Multidisciplinary study of the health and nutritional status of persons living in households at risk of poverty with children in Germany (MEGA_kids): Study design and methods.

Background: In Germany, the nutritional situation of adults and children living in households at risk of poverty has been insufficiently studied so far. Aim: The aim of the mixed-methods study MEGA_kids is to gain a deeper understanding of the nutritional situation including socioeconomic, behavioral, and attitudinal factors and health characteristics among persons living in families at risk of poverty. Method: MEGA_kids is a mixed-methods cross-sectional study consisting of four modules combining quantitative and qualitative methods. The first module (A) applies self-administered questionnaires to assess the individual's diet, household food insecurity, and several other factors among adults and children of 500 households. Cash receipts are used to assess household's food expenses. For the second module (B), a semistructured interview guide is used to identify factors influencing food security and nutritional quality from the perspective of a subsample of module A (n = 20). The third module (C) applies the participatory World Café technique to explore experiences and generate ideas for tailored support measures for a healthy diet from the perspective of 40 parents participating in module A. Finally, the fourth module (D) investigates the knowledge and usage of existing nutrition-related preventive measures among 200 parents at risk of poverty by using an online questionnaire. Conclusion: By providing a comprehensive picture of nutritional aspects of families living at risk of poverty, MEGA_kids will guide officials to target and prioritize public health nutrition measures, inform policy makers to implement and improve healthy policies and, finally, identify research gaps to be prioritized.

A consensus document on definition and diagnostic criteria for orthorexia nervosa.

PURPOSE: Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with "correct" eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included. METHODS: 47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A-Definition, Clinical Aspects, Duration; B-Consequences; C-Onset; D-Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants. RESULTS: 27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON. CONCLUSIONS: This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel. LEVEL OF EVIDENCE: Level V: opinions of expert committees.

Comparison of food and beverage products' availability, variety, price and quality in German and US supermarkets.

OBJECTIVE: To assess availability, variety, price and quality of different food products in a convenience sample of supermarkets in Germany and the USA. DESIGN: Cross-sectional study using an adapted version of the Bridging the Gap Food Store Observation Form. SETTING: Information on availability, quality, price and variety of selected food products in eight German and seven US supermarkets (discount and full service) was obtained and compared by country. RESULTS: A general tendency for lower prices of fruits and vegetables in Germany was observed, while produce quality and variety did not seem to differ between countries, with the exception of the variety of some vegetables such as tomatoes. Chips and cereals did not differ significantly in variety nor price. In both countries, high energy-dense foods were lower in energy costs than lower energy-dense foods. CONCLUSIONS: The influence of food prices and availability on consumption should be further explored, including the impact of country differences.

Impact of a smoking cessation program on smoking prevalence and food security among food pantry users - a study protocol for a pragmatic cluster randomised controlled trial.

BACKGROUND: Among food pantry users there is a high prevalence of both smoking and food insecurity, which may be related to one another. This study aims to evaluate the impact of a smoking cessation program carried out in food pantries on the smoking status and the food security status of food pantry users. METHODS / DESIGN: Before starting the cluster randomised controlled trial, stakeholders will be engaged to adapt a behavioural group counselling program for smoking cessation to the needs of the food pantry users in a pre study. Food pantry users and workers as well as other experts, such as smoking cessation trainers, social workers, and psychologists, will be involved, using the world café technique and telephone interviews and a qualitative thematic analysis for data analysis to design the concept of the intervention program will be applied. In the second phase, the impact of the intervention on the smoking status and on food insecurity will be investigated by a cluster randomised controlled trial. A total of 416 food pantry users across 32 clusters (food pantries) in Berlin, Germany, should be recruited and randomly assigned to either the intervention group or the waiting list control group. The intervention will consist of a behavioural group counselling program for smoking cessation, specially tailored for food pantry users, as well as optional nicotine replacement therapy and the implementation of environmental smoking reduction measures in the food pantries. The primary outcomes 6 months after the treatment will be self-reported continuous smoking abstinence, validated by exhaled carbon monoxide (< 10 ppm of carbon monoxide), and increased food security level (the percentage of participants with an improved food security level). DISCUSSION: This study will be the first long-term investigation into the effect of a smoking cessation program on smoking status and food insecurity. The results of this study will inform the implementation of smoking cessation programs in food pantries throughout Germany. TRIAL REGISTRATION: Prospectively registered DRKS00020037 . Registered 29 April 2020.

Preparation sequence of two snack components influences snack composition and calorie intake.

Many contextual factors appear to influence both food intake as well as quality perception. A recent study showed the influence of pouring sequence in food preparation on food amount, ingredient ratio and calorie content. Two studies were conducted to further investigate the influence of pouring and preparation order on food intake. Using a within-subject design in study 1, participants were randomized to either pour yogurt or muesli first into a bowl before consuming the prepared snack. While the total amount of the snack did not differ between the two pouring order groups, participants poured significantly more yogurt and muesli when either snack component was poured first compared to when poured second. The second study used a real world setting asking participants to follow a certain preparation order when pouring their muesli and yogurt at home for one week. Again, whichever component was poured or spooned first was significantly more than when poured second. This effect remained over time. Depending on the caloric content of each snack component, the preparation sequence influenced total calorie consumption. It can be concluded that preparation sequence impacts total calorie intake even over time and has the potential to be used as a tool in weight management.

Psychometric evaluation of the English version of the Düsseldorf Orthorexie Scale (DOS) and the prevalence of orthorexia nervosa among a U.S. student sample.

PURPOSE: Recently, the concept of orthorexia nervosa (ON) as a potential new variant of disordered eating behavior has gained popularity. However, published prevalence rates appear to be questionable given the lack of validity of the available questionnaires. The Düsseldorf Orthorexie Scale (DOS) is a validated questionnaire only available in German to measure orthorexic behavior. METHODS: The DOS was translated into English using the back-translation process. Cronbach's alpha was used to establish internal consistency and an intra-class correlation coefficient was calculated to assess reliability. The Eating Habits Questionnaire (EHQ) was used to test construct validity and the Eating Disorders Inventory was used to test discriminant validity. Principal and confirmatory factor analyses were carried out to test the factor structure. The sample consists of 384 university students in the U.S. RESULTS: English (E)-DOS and EHQ were highly correlated (r = 0.76, p < .001) indicating very good construct validity. Cronbach's alpha coefficient reached 0.88, indicating very good internal consistency. Confirmatory factor analyses revealed a poorly fitted one-factor model, but good results for the standardized coefficients for the 10 items ranging between 0.52 and 0.82 were found. According to the E-DOS, 8.0% of the students exceeded the preliminary cut-off score, while an additional 12.4% would be considered being at risk of developing ON. CONCLUSIONS: The E-DOS appears to be a valid, reliable measure for assessing ON. The results revealed higher prevalence rates for orthorexic behavior among U.S. students compared to German students. Cultural aspects could play a role in those differences. LEVEL OF EVIDENCE: Descriptive study, Level V.

Students' adherence to dietary recommendations and their food consumption habits.

BACKGROUND: Habitual behavior rather than intention has been linked to food intake patterns. AIM: The purpose of this study was to examine the adherence to dietary recommendations in university students and to analyze whether habit strength predicts food consumption. METHODS: A student sample of the University (University of Hohenheim) was recruited ( n = 103; age range 18-30 years). Habit strength for consuming the food groups fruits, vegetables, whole grains, milk, meat, convenience foods, sugary and savory snacks, water and sugar-sweetened beverages was measured using a questionnaire. Food intake was measured via a self-administered online food frequency survey two weeks later, which was then compared to dietary recommendations. For associations of habit strength and consumption, Kendall's Tau-c correlation coefficient was calculated. RESULTS: The majority of students failed to meet the recommendations for all food groups except meat, eggs, oil, fat, and water. Only 4.2% of men (15.4% of women) consumed the recommended daily amount of vegetables. Fruit recommendations were met by 20.8% of men (43.6% of women). Habit strength was significantly associated with the consumption of most food groups. CONCLUSION: Adhering to dietary recommendations appeared to be difficult. Educational efforts should be undertaken to improve students' diet considering habit strength as an important determinant of food intake.

Prevalence and predictors of orthorexia nervosa among German students using the 21-item-DOS.

PURPOSE: Orthorexia nervosa (ON) describes the constant pathological preoccupation with "healthy" nutrition. The current results regarding the prevalence of ON differ widely possibly because of invalid measurement tools. This study aimed to investigate ON prevalence in a sample of German students and to examine age, gender, semester, and nutritional knowledge as potential predictors of ON by comparing nutrition science (NS) with economics (ES) students. METHODS: A total of 446 university students participated in the survey (NS 188, ES 268). ON was determined using the 21-item-DOS, which is a well-constructed, validated, and reliability-tested questionnaire. Age, gender, and semester were also assessed. RESULTS: Of the total sample, 3.3 % were classified as having ON and 9.0 % were at risk of developing ON. Older students scored significantly higher on the subscale "avoidance of additives" compared with younger students and students of lower semester suffered significantly more often from ON than students of higher semester. In addition, comparing field of study showed no significant difference in the prevalence of ON or the risk of developing ON between female NS and ES students. However, mean values for the three DOS subscales were higher among female NS students, albeit far below values indicating pathological behavior. CONCLUSIONS: The prevalence of ON appears to be low in this sample of German university students. Female NS students do not seem to have higher prevalence of ON or risk of developing ON.

First come, first served. Does pouring sequence matter for consumption?

Various environmental factors associated with eating and drinking affect people's food choice and food intake. Lately, the role of tableware has been studied in more detail. The aim of this study was to determine whether pouring sequence of food components affects portion size. Study 1 invited participants to pour a beverage containing both apple juice and sparkling water. Pouring apple juice first increased juice by almost 25% compared to pouring water first. Pouring water first increased water by almost 19% compared to pouring juice first confirming our hypothesis that pouring sequence affects the ratio poured. Study 2 asked participants to prepare themselves a snack containing cereals with milk. Within-subject comparisons revealed that pouring milk before cereals significantly increased both milk and cereal amounts resulting in larger overall portion size compared to pouring cereals before adding milk. Habitual tendencies for preparing foods causing a perception bias or a perception bias itself could be possible explanations for the divergent study findings. These findings show for the first time the influence of pouring and preparation sequence on portion size.

An explorative cross-sectional study examining self-reported health and nutritional status of disadvantaged people using food banks in Germany.

BACKGROUND: Even in high-income countries some population groups depend on food banks to support their food intake. We aimed to explore and compare health and nutritional status of food bank clients (Tafel e.V.) in different cities in Germany. METHODS: In a cross-sectional study, self-reported health and nutritional status of food bank clients living in three cities (Berlin - capital, Ludwigsburg- affluent city, Fulda - small town) which differ in size, available income and poverty rate, were assessed and compared to survey variables of the low socioeconomic status population of national surveys (DEGS and GEDA). RESULTS: Across cities, food bank clients (N = 276, response rate of 21.5 %) did not differ in main socio-demographic characteristics (age, nationality, education, professional qualification, household income). Smoking, having at least one chronic illness, estimating their own health status as moderate to poor and low consumption of fruits and vegetables were common characteristics. Comparing selected variables with the low socioeconomic status population of DEGS and GEDA, differences were found for a higher prevalence of diabetes among food bank clients and a worse self-reported health status. Considerably lower fruit consumption and lower hypertension prevalence among female and lower overweight rates among male food bank clients were found. CONCLUSIONS: Although people using food banks vary in socio-demographic background, no differences for main demographics across the cities were found. In addition, the study suggests that for some health- and nutrition-related variables, national surveys in Germany might underestimate socioeconomic differences.

Predictors of meeting physical activity and fruit and vegetable recommendations in 9-11-year-old children.

OBJECTIVE: Childhood obesity represents a significant public health problem. This study examined physical activity and nutrition behaviours and attitudes of 9-11-year-olds, and factors influencing these behaviours. DESIGN: Study participants recorded pedometer steps for 7 days and completed physical activity enjoyment, food attitudes and food frequency questionnaires. Fruit and vegetable sales data were collected from schools. The setting for the study was elementary schools in metropolitan Denver, Colorado (USA). METHOD: Logistic regression was used to determine significant predictors of meeting physical activity/fruit and vegetable intake recommendations. RESULTS: Overall, 42.0% of boys and 44.1% of girls met step count recommendations. Further, 30.9% of boys and 32.8% of girls met step count requirements associated with low risk for overweight/obesity. Enjoyment of physical activity significantly predicted achieving recommendations. Overall, 66.4%, 51.3% and 65.8% of 9-11-year-olds achieved adequate fruit, vegetable, or fruit and vegetable intake, respectively. Enjoyment of fruit/vegetable consumption, perceived parental intake and encouragement and cups of vegetables purchased predicted achieving adequate intake. CONCLUSION: The majority of young people aged 9-11 years failed to meet step count recommendations to prevent the risk for overweight/obesity. A significant proportion also failed to achieve adequate fruit and/or vegetable intake. Future programmes and interventions should affect multiple environments in order to improve child enjoyment of physical activity and fruit/vegetable intake in order to improve the physical, mental and emotional health of children.

Validation of the English Version of the General Dietary Behavior Inventory (GDBI-E).

In medical science and practice, dietary behavior is mostly assessed by item-extensive questionnaires (e.g., food-frequency-questionnaires) or by questionnaires focusing on psychological aspects of dietary behavior neglecting dietary quality or quantity. In consequence, these questionnaires do not capture the full bandwidth of dietary behavior or are less effective in the assessment of dietary behavior because of the large item pools. Therefore, the aim of this validation study was to translate the existing General Dietary Behavior Inventory (GDBI), which was constructed as a behavior-related, as well as effective, instrument, and verifying its construct and criterion validity. This inventory is based on the general nutrition recommendations of the World Health Organization (WHO). Our English-speaking convenience sample consisted of 263 participants. The study results confirmed convergent, as well as criterion validity of the English version of the GDBI (GDBI-E). Discriminant validity of the GDBI-E could mainly be verified. Different dietary behavior clusters were identified in a cluster analysis. The found clusters represented a rather healthy and a rather unhealthy dietary behavior in the sample according to the recommendations of the WHO. The results underpinned the validity of the GDBI-E. The GDBI-E is applicable in research and clinical practice to assess dietary behavior in the English-speaking population.

Outcomes addressed in randomized controlled lifestyle intervention trials in community-dwelling older people with (sarcopenic) obesity-An evidence map.

Obesity and sarcopenic obesity (SO) are characterized by excess body fat with or without low muscle mass affecting bio-psycho-social health, functioning, and subsequently quality of life in older adults. We mapped outcomes addressed in randomized controlled trials (RCTs) on lifestyle interventions in community-dwelling older people with (sarcopenic) obesity. Systematic searches in Medline, Embase, Cochrane Central, CINAHL, PsycInfo, Web of Science were conducted. Two reviewers independently performed screening and extracted data on outcomes, outcome domains, assessment methods, units, and measurement time. A bubble chart and heat maps were generated to visually display results. Fifty-four RCTs (7 in SO) reporting 464 outcomes in the outcome domains: physical function (n = 42), body composition/anthropometry (n = 120), biomarkers (n = 190), physiological (n = 30), psychological (n = 47), quality of life (n = 14), pain (n = 4), sleep (n = 2), medications (n = 3), and risk of adverse health events (n = 5) were included. Heterogeneity in terms of outcome definition, assessment methods, measurement units, and measurement times was found. Psychological and quality of life domains were investigated in a minority of studies. There is almost no information beyond 52 weeks. This evidence map is the first step of a harmonization process to improve comparability of RCTs in older people with (sarcopenic) obesity and facilitate the derivation of evidence-based clinical decisions.

Visual attention towards food during unplanned purchases - A pilot study using mobile eye tracking technology.

This pilot study aims to investigate the relationships between consumers' weight status, energy density of food and visual attention towards food during unplanned purchase behavior in a real-world environment. After more than a decade of intensive experimental eye tracking research on food perception, this pilot study attempts to link experimental and field research in this area. Shopping trips of participants with different weight status were recorded with mobile eye tracking devices and their unplanned purchase behavior was identified and analyzed. Different eye movement measurements for initial orientation and maintained attention were analyzed. Differences in visual attention caused by energy density of food were found. There was a tendency across all participants to look at low energy density food longer and more often.

Development and Validation of the General Dietary Behavior Inventory (GDBI) in Scope of International Nutrition Guidelines.

Unhealthy eating is associated with various diseases, such as cardiovascular, neurodegenerative, or oncological. There are neither economical nor behavior-related questionnaires available in the German language to assess general dietary behavior. Therefore, the aim of this validation study was to develop an instrument considering these aspects and verifying its construct and criterion validity. The new questionnaire is based on the general nutrition recommendations of the World Health Organization and the German Nutrition Society. It consists of 16 items that contrast dietary behaviors on a semantic differential scale. Our German-speaking convenience sample consisted of 428 participants. The construct validity of the General Dietary Behavior Inventory (GDBI) could be confirmed by examining convergent and discriminant validity. Furthermore, criterion validity was confirmed (significant negative correlations with body weight, Body Mass Index, and positive correlations with physical/mental health as well as life satisfaction). A cluster analysis revealed two different dietary behavior clusters representing a rather healthy and a rather unhealthy dietary behavior cluster. The results indicate that the GDBI is a validated and economical instrument to assess general dietary behavior. In practical research, this questionnaire helps to assess dietary behavior and to derive interventions for a healthy dietary behavior in concordance with international nutrition recommendations.

The Role of Dishware Size in the Perception of Portion Size in Children and Adolescents with Obesity.

PURPOSE: The influence of dishware on portion size perception in children and adolescents is inconclusive. This study investigated how children and adolescents with both obesity and a normal weight perceived portion size in different sized and shaped dishware items. METHODS: The study included 60 children and adolescents with overweight and obesity (OBE) and 27 children and adolescents with normal weight (NW) aged from 9 to 17 years. The participants estimated quantities in three pairs of drinking glasses, one pair of bowls and two pairs of plates which varied in size and shape. The children were instructed to state intuitively which portion they would choose for big or small thirst/hunger. Thereafter they were asked to determine the exact amount by answering which dishware item contained the larger/smaller portion (cognitive evaluation). RESULTS: There were no substantial differences in the intuitive evaluation of portion sizes between OBE and NW. During the cognitive evaluation, OBE estimated the amount of water in the glasses more correctly compared to NW (61% vs. 43%; p = 0.008); OBE estimated the amount of lentils in the bowls and on the plates significantly less correctly (39%) compared to NW (56%; p = 0.013). CONCLUSIONS: Habit formation and environmental stimuli might play a greater role in estimating food amounts in dishware than the child's and adolescent's body weight.

Determinants of Physical Activity and Screen Time Trajectories in 7th to 9th Grade Adolescents-A Longitudinal Study.

Physical activity (PA) in youth tends to decline with increasing age, while sedentary behaviour including screen time (ST) increases. There are adolescents, however, whose PA and ST do not follow this pattern. The aim of this study is (i) to examine trajectories in PA and ST from grade 7-9 among students in Berlin, and (ii) to investigate the relationship of these trajectories with individual factors and school type. For the present analyses, changes in students' PA and ST across three time points from 7th to 9th grade were assessed via self-report questionnaires. Positive and negative trajectories were defined for both PA (positive: increasing or consistently high, negative: decreasing or consistently low) and ST (vice versa). Multivariable logistic regression analyses were performed to identify possible predictors of PA and ST trajectories. In total, 2122 students were included (50.2% girls, mean age 12.5 (standard deviation 0.7) years). Compared to grade 7, less students of grade 9 fulfilled PA and ST recommendations (PA: 9.4% vs. 13.2%; ST: 19.4% vs. 25.0%). The positive PA trajectory included 44% of all students (63% boys), while the positive ST trajectory included 21% of all students (30% boys). Being a boy was significantly associated with a positive PA trajectory, while being a girl, having a high socioeconomic status, and attending a high school, were significantly associated with a positive ST trajectory. Different PA and ST trajectories among adolescents should be taken into account when implementing prevention programs for this target group.

Effective SLOPE: EffectS of Lifestyle interventions in Older PEople with obesity: a systematic review and network meta-analysis protocol.

INTRODUCTION: Obesity is highly prevalent in older adults aged 65 years or older. Different lifestyle interventions (diet, exercise, self-management) are available but benefits and harms have not been fully quantified comparing all available health promotion interventions. Special consideration must be given to functional outcomes and possible adverse effects (loss of muscle and bone mass, hypoglycaemia) of weight loss interventions in this age group. The objective of this study is to synthesise the evidence regarding the effects of different types and modalities of lifestyle interventions, or their combinations, on physical function and obesity-related outcomes such as body composition in older adults with obesity. METHODS AND ANALYSES: Six databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Psychinfo and Web of Science) and two trial registries (Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform) will be searched for randomised controlled trials of lifestyle interventions in older adults with obesity. Screening (title/abstract and full-text) and data extraction of references as well as assessment of risk of bias and rating of the certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluation for network meta-analyses) will be performed by two reviewers independently. Frequentist random-effects network meta-analyses will be conducted to determine the pooled effects from each intervention. ETHICS AND DISSEMINATION: We will submit our findings to peer-reviewed journals and present at national and international conferences as well as in scientific medical societies. Patient-targeted dissemination will involve local and national advocate groups. PROSPERO REGISTRATION NUMBER: CRD42019147286.