High availability of vegetables and fruit through government-funded school lunch is not reflected in 4th grade pupils' intake.

Background: An increased intake of vegetable and fruit (VF) through school meals can contribute to the prevention of non-communicable diseases. Objective: The purpose of this study was to investigate what types of VF 4th grade pupils (10-11 years old) choose, how much they eat when they are given the opportunity to serve themselves from the daily vegetable buffet available at lunch, and whether this varies with socioeconomic background and gender. Design: A cross-sectional study design was used where pupils' VF intake was measured during 5 days with a photographic method. In total, 196 pupils from nine public schools participated. Results: The results show that pupils on average ate less than one type of VF per day from the vegetable buffet. Girls, pupils with a higher socio-economic status (SES) and those with a more frequent VF intake at home, ate more types of VF per day from the vegetable buffet than their counterparts. The median intake of VF from the vegetable buffet was generally low, 20.4 g/day. The intake was two thirds higher for pupils with higher SES in comparison with pupils with lower SES; 25 g/day versus14 g/day (P = 0.001). No gender differences in grams per day of VF were identified (P = 0.123). Discussion: This study indicates that a well-stocked vegetable buffet as part of government-funded school lunch does not automatically contribute substantially to the recommended daily intake of VF among a sample of 4th grade pupils in a high-income country like Sweden. Conclusions: The results of the study can be interpreted as a missed opportunity to increase the intentional consumption of VF among pupils in a way that would have implications for public health as well as attenuating differences between socioeconomic groups.

Improved Peripheral and Hepatic Insulin Sensitivity after Lifestyle Interventions in Type 2 Diabetes Is Associated with Specific Metabolomic and Lipidomic Signatures in Skeletal Muscle and Plasma.

Lifestyle interventions with weight loss can improve insulin sensitivity in type 2 diabetes (T2D), but mechanisms are unclear. We explored circulating and skeletal muscle metabolite signatures of altered peripheral (pIS) and hepatic insulin sensitivity (hIS) in overweight and obese T2D individuals that were randomly assigned a 12-week Paleolithic-type diet with (diet-ex, n = 13) or without (diet, n = 13) supervised exercise. Baseline and post-intervention measures included: mass spectrometry-based metabolomics and lipidomics of skeletal muscle and plasma; pIS and hIS; ectopic lipid deposits in the liver and skeletal muscle; and skeletal muscle fat oxidation rate. Both groups lowered BMI and total % fat mass and increased their pIS. Only the diet-group improved hIS and reduced ectopic lipids in the liver and muscle. The combined improvement in pIS and hIS in the diet-group were associated with decreases in muscle and circulating branched-chain amino acid (BCAA) metabolites, specifically valine. Improved pIS with diet-ex was instead linked to increased diacylglycerol (34:2) and triacylglycerol (56:0) and decreased phosphatidylcholine (34:3) in muscle coupled with improved muscle fat oxidation rate. This suggests a tissue crosstalk involving BCAA-metabolites after diet intervention with improved pIS and hIS, reflecting reduced lipid influx. Increased skeletal muscle lipid utilization with exercise may prevent specific lipid accumulation at sites that perturb insulin signaling.

The liver-alpha-cell axis after a mixed meal and during weight loss in type 2 diabetes.

OBJECTIVE: Glucagon and amino acids may be regulated in a feedback loop called the liver-alpha-cell axis with alanine or glutamine as suggested signal molecules. We assessed this concept in individuals with type 2 diabetes in the fasting state, after ingestion of a protein-rich meal, and during weight loss. Moreover, we investigated if postprandial glucagon secretion and hepatic insulin sensitivity were related. METHODS: This is a secondary analysis of a 12-week weight-loss trial (Paleolithic diet ± exercise) in 29 individuals with type 2 diabetes. Before and after the intervention, plasma glucagon and amino acids were measured in the fasting state and during 180 min after a protein-rich mixed meal. Hepatic insulin sensitivity was measured using the hyperinsulinemic-euglycemic clamp with [6,6-2H2]glucose as a tracer. RESULTS: The postprandial increase of plasma glucagon was associated with the postprandial increase of alanine and several other amino acids but not glutamine. In the fasted state and after the meal, glucagon levels were negatively correlated with hepatic insulin sensitivity (rS = -0.51/r = -0.58, respectively; both P < 0.05). Improved hepatic insulin sensitivity with weight loss was correlated with decreased postprandial glucagon response (r = -0.78; P < 0.001). CONCLUSIONS: Several amino acids, notably alanine, but not glutamine could be key signals to the alpha cell to increase glucagon secretion. Amino acids may be part of a feedback mechanism as glucagon increases endogenous glucose production and ureagenesis in the liver. Moreover, postprandial glucagon secretion seems to be tightly related to hepatic insulin sensitivity.

Using a Paleo Ratio to Assess Adherence to Paleolithic Dietary Recommendations in a Randomized Controlled Trial of Individuals with Type 2 Diabetes.

This study is a secondary analysis of a randomized controlled trial using Paleolithic diet and exercise in individuals with type 2 diabetes. We hypothesized that increased adherence to the Paleolithic diet was associated with greater effects on blood pressure, blood lipids and HbA1c independent of weight loss. Participants were asked to follow a Paleolithic diet for 12 weeks and were randomized to supervised exercise or general exercise recommendations. Four-day food records were analyzed, and food items characterized as "Paleolithic" or "not Paleolithic". Foods considered Paleolithic were lean meat, poultry, fish, seafood, fruits, nuts, berries, seeds, vegetables, and water to drink; "not Paleolithic" were legumes, cereals, sugar, salt, processed foods, and dairy products. A Paleo ratio was calculated by dividing the Paleolithic calorie intake by total calorie intake. A multiple regression model predicted the outcome at 12 weeks using the Paleo ratio, group affiliation, and outcome at baseline as predictors. The Paleo ratio increased from 28% at baseline to 94% after the intervention. A higher Paleo ratio was associated with lower fat mass, BMI, waist circumference, systolic blood pressure, and serum triglycerides at 12 weeks, but not with lower HbA1c levels. The Paleo ratio predicted triglyceride levels independent of weight loss (p = 0.046). Moreover, an increased monounsaturated/saturated fatty acids ratio and an increased polyunsaturated/saturated fatty acids ratio was associated with lower triglyceride levels independent of weight loss. (p = 0.017 and p = 0.019 respectively). We conclude that a higher degree of adherence to the Paleolithic diet recommendations improved fat quality and was associated with improved triglyceride levels independent of weight loss among individuals with type 2 diabetes.

Exercise Training Adds Cardiometabolic Benefits of a Paleolithic Diet in Type 2 Diabetes Mellitus.

Background The accumulation of myocardial triglycerides and remodeling of the left ventricle are common features in type 2 diabetes mellitus and represent potential risk factors for the development of diastolic and systolic dysfunction. A few studies have investigated the separate effects of diet and exercise training on cardiac function, but none have investigated myocardial changes in response to a combined diet and exercise intervention. This 12-week randomized study assessed the effects of a Paleolithic diet, with and without additional supervised exercise training, on cardiac fat, structure, and function. Methods and Results Twenty-two overweight and obese subjects with type 2 diabetes mellitus were randomized to either a Paleolithic diet and standard-care exercise recommendations ( PD ) or to a Paleolithic diet plus supervised exercise training 3 hours per week ( PD - EX ). This study includes secondary end points related to cardiac structure and function, ie, myocardial triglycerides levels, cardiac morphology, and strain were measured using cardiovascular magnetic resonance, including proton spectroscopy, at baseline and after 12 weeks. Both groups showed major favorable metabolic changes. The PD - EX group showed significant decreases in myocardial triglycerides levels (-45%, P=0.038) and left ventricle mass to end-diastolic volume ratio (-13%, P=0.008) while the left ventricle end-diastolic volume and stroke volume increased significantly (+14%, P=0.004 and +17%, P=0.008, respectively). These variables were unchanged in the PD group. Conclusions Exercise training plus a Paleolithic diet reduced myocardial triglycerides levels and improved left ventricle remodeling in overweight/obese subjects with type 2 diabetes mellitus. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01513798.

Treadmill workstations in office workers who are overweight or obese: a randomised controlled trial.

BACKGROUND: Treadmill workstations that enable office workers to walk on a treadmill while working at their computers might increase physical activity in offices, but long-term effects are unknown. We therefore investigated whether treadmill workstations in offices increased daily walking time. METHODS: We did a randomised controlled trial of healthy office workers who were either overweight or obese. We recruited participants from 13 different companies, which comprised 17 offices, in Umeå, Sweden. We included people who were aged 40-67 years, had sedentary work tasks, and had a body-mass index (BMI) between 25 kg/m2 and 40 kg/m2. After the baseline measurement, we stratified participants by their BMI (25-30 kg/m2 and >30 to 40 kg/m2); subsequently, an external statistician randomly assigned these participants (1:1) to either the intervention group (who received treadmill workstations for optional use) or the control group (who continued to work at their sit-stand desks as usual). Participants in the intervention group received reminders in boosting emails sent out to them at four occasions during the study period. Researchers were masked to group assignment until after analysis of the primary outcome. After the baseline measurement, participants were not masked to group belongings. The primary outcome was total daily walking time at weekdays and weekends, measured at baseline, 2 months, 6 months, 10 months, and 13 months with the accelerometer activPAL (PAL Technologies, Glasgow, UK), which was worn on the thigh of participants for 24 h a day for 7 consecutive days. We used an intention-to-treat approach for our analyses. This trial is registered with ClinicalTrials.gov, number NCT01997970, and is closed to new participants. FINDINGS: Between Nov 1, 2013, and June 30, 2014, a total of 80 participants were recruited and enrolled (n=40 in both the intervention and control groups). Daily walking time during total time awake at weekdays increased between baseline and 13 months by 18 min (95% CI 9 to 26) in the intervention group and 1 min (-7 to 9) in the control group (difference 22 min [95% CI 7 to 37], pinteraction=0·00045); for weekend walking, the change from baseline to 13 months was 5 min (-8 to 18) in the intervention group and 8 min (-5 to 21) in the control group (difference -1 min [-19 to 17]; pinteraction=0·00045). Neither measure met our predetermined primary outcome of 30 min difference in total walking time between the intervention and control group, so the primary outcome of the trial was not met. One adverse event was reported in a participant who accidently stepped on their Achilles tendon. INTERPRETATION: In a sedentary work environment, treadmill workstations result in a statistically significant but smaller-than-expected increase in daily walking time. Future studies need to investigate how increasing physical activity at work might have potentially compensatory effects on non-work activity. FUNDING: Umeå University, the Västerbotten County Council, and the Mayo Clinic Foundation for Research.

Composition of School Meals in Sweden, Finland, and Iceland: Official Guidelines and Comparison With Practice and Availability.

BACKGROUND: Nutritious and attractive school meals can improve health equality and public health. Current official guidelines and recommendations on food and nutrient composition of school meals in 3 Nordic countries; Sweden, Finland, and Iceland, are described and compared with actual practice, ie, availability of foods and nutrients in served reference meals in 3 selected areas in each country. METHODS: A country comparison was made between official guidelines, and actual practice was studied in participating schools. Reference portions of school meals (N = 170) provided in 24 compulsory schools were photographed and weighed. Food and nutrient availability were compared with official guidelines in each country. RESULTS: Emphasis of recommendations on whole-grain bread in Sweden, whole grains in Finland, and fish in Iceland were reflected in food availability. The energy content of the meals provided was lower than guidelines and there was a large variation in energy content between days. CONCLUSIONS: The guidelines regarding food availability were quite well followed, but the large variation in energy and nutrient content of provided school meals between days indicates a need for standardization.

A heterogeneous response of liver and skeletal muscle fat to the combination of a Paleolithic diet and exercise in obese individuals with type 2 diabetes: a randomised controlled trial.

AIMS/HYPOTHESIS: The aim of the study was to investigate ectopic fat deposition and insulin sensitivity, in a parallel single-blinded randomised controlled trial, comparing Paleolithic diet alone with the combination of Paleolithic diet and exercise in individuals with type 2 diabetes. METHODS: Thirty-two individuals with type 2 diabetes with BMI 25-40 kg/m2 and 30-70 years of age followed a Paleolithic diet ad libitum for 12 weeks. In addition, study participants were randomised by computer program to either supervised combined exercise training (PD-EX group) or standard care exercise recommendations (PD group). Staff performing examinations and assessing outcomes were blinded to group assignment. Thirteen participants were analysed in each group: hepatic and peripheral insulin sensitivity were measured using the hyperinsulinaemic-euglycaemic clamp technique combined with [6,6-2H2]glucose infusion, and liver fat was assessed by proton magnetic resonance spectroscopy; both analyses were secondary endpoints. Intramyocellular lipid (IMCL) content was measured by magnetic resonance spectroscopy as a secondary analysis. All examinations were performed at Umeå University Hospital, Umeå, Sweden. RESULTS: Both study groups showed a median body weight loss of 7 kg. Fat mass decreased by 5.7 kg in the PD group and by 6.5 kg in the PD-EX group. Maximum oxygen uptake increased in the PD-EX group only. Liver fat showed a consistent reduction (74% decrease) in the PD group, while the response in the PD-EX group was heterogeneous (p < 0.05 for the difference between groups). IMCL content of the soleus muscle decreased by 40% in the PD group and by 22% in the PD-EX group (p < 0.05 for the difference between groups). Both groups improved their peripheral and adipose tissue insulin sensitivity, but not their hepatic insulin sensitivity. Plasma fetuin-A decreased by 11% in the PD group (p < 0.05) and remained unchanged in the PD-EX group. Liver fat changes during the intervention were correlated with changes in fetuin-A (rS = 0.63, p < 0.01). Participants did not report any important adverse events caused by the intervention. CONCLUSIONS/INTERPRETATION: A Paleolithic diet reduced liver fat and IMCL content, while there was a tissue-specific heterogeneous response to added exercise training. TRIAL REGISTRATION: ClinicalTrials.gov NCT01513798 FUNDING: Swedish Diabetes Research Foundation, County Council of Västerbotten, Swedish Heart and Lung Foundation, King Gustav V and Queen Victoria's Foundation.

Benefits of a Paleolithic diet with and without supervised exercise on fat mass, insulin sensitivity, and glycemic control: a randomized controlled trial in individuals with type 2 diabetes.

BACKGROUND: Means to reduce future risk for cardiovascular disease in subjects with type 2 diabetes are urgently needed. METHODS: Thirty-two patients with type 2 diabetes (age 59 ± 8 years) followed a Paleolithic diet for 12 weeks. Participants were randomized to either standard care exercise recommendations (PD) or 1-h supervised exercise sessions (aerobic exercise and resistance training) three times per week (PD-EX). RESULTS: For the within group analyses, fat mass decreased by 5.7 kg (IQR: -6.6, -4.1; p < 0.001) in the PD group and by 6.7 kg (-8.2, -5.3; p < 0.001) in the PD-EX group. Insulin sensitivity (HOMA-IR) improved by 45% in the PD (p < 0.001) and PD-EX (p < 0.001) groups. HbA1c decreased by 0.9% (-1.2, -0.6; p < 0.001) in the PD group and 1.1% (-1.7, -0.7; p < 0.01) in the PD-EX group. Leptin decreased by 62% (p < 0.001) in the PD group and 42% (p < 0.001) in the PD-EX group. Maximum oxygen uptake increased by 0.2 L/min (0.0, 0.3) in the PD-EX group, and remained unchanged in the PD group (p < 0.01 for the difference between intervention groups). Male participants decreased lean mass by 2.6 kg (-3.6, -1.3) in the PD group and by 1.2 kg (-1.3, 1.0) in the PD-EX group (p < 0.05 for the difference between intervention groups). CONCLUSIONS: A Paleolithic diet improves fat mass and metabolic balance including insulin sensitivity, glycemic control, and leptin in subjects with type 2 diabetes. Supervised exercise training may not enhance the effects on these outcomes, but preserves lean mass in men and increases cardiovascular fitness. Copyright © 2016 John Wiley & Sons, Ltd.

The Effect of Schooling on Basic Cognition in Selected Nordic Countries.

The present study investigated schooling effects on cognition. Cognitive data were collected as part of a research project (ProMeal) that investigated school meals and measured the intake of school lunch in relation to children's health, cognitive function, and classroom learning in four Nordic countries, among children between 10-11 years of age. It was found that Finnish pupils attending 4th grade were not, on any measure, outperformed by Norwegian and Icelandic pupils attending 5th and Swedish pupils attending 4th grade on a task measuring working memory capacity, processing speed, inhibition, and in a subsample on response- and attention control. Moreover, boys were found to perform superior to girls on tasks measuring processing speed. However, girls were found to perform better on tasks related to attention and self-control. The results are discussed in relation to the reciprocal association between cognition and schooling and whether these results reflect quality differences between schools in the four Nordic countries; most notably in comparison to Finland.

Development and Validation of a Photographic Method to Use for Dietary Assessment in School Settings.

OBJECTIVE: To develop and validate a photographic method aimed at making assessment of dietary intake in school canteens non-obstrusive, practical and feasible. METHODS: The study was conducted in two elementary schools representing two different school canteen systems; main dish being served by canteen staff (Iceland), and complete self-serving (Sweden). Food items in serving and leftovers were weighed and photographed. Trained researchers estimated weights of food items by viewing the photographs and comparing them with pictures of half and full reference portions with known weights. Plates of servings and leftovers from 48 children during five school days (n = 448 plates) and a total of 5967 food items were estimated. The researchers' estimates were then compared with the true weight of the foods and the energy content calculated. RESULTS: Weighed and estimated amounts correlated across meals both in grams and as total energy (0.853-0.977, p<0.001). The agreement between estimated energy content in school meals was close to the true measurement from weighed records; on average 4-19 kcal below true values. Organisation of meal service impacted the efficacy of the method as seen in the difference between countries; with Iceland (served by canteen staff) having higher rate of acceptable estimates than Sweden (self-serving), being 95% vs 73% for total amount (g) in serving. Iceland more often had serving size between or above the half and full reference plates compared with Sweden. CONCLUSIONS: The photographic method provides acceptable estimates of food and energy intake in school canteens. However, greater accuracy can be expected when foods are served by canteen staff compared with self-serving.

School meal provision, health, and cognitive function in a Nordic setting - the ProMeal-study: description of methodology and the Nordic context.

BACKGROUND: School meals, if both nutritious and attractive, provide a unique opportunity to improve health equality and public health. OBJECTIVE: To describe the study rationale, data collection, and background of participants in the study 'Prospects for promoting health and performance by school meals in Nordic countries' (ProMeal). The general aim was to determine whether overall healthiness of the diet and learning conditions in children can be improved by school lunches, and to capture the main concerns regarding school lunches among children in a Nordic context. DESIGN: A cross-sectional, multidisciplinary study was performed in Finland, Iceland, Norway, and Sweden on pupils (n=837) born in 2003. RESULTS: In total 3,928 pictures of school lunches were taken to capture pupils' school lunch intake. A mean of 85% of all parents responded to a questionnaire about socioeconomic background, dietary intake, and habitual physical activity at home. Cognitive function was measured on one occasion on 93% of the pupils during optimal conditions with a Stroop and a Child Operation Span test. A mean of 169 pupils also did an Integrated Visual and Auditory Continuous Performance Test after lunch over 3 days. In total, 37,413 10-sec observations of classroom learning behavior were performed. In addition, 753 empathy-based stories were written and 78 focus groups were conducted. The pupils had high socioeconomic status. CONCLUSIONS: This study will give new insights into which future interventions are needed to improve pupils' school lunch intake and learning. The study will provide valuable information for policy making, not least in countries where the history of school meals is shorter than in some of the Nordic countries.

Overweight and Obese Children's Ability to Report Energy Intake Using Digital Camera Food Records during a 2-Year Study.

The objective was to evaluate overweight and obese children's ability to report reproducible and valid estimates of energy intake (EI) by using digital camera food records (FR) during a 2-year study, compared with objectively measured total energy expenditure (TEE). Seventy-three overweight/obese children, aged 8-12 years at inclusion, kept FR with the help of digital cameras for 16 days in total, on 7 occasions during a 2-year period. On the same days, their TEE was registered with SenseWear Armband (SWA). The children underestimated their EI by -2.8 (2.4) MJ/d on the first assessment occasion (95% CI: -3.3, -2.3). Reporting accuracy did not differ between the 7 assessment occasions (P = 0.15). Variables negatively associated with reporting accuracy relative to TEE were increased age (95% CI: -0.07, -0.01) and BMI z-score (95% CI: -0.18, -0.06). Further, reporting accuracy relative to TEE was lower for girls than boys (95% CI: -0.14, -0.01) and on weekdays compared with weekend days (95% CI: -0.08, -0.001). In conclusion, overweight and obese children were able to report their EI using a digital camera FR with good reproducibility over a 2-year period, even though their EI was underestimated compared with objectively measured TEE.

Improved dietary intake among overweight and obese children followed from 8 to 12 years of age in a randomised controlled trial.

More knowledge about improving dietary intake in secondary preventive actions against childhood overweight and obesity is needed. The objective was to evaluate the impact of a 2-year intervention on energy, macronutrient and food intake of overweight and obese children participating in a randomised controlled trial. Children (8-12 years old) living in Sweden were recruited to participate for 2 years between 2006 and 2009. The children were randomised into either an intervention group (n 58), participating in an intervention concerning food habits, physical activity and behavioural change, or a control group (n 47). Dietary intake at baseline and the 2-year measurement were assessed with a diet history interview covering 14 d. Energy intake (EI) of the intervention and control groups was underestimated by 28 and 21 %, respectively, after 2 years, but with no difference between the groups (P = 0·51). After 2 years of intervention, the intervention group, compared with the control group, had a lower intake of sugar-sweetened beverages (P = 0·015) as well as a higher intake of foods high in fibre, low in saturated fat, sugar and salt (P = 0·031). Further, a lower EI in relation to BMR, lower total fat, MUFA and cholesterol was seen in the intervention group compared with the control group. In conclusion, the food and nutrient intake of overweight and obese children was improved after participating in a 2-year intervention programme. Dietary counselling should be included in secondary preventive actions against childhood overweight and obesity to promote healthy food habits.

Effects on metabolic health after a 1-year-lifestyle intervention in overweight and obese children: a randomized controlled trial.

Objective. To evaluate the effect of a family-based intervention on anthropometric and metabolic markers in overweight and obese children. Methods. Overweight or obese 8-12 years olds (n = 93) were randomized into intervention or control groups. The intervention group participated in a program aiming for lifestyle changes regarding food habits and physical activity. Anthropometric measures and venous blood samples were collected from all children at baseline and after 1 year. Results. BMI z-scores decreased in both groups, 0.22 (P = 0.002) and 0.23 (P = 0.003) in intervention and control group, respectively, during the 1-year study, but there was no difference in BMI between the groups at 1-year measurement (P = 0.338). After 1 year, there was a significant difference in waist circumference, waist/hip ratio, and apolipoprotein B/A1 ratio between intervention and control group. Conclusions. The intervention had limited effects on anthropometrics and metabolic markers, which emphasizes the need of preventing childhood overweight and obesity.

A one-year intervention has modest effects on energy and macronutrient intakes of overweight and obese Swedish children.

To decrease BMI in overweight and obese children, improved dietary intake and increased physical activity are key elements. Our objective was to evaluate the impact of a 1-y food and physical activity intervention on energy and macronutrient intake in overweight and obese children. A randomized open trial was conducted with 92 overweight or obese 10.4 ± 1.08-y-old children. The intervention included 14 group sessions with different themes regarding food and physical activity. Dietary intake was assessed with diet history interviews covering 14 d at baseline and 4-d food records after 1 y and was evaluated according to national dietary recommendations. The control group participated in the same measurements as the intervention group but did not take part in group sessions. After 1 y, both groups had decreased their energy intake (EI) relative to total energy expenditure, but the effect was more pronounced for the intervention group than for the control group. At 1 y follow-up, a larger proportion of children in the intervention group compared with the control group met the recommended intake of refined sugar (P = 0.019). However, the groups did not differ in the proportion children who met the recommended intake of dietary fiber. Further, SFA intake relative to total EI did not differ between the groups at 1 y follow-up. In conclusion, despite a rather comprehensive intervention, only modest effects were achieved with respect to reduced EI and improved macronutrient intake.

Energy intake of Swedish overweight and obese children is underestimated using a diet history interview.

Estimating energy intake (EI) of a child by using a diet history interview (DHI) method may be a challenge because of difficulty for the child to remember what has been eaten as well as to report portion sizes. The aim of this research was to validate reported EI from a DHI in children classified as overweight or obese by comparing the reported EI to total energy expenditure (TEE) measured by 2 objective measures. Eighty-five 10.5- +/- 1.1-y-old overweight and obese children, with help from 1 or 2 parents, reported their EI 2 wk retrospectively in a DHI. Reported EI was compared with TEE, as measured by SenseWear armband (n = 85) and the doubly-labeled water (DLW) method (n = 21), during the same period as the DHI. Reported EI was underestimated by 14% when validated against both the armband and DLW method. Underestimation did not differ between boys and girls. However, the EI of obese children was underestimated by 22%, which is twice the rate as for the overweight children (95% CI: 0.55, 3.08). Underestimated EI was negatively correlated with BMI (r = -0.38; P = <0.01) as well as age (r = -0.21; P = 0.05). EI is underestimated to a higher extent among children with higher BMI and higher age when using a DHI method. The findings show the importance of validating dietary intake of children in general and in overweight and obese children in particular.