006), girls' daily energy intake from fast food has remained nearly constant, whereas that of boys has dropped substantially. From a nutrition physiology perspective, the aim should be to further reduce fast food consumption.

Maternal prepregnancy BMI or weight and offspring's blood pressure: Systematic review.

Emerging evidence suggests that maternal prepregnancy body mass index or weight (MPBW) may be associated with offspring's blood pressure (BP). Therefore, we conducted a systematic review-following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement-to assess and judge the evidence for an association between MPBW with offspring's later BP. Five data bases were searched without limits. Risk of bias was assessed using the "Tool to Assess Risk of Bias in Cohort Studies," and an evidence grade was allocated following the World Cancer Research Fund criteria. Of 2,011 publications retrieved, 16 studies (all cohort studies) were included in the systematic review; thereof, 5 studies (31%) were rated as good-quality studies. Overall, data from 63,959 participants were enclosed. Systolic BP was analysed in 15 (5 good quality), diastolic BP in 12 (3 good quality), and mean arterial pressure in 3 (no good quality) studies. Five good-quality studies of MPBW with offspring's systolic BP as the outcome and 1 good-quality study with offspring's diastolic BP as the outcome observed a significant association. However, after adding offspring's anthropometry variables to the statistical model, the effect attenuated in 4 studies with systolic BP to nonsignificance, the study with diastolic BP remained significant. No good-quality studies were found with respect to offspring's later mean arterial pressure. In conclusion, this systematic review found suggestive, but still limited, evidence for an association between MPBW with offspring's later BP. The available data suggest that the effect might be mainly mediated via offspring's anthropometry.

Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review.

OBJECTIVE: To analyse and compare the cost-effectiveness of different interventions to reduce salt consumption. DESIGN: A systematic review of published cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) was undertaken in the databases EMBASE, MEDLINE (PubMed), Cochrane and others until July 2016. Study selection was limited to CEA and CUA conducted in member countries of the Organisation for Economic Co-operation and Development (OECD) in English, German or French, without time limit. Outcomes measures were life years gained (LYG), disability-adjusted life years (DALY) and quality-adjusted life years (QALY). Relevant aspects in modelling were analysed and compared. Quality assessments were conducted using the Drummond and Jefferson/British Medical Journal checklist. SETTING: OECD member countries. SUBJECTS: Mainly adults. RESULTS: Fourteen CEA and CUA were included in the review which analysed different strategies: salt reduction or substitution in processed foods, taxes, labelling, awareness campaigns and targeted dietary advice. Fifty-nine out of sixty-two scenarios were cost-saving. The incremental cost-effectiveness ratio in international dollars (Intl.$; 2015) was particularly low for taxes, a salt reduction by food manufacturers and labelling (303 900 Intl.$/DALY). However, only six studies analysed cost-effectiveness from a societal perspective and quality assessments showed flaws in conducting and a lack of transparency in reporting. CONCLUSIONS: A population-wide salt reduction could be cost-effective in prevention of hypertension and CVD in OECD member countries. However, comparability between study results is limited due to differences in modelling, applied perspectives and considered data.

Perspective: NutriGrade: A Scoring System to Assess and Judge the Meta-Evidence of Randomized Controlled Trials and Cohort Studies in Nutrition Research.

The objective of this study was to develop a scoring system (NutriGrade) to evaluate the quality of evidence of randomized controlled trial (RCT) and cohort study meta-analyses in nutrition research, building upon previous tools and expert recommendations. NutriGrade aims to assess the meta-evidence of an association or effect between different nutrition factors and outcomes, taking into account nutrition research-specific requirements not considered by other tools. In a pretest study, 6 randomly selected meta-analyses investigating diet-disease relations were evaluated with NutriGrade by 5 independent raters. After revision, NutriGrade was applied by the same raters to 30 randomly selected meta-analyses in the same thematic area. The reliability of ratings of NutriGrade items was calculated with the use of a multirater κ, and reliability of the total (summed scores) was calculated with the use of intraclass correlation coefficients (ICCs). The following categories for meta-evidence evaluation were established: high (8-10), moderate (6-7.99), low (4-5.99), and very low (0-3.99). The NutriGrade scoring system (maximum of 10 points) comprises the following items: 1) risk of bias, study quality, and study limitations, 2) precision, 3) heterogeneity, 4) directness, 5) publication bias, 6) funding bias, 7) study design, 8) effect size, and 9) dose-response. The NutriGrade score varied between 2.9 (very low meta-evidence) and 8.8 (high meta-evidence) for meta-analyses of RCTs, and it ranged between 3.1 and 8.8 for meta-analyses of cohort studies. The κ value of the ratings for each scoring item varied from 0.32 (95% CI: 0.22, 0.42) for risk of bias for cohort studies and 0.95 (95% CI: 0.91, 0.99) for study design, with a mean κ of 0.66 (95% CI: 0.53, 0.79). The ICC of the total score was 0.81 (95% CI: 0.69, 0.90). The NutriGrade scoring system showed good agreement and reliability. The initial findings regarding the performance of this newly established scoring system need further evaluation in independent analyses.

Evidence-Based Guideline of the German Nutrition Society: Fat Intake and Prevention of Selected Nutrition-Related Diseases.

As nutrition-related chronic diseases have become more and more frequent, the importance of dietary prevention has also increased. Dietary fat plays a major role in human nutrition, and modification of fat and/or fatty acid intake could have a preventive potential. The aim of the guideline of the German Nutrition Society (DGE) was to systematically evaluate the evidence for the prevention of the widespread diseases obesity, type 2 diabetes mellitus, dyslipoproteinaemia, hypertension, metabolic syndrome, coronary heart disease (CHD), stroke, and cancer through the intake of fat or fatty acids. The main results can be summarized as follows: it was concluded with convincing evidence that a reduced intake of total and saturated fat as well as a larger intake of polyunsaturated fatty acids (PUFA) at the expense of saturated fatty acids (SFA) reduces the concentration of total and low-density lipoprotein cholesterol in plasma. Furthermore, there is convincing evidence that a high intake of trans fatty acids increases risk of dyslipoproteinaemia and that a high intake of long-chain polyunsaturated n-3 fatty acids reduces the triglyceride concentration in plasma. A high fat intake increases the risk of obesity with probable evidence when total energy intake is not controlled for (ad libitum diet). When energy intake is controlled for, there is probable evidence for no association between fat intake and risk of obesity. A larger intake of PUFA at the expense of SFA reduces risk of CHD with probable evidence. Furthermore, there is probable evidence that a high intake of long-chain polyunsaturated n-3 fatty acids reduces risk of hypertension and CHD. With probable evidence, a high trans fatty acid intake increases risk of CHD. The practical consequences for current dietary recommendations are described at the end of this article.

Early Diet and Later Cancer Risk: Prospective Associations of Dietary Patterns During Critical Periods of Childhood with the GH-IGF Axis, Insulin Resistance and Body Fatness in Younger Adulthood.

Early life, adiposity rebound, and puberty represent critical growth periods when food choices could have long-term relevance for cancer risk. We aimed to relate dietary patterns during these periods to the growth hormone-insulin-like-growth-factor (GH-IGF) axis, insulin resistance, and body fatness in adulthood. Data from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study participants with outcome data at 18-37 years, and ≥2 dietary records during early life (1-2 yr; n = 128), adiposity rebound (4-6 years, n = 179), or puberty (girls 9-14, boys 10-15 yr; n = 213) were used. Dietary patterns at these ages were derived by 1) reduced rank regression (RRR) to explain variation in adult IGF-I, IGF-binding protein-3 (IGFBP-3), homoeostasis model assessment for insulin resistance (HOMA-IR) and fat-mass index; 2) principal component analysis (PCA). Regarding RRR, the patterns "cake/canned fruit/cheese & eggs" (early life), "sweets & dairy" (adiposity rebound) and "high-fat foods" (pubertal boys) were independently associated with higher adult HOMA-IR. Furthermore, the patterns "favorable carbohydrate sources" (early life), "snack & convenience foods" (adiposity rebound), and "traditional & convenience carbohydrates" (pubertal boys) were related to adult IGFBP-3 (P trend < 0.01). PCA identified "healthy" patterns for all periods, but none was associated with the outcomes (P trend > 0.1). In conclusion, dietary patterns during sensitive growth periods may be of long-term relevance for adult insulin resistance and IGFBP-3.

Physical Activity, Bone Health, and Obesity in Peri-/Pre- and Postmenopausal Women: Results from the EPIC-Potsdam Study.

Physical activity (PA) is suggested to increase the peak bone mass and to minimize age-related bone loss, and thereby to reduce the risk of osteoporosis. However, the relation between PA and bone health considering the obesity status is unclear so far. The present study examines the association between PA levels and calcaneal broadband ultrasound attenuation (BUA), particularly under consideration of obesity. Data from a population-based sample of 6776 German women from the EPIC-Potsdam cohort were analyzed. Calibrated PA data were used. Statistical analyses were stratified by menopausal and obesity status. Multiple linear regression was used to model the relationship between PA and BUA levels after adjustment for age, body mass index (BMI), smoking status, education, alcohol and calcium intake, and hormone use. Peri-/premenopausal had higher BUA levels (112.39 ± 10.05 dB/MHz) compared to postmenopausal women (106.44 ± 9.95 dB/MHz). In both groups, BUA levels were higher in the fourth compared to the lowest quartile of PA (p for trend < 0.05). In women with BMI < 30, but not BMI ≥ 30 kg/m(2), PA remained positively associated with BUA levels (p for interaction = 0.03). However, when waist circumference higher than 88 cm or body fat percentage (BF%) measures above the median were used to define obesity, a significant positive relationship was also observed in women with BMI < 30 kg/m(2) but with higher waist circumference or BF%. In conclusion, our results strengthen the hypothesis that PA has a positive influence on BUA levels, though dependent on weight.

Access to Difficult-to-reach Population Subgroups: A Family Midwife Based Home Visiting Service for Implementing Nutrition-related Preventive Activities - A Mixed Methods Explorative Study.

Health and social inequality are tightly linked and still pose an important public health problem. However, vulnerable and disadvantaged populations are difficult to reach for health-related interventions. Given the long-lasting effects of an adverse, particular nutrition-related, intrauterine and neonatal environment on health development (perinatal programming), an early and easy access is essential for sustainable interventions. The goal of this explorative study was therefore to elucidate whether an existing access of family midwives (FMs) to families in need of support could be an option to implement effective public health and nutrition interventions. To that end three research objectives were formulated: (1) to determine whether a discernible impact of home visits by FMs can be described; (2) to identify subgroups among these families in need of more specific interventions; (3) to determine how relevant nutrition-related topics are for both FMs and the supported families. For addressing these objectives a mixed methods design was used: Routine documentation data from 295 families visited by a family midwife (FM) were analyzed (secondary analysis), and structured expert interviews with FMs were conducted and analyzed. Study reporting followed the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) statement. Based on the FMs reports, a significant improvement (p < 0.001) regarding psycho-social variables could be determined after the home visits. Single mothers, however, seemed to benefit less from the FMs service compared to their counterparts (p = 0.015). Nutritional counseling was demanded by 89% of the families during the home visits. In addition, nutrition-related topics were reported in the interviews to be of high interest to both families and the FMs. Based on the obtained results it is concluded that FMs home visits offer a promising access to vulnerable and disadvantaged families for implementing nutrition-related preventive activities.

Is breastfeeding related to bone properties? A longitudinal analysis of associations between breastfeeding duration and pQCT parameters in children and adolescents.

Nutritive and bioactive components of human milk could be involved in programming metabolic systems that affect bone growth throughout the life course. Bone properties in childhood and adolescence might differ, depending on breastfeeding duration. Thus, breastfeeding could be a relevant factor in the context of primary osteoporosis prevention. The prospective association between breastfeeding duration and bone properties was investigated using the data of 284 participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed Study. Breastfeeding duration was assessed during infancy. Bone properties were measured by peripheral quantitative computed tomography (pQCT) at ages 5-23 years. Cortical volumetric bone mineral density, cortical bone mineral content, strength strain index, total cross-sectional area of the bone and cross-sectional area of the cortical bone were determined at the 65% site of the radius. Linear regression analyses were performed to check for differences in pQCT parameters of subjects who had not or shortly been breastfed (0-16 weeks) and subjects who had been breastfed for a long duration (≥17 weeks). Multivariable models adjusted for age, gender, forearm length, muscle cross-sectional area, body mass index standard deviation score (SDS), height SDS and socio-economic status did not yield associations between breastfeeding duration and pQCT parameters. These findings suggest neither protective nor adverse effects of prolonged breastfeeding on bone health in childhood and adolescence. Influences of early nutrition on bone growth might be overridden by current effects of mechanical loads on bone physiology.