THE NUTRITION SURVEY ESKIMO II - DESIGN, EXECUTION AND PUBLIC HEALTH POLICY RELEVANCE - ERNÄHRUNGS UMSCHAU
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Science & Research | Original Contribution Reproduction and dissemination – also partial – applicable to all media only with
written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
Peer-reviewed | Manuscript received: December 01, 2017 | Revision accepted: February 26, 2018
The nutrition survey EsKiMo II –
design, execution and public health
policy relevance
Anna-Kristin Brettschneider, Clarissa Lage Barbosa, Marjolein Haftenberger,
Karoline Heide, Melanie Frank, Eleni Patelakis, Hanna Perlitz, Franziska Lehmann,
Almut Richter, Gert BM Mensink
contexts, such as schools and day-
Abstract care facilities, is often the subject of
much criticism. For instance, stud-
Regular nutrition surveys are important for health policy measures. As part of
ies on meal quality have shown that
the second wave of the “German Health Interview and Examination Survey for
only a fifth of daycare centers and
Children and Adolescents” (KiGGS Wave 2; 2014–2017), the nutrition study – Es-
only a quarter of schools base their
KiMo II – was once again conducted about ten years after the first “Eating Study
menus on the quality standards
as a KiGGS Module» (EsKiMo; 2006). In the period from June 2015 to September
of the German Nutrition Society
2017, nutritional data were collected from 2,644 children and adolescents. Pa-
(Deutsche Gesellschaft für Ernährung
rents of children aged 6 to 11 years were instructed in how to keep a food record
[DGE]) [4, 5].
for a total of four days; nutrition interviews were conducted with 12- to 17-ye-
During childhood taste preferences
ar-old adolescents using the modified diet history software known as DISHES.
and dietary habits develop, and it
The results of EsKiMo II will provide actual data on the nutrition status of children
is highly likely that these prefer-
and adolescents aged 6 to 17 years living in Germany, and will therefore offer an
ences and habits will continue into
information basis for policy decisions.
adulthood [6, 7]. Overweight during
Keywords: children and adolescents, food consumption, intake of nutrients,
childhood and adolescence which oc-
KiGGS, EsKiMo
curs due to poor diet among other
factors, often persists into adult-
hood, bringing with it all of the
associated health consequences.
Therefore, essential foundations for
a healthy lifestyle are already being
Background laid in childhood and adolescence.
However, many children and ado-
Optimal intake of energy and nu- lescents grow up in an environment
trients is particularly important for that facilitates weight gain, result-
children and adolescents as they are ing in people becoming overweight
still developing [1]. However, our [8]. For example, sweets and pastries
dietary behavior is in a state of con- are often sold in kiosks in schools.
stant change. Trends such as “su- “Children’s foods” often contain too
perfoods”, organic foods, and the much sugar and fat. The food indus-
Citation:
current vegan trend, as well as the try tries to influence the purchasing
Brettschneider A-K, Lage Barbosa
growing range of products available behavior as well as children’s and
C, Haftenberger M et al. (2018)
in supermarkets are all factors that adolescent’s dietary habits by using
The nutrition survey EsKiMo II
can influence our dietary habits [2]. colorful advertisements aimed at
– design, execution and public
In addition, living conditions have children or advertising messages di-
health policy relevance. Ernah-
changed in recent years: An increas- rected at parents that emphasize the
rungs Umschau 65(5): 80–88
ing proportion of children and ad- health benefits of their products [9].
This article is available online: olescents are now being taken care In 2006, as part of the baseline study
DOI: 10.4455/eu.2018.018 of at daycare facilities [3]. However, of the “German Health Interview
the food available in communal and Examination Survey for Chil-
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written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
dren and Adolescents” (KiGGS) con- changes will influence dietary hab- to be made for the age group of
ducted by the Robert Koch Institute its, and as a result, the quality of 0–17 years. A total of 15,023 chil-
(RKI), the Germany-wide “Eating nutrition among children and ado- dren and adolescents were surveyed
Study as a KiGGS Module” (EsKiMo, lescents in Germany and their nu- for the first time, and a subsample
hereinafter referred to as EsKiMo tritional and health status, regular, of them also underwent a physical
I) was conducted for the first time representative assessment of food examination [13]. This means that
with 2,506 children and adolescents and nutrient intake is required. there are also a number of biochem-
aged 6 to 17 years. EsKiMo I showed Again, a nutrition module (EsKiMo ical parameters, such as blood lipid
that children and adolescents in Ger- II) was implemented in a new wave levels, available, which may allow
many had an adequate intake of of the KiGGS study, KiGGS Wave conclusions to be drawn about nu-
most vitamins and minerals, but 2. The aim of EsKiMo II is to collect tritional status.
were not eating enough plant-de- up-to-date data to provide a repre-
rived foods such as fruit, vegeta- sentative overview of the current
Study population
bles, potatoes, bread, and other nutritional status of 6-17-year-old
fiber-rich foods. The proportion of children and adolescents living in KiGGS offers the opportunity to
carbohydrates in the overall food Germany. The results of EsKiMo II study subgroups of the study pop-
intake did correspond to German will show the extent to which the ulation in greater detail regard-
Nutrition Society recommendations, nutrition situation described above ing specific issues using modules.
but most carbohydrates were con- still applies today. The methods Thanks to this arrangement, it was
sumed in the form of foods with a used in the EsKiMo study are very possible to conduct the nutritional
high sugar content or in the form of effort-intensive, which is why fur- survey EsKiMo II as a module study
foods made of white flour. The main ther details about the conduct of within the framework of KiGGS
sources of sugar were sweets and the study are described below. This Wave 2 from June 2015 to Septem-
sugar sweetened beverages, which should also provide a foundation ber 2017. In order to ensure that the
were consumed by children and ad- for future publications. The planned data gathered was representative,
olescents too frequently and in too usage of the results of EsKiMo II is the regional and seasonal distribu-
large amounts. Furthermore, the also specified. tion of the sample points visits was
recommended consumption levels considered in the study design. The
for meat and sausages were greatly target sample size for EsKiMo II was
exceeded, which led to an increased about 2,600 participants. This num-
Methods
intake of undesirable saturated fatty ber is based on an equal distribution
acids [10]. The KiGGS Study of boys and girls across each year
Policy measures and intervention of age included in the study (at least
programs have been established as The KiGGS study is part of the 100 boys and 100 girls from each
an effort to improve this situation. health monitoring for Germany and year of age band) and an equal dis-
The national action plan “IN FORM is performed by the RKI at regular tribution across the sample points.
– German national initiative to pro- intervals. One of its aims is to gather Participants who took part in ex-
mote healthy diets and physical ac- population data on the health sta- aminations and interviews in the
tivity”, launched in 2008, aims to tus of children and adolescents liv- cross-sectional part of KiGGS Wave
bring lasting improvements in die- ing in Germany. The KiGGS baseline 2 at the age of 6–17 years who had
tary and physical activity habits in study was conducted by the RKI given their consent for being con-
Germany by 2020. IN FORM has nationwide at 167 sample points tacted again were invited to partici-
supported various health promo- from 2003 to 2006 as a combined pate in EsKiMo II. Details about the
tion and disease prevention projects interview and examination survey study are described elsewhere [14].
in recent years, such as projects to with 17,641 children and adoles- Before the study began, it was ap-
improve the quality of food pro- cents. The first follow-up survey, proved by the Ethics Committee of
vided in schools [11]. The German KiGGS Wave 1, was conducted by Hannover Medical School and the
government’s latest sustainability telephone from 2009 to 2012. The German Federal Commissioner for
strategy deals with existing and second follow-up survey, KiGGS Data Protection and Freedom of In-
planned measures for the preven- Wave 2, was once again conducted formation. An interview was con-
tion of overweight and obesity in as a combined interview and exam- ducted after information had been
children and adolescents, including ination survey from 2014 to 2017. given and a written declaration of
plans to further develop the national Participants from the baseline study consent had been obtained from the
action plan IN FORM [12]. were invited to take part again. In legal guardians of minors and from
In order to draw conclusions about addition, a new sample was taken, adolescents themselves if aged 14
the extent to which the described allowing representative statements years or over.
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written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
intake accounted for by individ-
ual energy contributing nutrients,
compared to the German Nutrition
Society recommendations [1].
Dietary interviews
For adolescents aged 12 to 17 years,
the DISHES (Dietary Interview Soft-
ware For Health Examination Stud-
ies) software was used. DISHES is
a computer program developed by
the RKI that is used to record usual
dietary intake over the past four
weeks using a modified dietary his-
tory method. In an about one hour-
long face-to-face interview, the con-
sumption frequencies and portion
sizes of all foods consumed were re-
corded by trained nutritionists, or-
Fig. 1: Example page from a food record ganized by meal (breakfast, lunch,
(table translated from German original for better understanding) dinner, late-night snacks, or other
snacks). Details about the DISHES
software can be found elsewhere
Dietary assessment tion (e.g. fat content), the time [17]. When conducting the inter-
and location of consumption, the views, it was essential to recognize
Dietary assessments are a particular weighted amount served, and the and use regional food names. For
challenge when it comes to children weighted plate waste (• Figure 1). example, the various regional syn-
and adolescents. Younger children An additional, shortened version of onyms for bread rolls [“Brötchen”],
require help from their parents be- the weighted food record was pro- such as “Semmeln”, “Wecken”, or
cause they lack nutritional knowl- vided for situations in which the “Schrippen” were used in order to
edge and the required memory ca- amount of food consumed could record the consumption of bread
pacity [15]. As for adolescents, a not be weighted (e.g. in school can- rolls. Following the interview, the
method that is both less time-con- teens or restaurants) [14]. House adolescents received €15 in cash as
suming and burdensome needs to be visits were conducted by trained a thank you for their participation.
used in order to keep dropout rates nutritionists from the EsKiMo team, Furthermore, after a few weeks, an
to a minimum [16]. This is why in which instructions on how to fill individual nutritional evaluation
EsKiMo II uses different dietary as- out the food record and how to use was sent, containing information
sessment tools depending on the age the digital kitchen scale provided by on total energy intake and the pro-
of the participant. In order to ensure the EsKiMo II study were given. The portion of energy intake accounted
good comparability between the re- instruction lasted about 30 min- for different macronutrients. The
sults from EsKiMo I and EsKiMo II, utes. The parents or legal guardians overview also provides information
widely the same dietary assessment of the participants had the option about average daily intake levels of
tools were used. to contact the EsKiMo team by tele- selected vitamins and minerals such
phone or e-mail with any questions. as vitamin C, iron, and magnesium,
Food records The study participants sent the and about the most important food
For the 6 to 11-year-old age group, completed food records back to the sources of these substances which
the parents (or legal guardians) RKI in a postage-paid envelope and were mentioned in the interview.
were asked to keep a weighted food received a gift voucher with a value In addition, nutrition information
record for three days and for one of €20 as an incentive, as experience about which foods are particularly
additional separate day. The days has shown that this increases will- good for balancing out any potential
to be recorded were established in ingness to participate. In addition, deficits was also sent.
advance using a randomized pro- after a few weeks, a personal nutri-
cedure. The foods consumed were tional evaluation was sent, contain- Short questionnaire
recorded in detail, including spec- ing information on average total In addition to the dietary assessment
ifications such as the brand name energy intake from the four days tools described above, further infor-
of the product, a product descrip- as well as the proportion of energy mation such as special dietary hab-
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its, school catering, supplements, funding organisation”, “child does ipants, arranging appointments by
and consumption of specific foods not want to/child is frightened/ telephone, and the data protection
such as raw ground meat and raw burdensome for the child”, “child is and organizational aspects of the
eggs was also collected in a short healthy”, “too many surveys”, or field phases of the study. Practical
questionnaire as a computer-as- “other reasons”. training was also performed: The
sisted interview. The questionnaire Comprehensive information from instruction procedure on how to fill
was completed by the parents of KiGGS Wave 2 is available regard- in the food records was practiced
6- to 11-year-olds after the food re- ing all participants invited to take on RKI employees who have chil-
cord instruction, and by the 12- to part in EsKiMo II, meaning that it is dren aged 6 to 11 years and who
17-year-olds immediately after the possible to perform a detailed com- voluntarily agreed to take part. In
DISHES interview. parison of non-participants versus order to emulate realistic field con-
participants. ditions, four house visits were also
Non-responder questionnaire organized with parents who have
Persons who were invited to par- children in the target age group.
Practical execution
ticipate but did not participate in Parents were instructed in how to
EsKiMo II were asked by telephone Training fill in the food records and answered
or written questionnaire whether Prior to the start of the field phase, the short questionnaire regarding
any of the following reasons for the interviewers (four nutritionists) dietary habits. In addition, DISHES
non-participation applied: “Absent were trained in how to conduct interviews were conducted with
at the time of the interview”, “child the visits with the study partici- volunteers in order to establish an
acutely/chronically ill”, “other pants. The content of the training interview routine and to standardize
family member acutely/chronically included a general overview of both the conduct of the interviews. These
ill”, “child undergoing treatment/ studies KiGGS and EsKiMo, as well interviews were observed by the
in hospital at the time of the inter- as a presentation of and theoretical study coordinators so that a debrief-
view”, “no time”, “no interest/not and practical introduction to the ing session could follow. During the
convinced about the need for and dietary assessment tools used. In debriefing, any questions raised and
purpose of the study”, “worries addition, more detailed information any ambiguities brought to light
about data protection”, “too much was provided regarding the field by the conduct of the interviews
effort (takes too long)”, “never take execution of the study, how to act were addressed in order to achieve
part in surveys”, “because of the with participants, recruiting partic- optimized, standardized procedures.
Interviewer’s visit
1. a) Instruction on how filling telephone filling telephone
to keep the food record (FR) out 3 back follow-up 1 d FR out back follow-up
d FR to the if required + gift 1 d FR to the if required data personal
RKI voucher RKI entry assessment
4–6 weeks 1. b) DISHES interview 1–5 months
arrangement
obtaining sending of appoint- plausibility produkt- personal
address of ment 2. Short questionnaire checks research assessment
KiGGS invitation
@ 3. Time for questions
Fig. 2: Schedule for each tour in the EsKiMo study
d = day; DISHES = Dietary Interview Software for Health Examination Studies; FR = food record; KiGGS = German Health Interview and
Examination Survey for Children and Adolescents [Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland];
RKI = Robert Koch Institute
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written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
Subsequently, up until the start of Documentation of the field phase additional 109 participants were
the field phase, interviews were Personal data, such as addresses and recruited.
conducted with RKI employees and telephone numbers, and study-spe- During the final third of the data
with adolescents within the target cific data, such as attempts to ar- collection period, the invited sample
age group as further training. range appointments and date agree- size was increased. Originally, it was
ments with the participants were planned to only invite those who
Process of the field phase of documented in a database. In addi- had taken part in the physical ex-
EsKiMo II tion, other important information amination in KiGGS Wave 2 to take
• Figure 2 gives an overview of the about the participants, such as com- part in the EsKiMo study. However,
process of EsKiMo II. During the field pletion of the dietary assessment, this group of KiGGS participants
phase, which generally took place 3 the appointments for the one-day was too small to achieve the target
to 6 months after KiGGS Wave 2, a food records, reasons for non-par- sample size. Therefore, those who
total of 167 KiGGS sample points ticipation, and the creation of the only took part in the interview part
were visited once again in a total of personal nutritional assessment, of the KiGGS study were invited as
33 tours. During each tour, three in- was recorded. Standard letters were well.
terviewers visited one or two study generated using the database and
locations each, and were on the road their dispatch was noted in the par-
Quality assurance and data ma-
between 5 and 10 days. Interviews ticipant database.
nagement
and instructions on how to use the
food records also took place on Sat- Efforts to increase response and Immediately after each tour, a
urdays. The data collection period number of participants meeting between the interviewers
for each of the individual sample Various measures were used to and the coordinators took place
points was determined using a route reach the target sample size of in order to share experiences and
plan. The invitations were sent out about 2,600 participants. In order clarify any problems. During the
five weeks prior to the beginning of to increase the number of partici- field phase, the field coordinator
data collection. Those contained a pants, the interviewers were given conducted regular visits in order to
cover letter addressed to the parents follow-up training on telephone check the interviewers’ approach,
and a letter addressed to adolescents recruitment of participants, led by how they dealt with the partici-
aged 12 years and above, as well as internal RKI experts. During the pants, and whether they were con-
a flyer that provided information follow-up training, the existing ducting the interviews and provid-
about the study, its contents, and guidelines for conversations and ing the instructions correctly. Af-
its aims. In addition, a declaration argumentation examples were dis- terwards, the visits were evaluated
of consent, complete with a return cussed. In addition, the interview- with the interviewers.
envelope was included with the in- ers were given individual telephone
vitation letter, and the recipient was coaching. Food records
asked to sign the declaration and After about half of the data collec- Once the food records were received
send it back to the RKI. At the same tion period had passed, the inter- at the RKI, an initial check on their
time, the recipient was asked to pro- viewers also contacted participants completeness and plausibility was
vide up-to-date telephone numbers on site if no valid telephone number performed. Any ambiguities, such
and suitable times to call to arrange was available or if the participants as missing entries for amounts or
an appointment. A data protection could not be reached by telephone. inaccurate product details, were
sheet was provided to inform the This measure resulted in the re- clarified by telephone, generally
participants themselves and the par- cruitment of 15 additional partic- within one week after the food re-
ents or legal guardians about data ipants. cord was received by post.
protection issues. Another measure that was used Data entry of the information from
Prior to each tour, appointments to increase the response was con- the food records was performed
were arranged with the participants ducting the instructions for the by trained nutritionists in accord-
or their parents (or legal guardians), weighted food records by telephone ance with a standardized data entry
mostly by telephone. Generally, the if it was not possible to arrange an manual. The data from the food re-
appointments were conducted at the appointment with the parents of cords were coded using a software
participant’s home. If a home visit the participants during the time that was specially developed by Pad-
was not possible or not desired, the in which the EsKiMo interviewers erborn University (EAT version 5.3)
instructions or the interviews could were on site. The required docu- using the German Nutrient Data
also be conducted in the EsKiMo car. mentation and materials were sent Base version 3.02. The average time
A total of 2.2% of the interviews by post in advance. Thanks to the taken to enter the data of a complete
took place in the car. telephone instruction measure, food record (all four days) was two
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Participants and participa-
tion rate
150 A total of 4,534 children and ado-
lescents (girls: N = 2,317; boys: N
120 = 2,217) were invited to take part,
of which 2,644 (girls: N = 1,361;
Girls
Frequency
90 boys: N = 1,283) were recruited
Boys for participation in EsKiMo II. Par-
60 ticipants in EsKiMo II are those for
whom at least one of the following
30
is available: the DISHES interview,
the food record, or the completed
short questionnaire. A food record
0
6 7 8 9 10 11 12 13 14 15 16 17 is available for 1,190 children, and a
Age in years DISHES interview for 1,353 adoles-
cents. The short questionnaire was
Fig. 3: EsKiMo participants by age and sex answered by 2,641 participants.
• Figure 3 shows participation by
age and gender: participation was
lowest among 6-year-old girls and
hours. Problems with data capture, Nutrition interviews 16- to 17-year-old boys, and it was
for example how to proceed on the highest among 11-year-old girls.
coding of foods that were not in- Promptly after each tour, the data 83 (1.8%) of those invited were
cluded in the German Nutrient Data from the DISHES interviews were classified as quality-neutral drop-
Base version 3.02, were documented processed. The foods recorded in outs because, for example, they had
and dealt with promptly. DISHES are coded according to Ger- moved away to an unknown loca-
In order to ensure the quality of man Nutrient Data Base version tion, or communication with the
the data entry from the food re- 3.02. During data processing, foods participant or their parents was not
cords, the coded data was checked that were mentioned in the inter- possible due to language problems.
by a second colleague by sampling view, but were not recorded in the After considering these cases, the
and checking randomly selected program, were added. In addition to participation rate was 59.4%. Infor-
weighted food records. In addition, the tests for completeness that are mation on the reasons for non-par-
the food records of 60 participants already integrated into the DISHES ticipation are available for 1,199
on individual, randomly selected re- software, various plausibility tests families who were invited to partici-
cord days were captured once again were conducted on the personal and pate in EsKiMo II. About a third said
by a trained student assistant with consumption data from DISHES. For they did not have time to participate
a nutritional background. This sec- instance, very low or very high re- in EsKiMo. Other common reasons
ond data capture procedure showed ported amounts of individual foods given for non-participation included
that there was a low rate of error were checked because very high or that it was too much effort, that the
in the initial data entry – 15 out of very low total energy intake may child did not want to take part, that
975 codes (1.5%) required correc- indicate data entry errors. With the those invited to participate were
tion. After the entries were made, consent of the participants, a digi- absent at the time of the interview,
the nutritional data (amounts of tal audio recording of the interview or that they had no interest in the
particular foods, e.g. very high or was made for quality assurance study or were not convinced about
very low beverage intake < 500 mL purposes. The audio files allowed the need for and purpose of the sur-
or > 3,000 mL per day, or energy post hoc checking of any data that vey.
intake < 1,000 kcal or > 2,500 kcal appeared to be implausible. Regular
per day) and body size and body listening to the audio files allowed
weight were checked for plausibil- systematic data entry errors to be
Utilisation of the results
ity. In addition, the specified reci- detected. In addition, this allowed
pes were checked with regard to feedback on the quality of the inter- The results of EsKiMo II will pro-
method of preparation, portion view to be given to the interviewers vide an up-to-date picture of the
sizes, and the presence of cooking as well as measures for improvement nutrition status of children and ad-
water or cooking liquids, and fats of the standardization of the execu- olescents aged 6 to 17 living in Ger-
used for cooking or frying. tion of the interview to be taken. many, and will help identify areas
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• media • Robert Koch Institute
• expert audiences • Federal Institute for Risk Assessment
• general population • Max Rubner-Institut
• participants and parents • Universities
• daycare centers and • German Nutrition Society
schools • European Food Safety Authority
• …. • ….
General public Science sector
Industry and Political sector
NGOs
• Federal Ministry of Food and Agriculture
• consumer centres
• German Federal Agency for Agriculture
• food industry
and Food
• professional organizations
• The Federal Centre for Nutrition
• federal associations
• Federal Ministry of Health
• health insurance providers
• Federal Ministry for the Environment,
• Foodwatch
Nature Conservation and Nuclear Safety
• ….
• ….
Fig. 4: Stakeholders of the results of the EsKiMo study
where dietary habits and nutrient fruit and vegetables is below the Food=Grade A”] was initiated as
intake are deficient compared to the recommended levels. In particular, part of IN FORM. This project sup-
recommendations of the German among the 6- to 11-year-olds, the ports schools in providing balanced
Nutrition Society. Therefore, the recommended vegetable consump- menus. In addition, the German Nu-
results will be an important source tion was only reached by 6% of trition Society Quality Standard for
of information for politicians, econ- boys and 7% of girls, whereas in School Catering was published in
omists, the general public, and other the group of 12- to 17-year-olds, 2007 and in 2008/09, networking
stakeholders such as health insur- it was reached by 18% of boys and centers for school catering were es-
ance providers (• Figure 4). The re- 29% of girls. Most children and tablished in all German federal states
sults of the KiGGS baseline study adolescents did not consume even with the aim of supporting schools
and EsKiMo I have raised the public half of the recommended amount. in the development, implementa-
health policy relevance of nutrition, The data also showed that the con- tion, and quality improvement of
physical activity, and health issues, sumption of sugar sweetened bev- optimal catering [5, 20]. However,
and various preventative measures, erages, snacks, sweets, and meat the standards are only recommen-
especially with the establishment and meat products was too high dations. A nationwide survey of the
of the action plan IN FORM, have [10]. quality of school catering conducted
been initiated and implemented as a Since children are more and more in 2014 showed that in recent
result. By comparing the results of spending all day in school or day- years, the range of food available in
EsKiMo II with EsKiMo I it will be care, school meals have an increas- many establishments has been ex-
possible, for the first time, to per- ing influence on dietary habits panded, the supply of beverages is
form comprehensive analyses of among children and adolescents. satisfactory and the supply of free
changes in dietary habits over the Therefore, school meals may offer water has increased, for example
last 10 years in Germany. an approach to improving the sit- through drinking water dispens-
Like other studies [18, 19], EsKiMo uation. In this context, the project ers. However, other criteria of the
I has shown that consumption of “Schule+Essen=Note 1” [“School+ German Nutrition Society Quality
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References
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recommended quantities of fruit be published in the course of 2018. Österreichische Gesellschaft für Ernährung,
and vegetables are far from being A comprehensive project report will Schweizerische Gesellschaft für Ernährungs-
reached [5]. be available by 2019. EsKiMo II forschung. Referenzwerte für die Nähr
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Federal Ministry of Food and Ag- time, to perform comprehensive 2. Popkin BM (2015) Nutrition transition and
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2016. In addition to the measures to whether specific measures have mann Stiftung (2014)
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