Dietary sources of free sugars in the diet of European children: the IDEFICS Study.

OBJECTIVE: To report dietary free sugars consumption and their different types and food sources in European children. METHODS: The present study is based on the IDEFICS study, a European multicenter cohort study in children (2-9 years old) from eight countries, comprising 8308 children (51.4% males). Dietary intake of the previous 24 h was assessed using a computer-assisted 24-h dietary recalls (24-HDR) and the different types of sugars were assessed using the German food composition database. RESULTS: Mean total energy intake was 1720 (SD 477) kcal/d for boys and 1631 (SD 451) kcal/d for girls. Total sugars intake was 98 (SD 52) g/day for boys and 93 (SD 49) g/day for girls. Free sugars intake was 81 (SD 49) g/day for boys and 77 (SD 47) g/day for girls. Girls had significantly lower intakes of energy, total and free sugars compared with than boys but did not differ in terms of percent of energy from total (23%) or free sugars (18%). There were large variations between countries in average % energy from free sugars (ranging from 13% in Italy to 27% in Germany). Less than 20% of children were within the recommended intake of 10% of energy from free sugars. The food groups that contributed substantially to free sugars intakes were "Fruit juices", "Soft drinks", "Dairy" and "Sweets and candies". CONCLUSIONS: The contribution of free sugars to total energy intake in European children is higher than recommendations. The main food contributors to free sugars intake are sweetened beverages ("Fruit juices" and "Soft drinks"). It is especially important to reduce children's intake of free sugars, focusing in target population on certain foods and food groups.

Dietary calcium intake and adiposity in children and adolescents: Cross-sectional and longitudinal results from IDEFICS/I.Family cohort.

BACKGROUND AND AIMS: Studies in children and adolescents suggest that higher dairy consumption may exert a protective effect on adiposity. However, only few studies examined the association between dietary calcium intake and body mass measures with conflicting results. We evaluated the association between total dietary calcium, calcium from dairy and non-dairy sources and anthropometric indices in a large European cohort of children and adolescents. METHODS AND RESULTS: As many as 6,696 children belonging to the IDEFICS study were eligible for the cross-sectional analysis (Boys = 51%; age 6.0 ± 1.8 years; mean ± SD). Of these, 2,744 were re-examined six years later (Boys = 49.6%; age = 11.7 ± 1.8 years) in the framework of the I.Family study. The exposures were the baseline energy-adjusted total, dairy and non-dairy calcium intakes measured by a validated 24-h dietary recall. Multivariable linear regression was used to determine the association between calcium intake and z-scores of anthropometric indices (body mass index, BMI; waist circumference, WC; sum of skinfolds, SS; fat mass index, FMI) at baseline, and their variation over the 6 years follow-up. The association of dietary calcium with the incidence of overweight/obesity was also assessed. At baseline, an inverse association between total calcium intake and all the adiposity indices was consistently observed in boys, while only SS and FMI were significant in girls. The prevalence of overweight/obesity decreased significantly (P < 0.0001) across tertiles of calcium intake, in both sexes. Over the follow-up, boys with higher baseline calcium intake value showed significantly lower increase in BMI, WC and FMI z-scores, while in girls only a lower increase in WC z-score was observed. Only in boys, the risk to become overweight/obese decreased significantly across tertiles of calcium intake. Similar results were observed by analyzing only dietary calcium from dairy, while no association was observed between non-dairy calcium and adiposity indices. CONCLUSIONS: We showed in a large cohort of European children and adolescents that dietary calcium intake may play a role in the modulation of body fat in developmental age. The association between dietary calcium and adiposity indices was driven by dairy calcium, while no effect was observed for non-dairy calcium intake. The existence of a sex-related difference in the association deserves further investigations.

A within-sibling pair analysis of lifestyle behaviours and BMI z-score in the multi-centre I.Family study.

BACKGROUND AND AIMS: By investigating differences in lifestyle behaviours and BMI in sibling pairs, family-level confounding is minimized and causal inference is improved, compared to cross-sectional studies of unrelated children. Thus, we aimed to investigate within-sibling pair differences in different lifestyle behaviours and differences in BMI z-scores in children and adolescents. METHODS AND RESULTS: We examined three groups of sibling pairs 1) all same-sex sibling pairs with maximum 4 years age difference (n = 1209 pairs from 1072 families in 8 countries, mean age 10.7 years, standard deviation 2.4 years), 2) sibling pairs discordant for overweight (n = 262) and 3) twin pairs (n = 85). Usual dietary intake was estimated by 24-h recalls and time spent in light (LPA) and moderate-to-vigorous physical activity (MVPA) was measured by accelerometers. Screen time, sleep and dieting for weight loss were assessed by questionnaires. Within all 3 groups of sibling pairs, more time in MVPA was associated with lower BMI z-score. Higher energy intake was associated with higher BMI z-score within twin pairs and within all sibling pairs who were not currently dieting for weight loss. Regarding LPA, screen time or sleep duration, no or inconsistent associations were observed for the three groups of sibling pairs. CONCLUSIONS: MVPA and energy intake were associated with BMI differences within sibling and twin pairs growing up in the same home, thus independent of family-level confounding factors. Future studies should explore whether genetic variants regulating appetite or energy expenditure behaviours account for weight differences in sibling pairs.

A prospective evaluation of plasma phospholipid fatty acids and breast cancer risk in the EPIC study.

BACKGROUND: Intakes of specific fatty acids have been postulated to impact breast cancer risk but epidemiological data based on dietary questionnaires remain conflicting. MATERIALS AND METHODS: We assessed the association between plasma phospholipid fatty acids and breast cancer risk in a case-control study nested within the European Prospective Investigation into Cancer and Nutrition study. Sixty fatty acids were measured by gas chromatography in pre-diagnostic plasma phospholipids from 2982 incident breast cancer cases matched to 2982 controls. Conditional logistic regression models were used to estimate relative risk of breast cancer by fatty acid level. The false discovery rate (q values) was computed to control for multiple comparisons. Subgroup analyses were carried out by estrogen receptor (ER) and progesterone receptor expression in the tumours. RESULTS: A high level of palmitoleic acid [odds ratio (OR) for the highest quartile compared with the lowest OR (Q4-Q1) 1.37; 95% confidence interval (CI), 1.14-1.64; P for trend = 0.0001, q value = 0.004] as well as a high desaturation index (DI16) (16:1n-7/16:0) [OR (Q4-Q1), 1.28; 95% C, 1.07-1.54; P for trend = 0.002, q value = 0.037], as biomarkers of de novo lipogenesis, were significantly associated with increased risk of breast cancer. Levels of industrial trans-fatty acids were positively associated with ER-negative tumours [OR for the highest tertile compared with the lowest (T3-T1)=2.01; 95% CI, 1.03-3.90; P for trend = 0.047], whereas no association was found for ER-positive tumours (P-heterogeneity =0.01). No significant association was found between n-3 polyunsaturated fatty acids and breast cancer risk, overall or by hormonal receptor. CONCLUSION: These findings suggest that increased de novo lipogenesis, acting through increased synthesis of palmitoleic acid, could be a relevant metabolic pathway for breast tumourigenesis. Dietary trans-fatty acids derived from industrial processes may specifically increase ER-negative breast cancer risk.

Dietary glycemic index, glycemic load, and cancer risk: results from the EPIC-Italy study.

Factors linked to glucose metabolism are involved in the etiology of several cancers. High glycemic index (GI) or high glycemic load (GL) diets, which chronically raise postprandial blood glucose, may increase cancer risk by affecting insulin-like growth factor. We prospectively investigated cancer risk and dietary GI/GL in the EPIC-Italy cohort. After a median 14.9 years, 5112 incident cancers and 2460 deaths were identified among 45,148 recruited adults. High GI was associated with increased risk of colon and bladder cancer. High GL was associated with: increased risk of colon cancer; increased risk of diabetes-related cancers; and decreased risk of rectal cancer. High intake of carbohydrate from high GI foods was significantly associated with increased risk of colon and diabetes-related cancers, but decreased risk of stomach cancer; whereas high intake of carbohydrates from low GI foods was associated with reduced colon cancer risk. In a Mediterranean population with high and varied carbohydrate intake, carbohydrates that strongly raise postprandial blood glucose may increase colon and bladder cancer risk, while the quantity of carbohydrate consumed may be involved in diabetes-related cancers. Further studies are needed to confirm the opposing effects of high dietary GL on risks of colon and rectal cancers.

Alcohol consumption and risk of urothelial cell bladder cancer in the European prospective investigation into cancer and nutrition cohort.

Findings on the association between alcohol consumption and bladder cancer are inconsistent. We investigated that association in the European Prospective Investigation into Cancer and Nutrition cohort. We included 476,160 individuals mostly aged 35-70 years, enrolled in ten countries and followed for 13.9 years on average. Hazard ratios (HR) for developing urothelial cell carcinoma (UCC; 1,802 incident cases) were calculated using Cox proportional hazards models. Alcohol consumption at baseline and over the life course was analyzed, as well as different types of beverages (beer, wine, spirits). Baseline alcohol intake was associated with a statistically nonsignificant increased risk of UCC (HR 1.03; 95% confidence interval (CI) 1.00-1.06 for each additional 12 g/day). HR in smokers was 1.04 (95% CI 1.01-1.07). Men reporting high baseline intakes of alcohol (>96 g/day) had an increased risk of UCC (HR 1.57; 95% CI 1.03-2.40) compared to those reporting moderate intakes (<6 g/day), but no dose-response relationship emerged. In men, an increased risk of aggressive forms of UCC was observed even at lower doses (>6 to 24 g/day). Average lifelong alcohol intake was not associated with the risk of UCC, however intakes of spirits > 24 g/day were associated with an increased risk of UCC in men (1.38; 95% CI 1.01-1.91) and smokers (1.39; 95% CI 1.01-1.92), compared to moderate intakes. We found no association between alcohol and UCC in women and never smokers. In conclusion, we observed some associations between alcohol and UCC in men and in smokers, possibly because of residual confounding by tobacco smoking.

Blood fatty acid composition in relation to allergy in children aged 2-9 years: results from the European IDEFICS study.

BACKGROUND/OBJECTIVES: Blood polyunsaturated fatty acids (PUFA) are involved in allergy development, but the etiological role of n-6 and n-3 PUFA is still controversial. A European multicenter study of children (IDEFICS) provided the opportunity to explore the cross-sectional association between fatty acids (FA) and allergy. SUBJECTS/METHODS: Blood FA levels were measured in 2600 children aged 2-9 years and were recorded as the percentage of weight of all FA detected. Logistic regression of allergy status on FA components was adjusted for age, sex, country, body mass index, family history of allergic disease, breast-feeding, and number of siblings. The results were given as odds ratios (OR) for current vs no allergy ever and an increase in FA by 1 s.d. RESULTS: Overall, higher proportions of n-6 PUFA were associated with higher odds of allergy (OR=1.21 (1.05, 1.40)). Monounsaturated FA (MUFA) were associated with reduced risk for allergy (OR=0.75 (0.65, 0.87)), whereas saturated FA did not differ by allergy status. The strongest associations were observed in children <4 years old, with ORs of allergy given as 1.62 (1.15, 2.29) for n-3 PUFA and 0.63 (0.42, 0.95) for MUFA. With regard to individual FA, these associations were independently observed for docosapentaenoic acid (22:5 n-3) and oleic acid (18:1 n-9). CONCLUSIONS: Both PUFA subtypes were positively associated with allergy in an age-dependent manner, whereas MUFA was associated with less allergy. The observation of high proportions of n-3 PUFA in allergic children younger than 4 years might help to understand the nature of early onset of atopic disease.

Meal patterns across ten European countries - results from the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study.

OBJECTIVE: To characterize meal patterns across ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study. DESIGN: Cross-sectional study utilizing dietary data collected through a standardized 24 h diet recall during 1995-2000. Eleven predefined intake occasions across a 24 h period were assessed during the interview. In the present descriptive report, meal patterns were analysed in terms of daily number of intake occasions, the proportion reporting each intake occasion and the energy contributions from each intake occasion. SETTING: Twenty-seven centres across ten European countries. SUBJECTS: Women (64 %) and men (36 %) aged 35-74 years (n 36 020). RESULTS: Pronounced differences in meal patterns emerged both across centres within the same country and across different countries, with a trend for fewer intake occasions per day in Mediterranean countries compared with central and northern Europe. Differences were also found for daily energy intake provided by lunch, with 38-43 % for women and 41-45 % for men within Mediterranean countries compared with 16-27 % for women and 20-26 % for men in central and northern European countries. Likewise, a south-north gradient was found for daily energy intake from snacks, with 13-20 % (women) and 10-17 % (men) in Mediterranean countries compared with 24-34 % (women) and 23-35 % (men) in central/northern Europe. CONCLUSIONS: We found distinct differences in meal patterns with marked diversity for intake frequency and lunch and snack consumption between Mediterranean and central/northern European countries. Monitoring of meal patterns across various cultures and populations could provide critical context to the research efforts to characterize relationships between dietary intake and health.

Healthy lifestyle index and risk of gastric adenocarcinoma in the EPIC cohort study.

Several modifiable lifestyle factors, including smoking, alcohol, certain dietary factors and weight are independently associated with gastric cancer (GC); however, their combined impact on GC risk is unknown. We constructed a healthy lifestyle index to investigate the joint influence of these behaviors on GC risk within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. The analysis included 461,550 participants (662 first incident GC cases) with a mean follow-up of 11.4 years. A healthy lifestyle index was constructed, assigning 1 point for each healthy behavior related to smoking status, alcohol consumption and diet quality (represented by the Mediterranean diet) for assessing overall GC and also body mass index for cardia GC and 0 points otherwise. Risk of GC was calculated using Cox proportional hazards regression models while adjusting for relevant confounders. The highest versus lowest score in the healthy lifestyle index was associated with a significant lower risk of GC, by 51% overall (HR 0.49 95% CI 0.35, 0.70), by 77% for cardia GC (HR 0.23 95% CI 0.08, 0.68) and by 47% for noncardia GC (HR 0.53 (95% CI 0.32, 0.87), p-trends<0.001. Population attributable risk calculations showed that 18.8% of all GC and 62.4% of cardia GC cases could have been prevented if participants in this population had followed the healthy lifestyle behaviors of this index. Adopting several healthy lifestyle behaviors including not smoking, limiting alcohol consumption, eating a healthy diet and maintaining a normal weight is associated with a large decreased risk of GC.

Consumption of fatty foods and incident type 2 diabetes in populations from eight European countries.

BACKGROUND/OBJECTIVES: Diets high in saturated and trans fat and low in unsaturated fat may increase type 2 diabetes (T2D) risk, but studies on foods high in fat per unit weight are sparse. We assessed whether the intake of vegetable oil, butter, margarine, nuts and seeds and cakes and cookies is related to incident T2D. SUBJECTS/METHODS: A case-cohort study was conducted, nested within eight countries of the European Prospective Investigation into Cancer (EPIC), with 12,403 incident T2D cases and a subcohort of 16,835 people, identified from a cohort of 340,234 people. Diet was assessed at baseline (1991-1999) by country-specific questionnaires. Country-specific hazard ratios (HRs) across four categories of fatty foods (nonconsumers and tertiles among consumers) were combined with random-effects meta-analysis. RESULTS: After adjustment not including body mass index (BMI), nonconsumers of butter, nuts and seeds and cakes and cookies were at higher T2D risk compared with the middle tertile of consumption. Among consumers, cakes and cookies were inversely related to T2D (HRs across increasing tertiles 1.14, 1.00 and 0.92, respectively; P-trend <0.0001). All these associations attenuated upon adjustment for BMI, except the higher risk of nonconsumers of cakes and cookies (HR 1.57). Higher consumption of margarine became positively associated after BMI adjustment (HRs across increasing consumption tertiles: 0.93, 1.00 and 1.12; P-trend 0.03). Within consumers, vegetable oil, butter and nuts and seeds were unrelated to T2D. CONCLUSIONS: Fatty foods were generally not associated with T2D, apart from weak positive association for margarine. The higher risk among nonconsumers of cakes and cookies needs further explanation.

Dietary energy density in young children across Europe.

OBJECTIVES: To describe energy density (ED; kcal g(-1)) of dietary intake of European children. METHODS: From 16, 228 children who participated in the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS) baseline examination, 8551 children with 24-h dietary recalls (24-HDR), with plausible reported energy intakes and complete covariate information were included in the present analysis. ED was calculated using two methods: (1) ED including solid foods (EDF) and (2) ED including solid foods and energy-containing beverages (EDF&B). Beverage energy was calculated in kcal per day. Dietary characteristics and body mass index (BMI) z-score of children aged 2 to <6 years and 6 to <10 years were compared between children with an overall EDF below the <25th percentile, between the 25th and 75th percentile as well as above the >75th percentile. Standardised regression coefficients were estimated to assess the association between dietary characteristics, BMI z-score and ED of the diet. RESULTS: Children with low EDF and EDF&B diets consumed less energy but higher quantity of food and beverages than children with high EDF and EDF&B diets. Consumption of caloric beverages decreased with increasing EDF&B of the diet owing to the relatively low ED of the beverages, in relation to solid foods. Generally, children with low EDF and EDF&B diets showed healthier food choices than peers with higher EDF and EDF&B diets. In this sample, EDF and EDF&B were not associated with BMI z-score. CONCLUSION: Health promotion strategies should proclaim lower ED diets by means of foods with high water and low fat content and mainly fruit and vegetable components. Excluding caloric beverages from EDF calculation is a useful method to avoid misinterpretation of true exposure to a high energy dense diet. We recommend excluding caloric beverages from EDF calculation when investigating the effect of ED on a certain (health) outcome.

Adherence to the obesity-related lifestyle intervention targets in the IDEFICS study.

BACKGROUND/OBJECTIVES: To address behaviours associated with childhood obesity, certain target values are recommended that should be met to improve children's health. In the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health Effects in Children and infantS) study such lifestyle recommendations were conveyed as six key messages. Here, we investigate the adherence of European children to these messages. METHODS: The IDEFICS intervention was based on the intervention mapping approach with the following six targets: increase water consumption (to replace sugar-containing beverages), increase fruit/vegetable consumption, reduce daily screen time, increase daily physical activity, improve the quality of family life and ensure adequate sleep duration. Internationally recommended target values were applied to determine the prevalence of children meeting these targets. RESULTS: In a cohort of 18,745 children participating in the IDEFICS baseline survey or newly recruited during follow-up, data on the above lifestyle behaviours were collected for a varying number of 8302 to 17,212 children. Information on all six behaviours was available for 5140 children. Although 52.5% of the cohort was classified in the highest category of water consumption, only 8.8% met the target of an intake of fruits/vegetables five times a day. The prevalence of children adhering to the recommendation regarding total screen time-below 1 h for pre-school children and 2 h for school children-was 51.1%. The recommended amount of at least 60 min of moderate-to-vigorous physical activity per day was fulfilled by 15.2%. Family life of the child measured by various indicators was considered as satisfactory in 22.8%. Nocturnal sleep duration of 11 (10) hours or more in pre-school (school) children was achieved by 37.9%. In general, children in northern countries and younger children showed better adherence to the recommendations. Only 1.1% of the children adhered to at least five of these recommendations. CONCLUSIONS: Current adherence of children to lifestyle recommendations to prevent childhood obesity is low where observed differences with respect to country, age and gender call for targeted intervention.

Country-specific dietary patterns and associations with socioeconomic status in European children: the IDEFICS study.

BACKGROUND/OBJECTIVES: Children from lower socioeconomic status (SES) may be at higher risk of unhealthy eating. We described country-specific dietary patterns among children aged 2-9 years from eight European countries participating in the IDEFICS study and assessed the association of dietary patterns with an additive SES indicator. SUBJECTS/METHODS: Children aged 2-9 years from eight European countries were recruited in 2007-2008. Principal component analysis was applied to identify dietary country-specific patterns. Linear regression analyses were applied to assess their association with SES. RESULTS: Two to four dietary patterns were identified in the participating regions. The existence of a 'processed' pattern was found in the eight regions. Also, a 'healthy' pattern was identified in seven of the eight regions. In addition, region-specific patterns were identified, reflecting the existing gastronomic and cultural differences in Europe. The 'processed' pattern was significantly inversely associated with the SES additive indicator in all countries except Sweden, whereas the 'healthy' pattern was positively associated with SES in the Belgian, Estonian, German and Hungarian regions, but was not significant in the Italian, Spanish and Swedish regions. CONCLUSIONS: A 'processed' pattern and a 'healthy' pattern were found in most of the participating countries in the IDEFICS study, with comparable food item profiles. The results showed a strong inverse association of SES with the 'processed' pattern, suggesting that children of parents with lower SES may be at higher risk of unhealthy eating. Therefore, special focus should be given to parents and their children from lower SES levels when developing healthy eating promotion strategies.

European children's sugar intake on weekdays versus weekends: the IDEFICS study.

OBJECTIVES: To compare the intake of total sugars, foods and drinks rich in added sugar, and energy in children on weekdays (Monday-Thursday), Fridays and weekends. METHODS: Dietary intake (g, kJ, energy %) was assessed using a computerized 24-h recall method in a sample of 2- to 9-year-old children from Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden who were participating in the IDEFICS baseline study (2007-2008). Analyses were performed in 9497 children by selecting one 24-h recall per child (for comparison of weekdays vs weekends, and Fridays vs weekdays and weekends). Selected stratified analyses were performed by country and age group. RESULTS: Intake of total sugars exceeded 20 energy % in all countries but one. In the non-stratified analyses, the intakes of total sugars and foods and drinks rich in added sugar were found to be higher on weekends compared with weekdays (both P<0.001), and intakes on Fridays were a mix between intakes on weekdays and weekends. Energy intake did not differ between weekdays and weekends. RESULTS were somewhat heterogeneous, both across countries and age groups. CONCLUSIONS: High intake of sugar remains an important nutritional problem in children of many European countries. Interventions aiming to prevent this diet pattern may optimize their impact by targeting dietary habits on Fridays and weekends. Furthermore, when conducting dietary assessment in children, data from weekends and Fridays in combination with a selection of Mondays to Thursdays are needed to capture habitual sugar intake. Age and dietary cultures should also be considered in dietary intervention and assessment as effect modifications were seen for both age and country.

Circulating prolactin and breast cancer risk among pre- and postmenopausal women in the EPIC cohort.

BACKGROUND: Experimental and epidemiological evidence suggests that prolactin might play a role in the etiology of breast cancer. We analyzed the relationship of prediagnostic circulating prolactin levels with the risk of breast cancer by menopausal status, use of postmenopausal hormone replacement therapy (HRT) at blood donation, and by estrogen and progesterone receptor status of the breast tumors. PATIENTS AND METHODS: Conditional logistic regression was used to analyze the data from a case-control study nested within the prospective European EPIC cohort, including 2250 invasive breast cancer and their matched control subjects. RESULTS: Statistically significant heterogeneity in the association of prolactin levels with breast cancer risk between women who were either pre- or postmenopausal at the time of blood donation was observed (Phet = 0.04). Higher serum levels of prolactin were associated with significant increase in the risk of breast cancer among postmenopausal women [odds ratio (OR)Q4-Q1 = 1.29 (95% confidence interval, CI, 1.05-1.58), Ptrend = 0.09]; however, this increase in risk seemed to be confined to women who used postmenopausal HRT at blood donation [ORQ4-Q1 = 1.45 (95% CI 1.08-1.95), Ptrend = 0.01], whereas no statistically significant association was found for the non-users of HRT [ORQ4-Q1 = 1.11 (95%CI 0.83-1.49), Ptrend = 0.80] (Phet = 0.08). Among premenopausal women, a statistically non-significant inverse association was observed [ORQ4-Q1 = 0.70 (95% CI 0.48-1.03), Ptrend = 0.16]. There was no heterogeneity in the prolactin-breast cancer association by hormone receptor status of the tumor. CONCLUSION: Our study indicates that higher circulating levels of prolactin among the postmenopausal HRT users at baseline may be associated with increased breast cancer risk.

Mediterranean diet, overweight and body composition in children from eight European countries: cross-sectional and prospective results from the IDEFICS study.

BACKGROUND & AIMS: A Mediterranean-like dietary pattern has been shown to be inversely associated with many diseases, but its role in early obesity prevention is not clear. We aimed to determine if this pattern is common among European children and whether it is associated with overweight and obesity. METHODS AND RESULTS: The IDEFICS study recruited 16,220 children aged 2-9 years from study centers in eight European countries. Weight, height, waist circumference, and skinfolds were measured at baseline and in 9114 children of the original cohort after two years. Diet was evaluated by a parental questionnaire reporting children's usual consumption of 43 food items. Adherence to a Mediterranean-like diet was calculated by a food frequency-based Mediterranean Diet Score (fMDS). The highest fMDS levels were observed in Sweden, the lowest in Cyprus. High scores were inversely associated with overweight including obesity (OR = 0.85, 95% CI: 0.77; 0.94) and percent fat mass (ß = -0.22, 95% CI: -0.43; -0.01) independently of age, sex, socioeconomic status, study center and physical activity. High fMDS at baseline protected against increases in BMI (OR = 0.87, 95% CI: 0.78; 0.98), waist circumference (OR = 0.87, 95% CI: 0.77; 0.98) and waist-to-height ratio (OR = 0.88, 95% CI: 0.78; 0.99) with a similar trend observed for percent fat mass (p = 0.06). CONCLUSIONS: Although a Mediterranean dietary pattern is inversely associated with childhood obesity, it is not common in children living in the Mediterranean region and should therefore be advocated as part of EU obesity prevention strategies.

Validity of 24-h recalls in (pre-)school aged children: comparison of proxy-reported energy intakes with measured energy expenditure.

BACKGROUND & AIMS: Little is known about the validity of repeated 24-h dietary recalls (24-HDR) as a measure of total energy intake (EI) in young children. This study aimed to evaluate the validity of proxy-reported EI by comparison with total energy expenditure (TEE) measured by the doubly labeled water (DLW) technique. METHODS: The agreement between EI and TEE was investigated in 36 (47.2% boys) children aged 4-10 years from Belgium and Spain using subgroup analyses and Bland-Altman plots. Low-energy-reporters (LER), adequate-energy-reporters (AER) and high-energy-reporters (HER) were defined from the ratio of EI over TEE by application of age- and sex-specific cut-off values. RESULTS: There was good agreement between means of EI (1500 kcal/day) and TEE (1523 kcal/day) at group level though in single children, i.e. at the individual level, large differences were observed. Almost perfect agreement between EI and TEE was observed in thin/normal weight children (EI: 1511 kcal/day; TEE: 1513 kcal/day). Even in overweight/obese children the mean difference between EI and TEE was only -86 kcal/day. Among the participants, 28 (78%) were classified as AER, five (14%) as HER and three (8%) as LER. CONCLUSION: Two proxy-reported 24-HDRs were found to be a valid instrument to assess EI on group level but not on the individual level.

Dietary patterns and longitudinal change in body mass in European children: a follow-up study on the IDEFICS multicenter cohort.

BACKGROUND/OBJECTIVES: Longitudinal studies investigating dietary patterns (DPs) and their association with childhood overweight/obesity are lacking in Europe. We identified DPs and investigated their association with overweight/obesity and changes in body mass index (BMI) in a cohort of European children. SUBJECTS/METHODS: Children aged 2-10 from eight European countries were recruited in 2007-2008. Food frequency questionnaires were collected from 14 989 children. BMI and BMI z-scores were derived from height and weight and were used to identify overweight/obese children. After 2 years (mean), anthropometric measurements were repeated in 9427 children. Principal component analysis was used to identify DPs. Simplified DPs (SDPs) were derived from DPs. Adjusted odds ratios (ORs) for overweight/obesity with increasing DP intake were estimated using multilevel logistic regression. Associations of BMI change with DP and SDP were assessed by multilevel mixed regression. Models were adjusted for baseline BMI, age, sex, physical activity and family income. RESULTS: Four DPs were identified that explained 25% of food intake variance: snacking, sweet and fat, vegetables and wholemeal, and protein and water. After 2 years, 849(9%) children became overweight/obese. Children in the highest vegetables and wholemeal tertile had lower risk of becoming overweight/obese (OR: 0.69, 95% confidence intervals (CIs): 0.54-0.88). Children in the highest SDP tertile of vegetables and wholemeal had similarly lower risk of becoming overweight/obese (OR: 0.64, 95% CIs: 0.51-0.82), and their BMI increased by 0.7 kg/m(2) over the study period-significantly less than the increase in the lowest tertile (0.84 kg/m(2)). CONCLUSIONS: Our findings suggest that promoting a diet rich in vegetables and wholemeal cereals may counteract overweight/obesity in children.

Dietary intake of acrylamide and pancreatic cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.

BACKGROUND: In 1994, acrylamide (AA) was classified as a probable human carcinogen by the International Agency for Research on Cancer. In 2002, AA was discovered at relatively high concentrations in some starchy, plant-based foods cooked at high temperatures. PATIENTS AND METHODS: A prospective analysis was conducted to evaluate the association between the dietary intake of AA and ductal adenocarcinoma of the exocrine pancreatic cancer (PC) risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort using Cox regression modeling. EPIC includes >500,000 men and women aged 35-75 at enrollment from 10 European countries. AA intake was estimated for each participant by combining questionnaire-based food consumption data with a harmonized AA database derived from the EU monitoring database of AA levels in foods, and evaluated in quintiles and continuously. RESULTS: After a mean follow-up of 11 years, 865 first incident adenocarcinomas of the exocrine pancreas were observed and included in the present analysis. At baseline, the mean dietary AA intake in EPIC was 26.22 µg/day. No overall association was found between continuous or quintiles of dietary AA intake and PC risk in EPIC (HR:0.95, 95%CI:0.89-1.01 per 10 µg/day). There was no effect measure modification by smoking status, sex, diabetes, alcohol intake or geographic region. However, there was an inverse association (HR: 0.73, 95% CI: 0.61-0.88 per 10 µg/day) between AA intake and PC risk in obese persons as defined using the body mass index (BMI, ≥ 30 kg/m(2)), but not when body fatness was defined using waist and hip circumference or their ratio. CONCLUSIONS: Dietary intake of AA was not associated with an increased risk of PC in the EPIC cohort.

Prevalence and determinants of misreporting among European children in proxy-reported 24 h dietary recalls.

Dietary assessment is strongly affected by misreporting (both under- and over-reporting), which results in measurement error. Knowledge about misreporting is essential to correctly interpret potentially biased associations between diet and health outcomes. In young children, dietary data mainly rely on proxy respondents but little is known about determinants of misreporting here. The present analysis was conducted within the framework of the multi-centre IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study and is based on 6101 children aged 2-9 years with 24 h dietary recall (24-HDR) and complete covariate information. Adapted Goldberg cut-offs were applied to classify the 24-HDR as 'over-report', 'plausible report' or 'under-report'. Backward elimination in the course of multi-level logistic regression analyses was conducted to identify factors significantly related to under- and over-reporting. Next to characteristics of the children and parents, social factors and parental concerns/perceptions concerning their child's weight status were considered. Further selective misreporting was addressed, investigating food group intakes commonly perceived as more or less socially desirable. Proportions of under-, plausible and over-reports were 8.0, 88.6 and 3.4 %, respectively. The risk of under-reporting increased with age (OR 1.19, 95 % CI 1.05, 1.83), BMI z-score of the child (OR 1.23, 95 % CI 1.10, 1.37) and household size (OR 1.12, 95 % CI 1.01, 1.25), and was higher in low/medium income groups (OR 1.45, 95 % CI 1.13, 1.86). Over-reporting was negatively associated with BMI z-scores of the child (OR 0.78, 95 % CI 0.69, 0.88) and higher in girls (OR 1.70, 95 % CI 1.27, 2.28). Further social desirability and parental concerns/perceptions seemed to influence the reporting behaviour. Future studies should involve these determinants of misreporting when investigating diet-disease relationships in children to correct for the differential reporting bias.