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Author's copy! Any use beyond the limits of copyright law without the consent of the publisher is prohibited and punishable. This applies in particular to duplications, translations, microfilming as well as storage and processing in electronic systems. DGE | Statement

Food Density and Body Weight

A scientific statement from the DGE

Angela Bechthold, Bonn

many are in a minority from the age Summary group of 30 to 34 (men) or 55 to 59 (women). 67 % of men and 53 % of Bearing in mind the high prevalence of overweight in the population, it women are overweight. At the same would be very interesting to identify the factors that influence increases time, increasing numbers of individ - in weight, or successful or weight maintenance. Numerous uals are obese; almost a quarter of studies have shown that is one of these factors. The adults are affected (23 % of men and German Society (DGE) introduces the concept of energy den - 24 % of women) [1, 2]. sity. Together with nutritional density, this is a useful concept in the eval - uation of – apart from drinks. Current scientific findings suggest As overweight is so prevalent, it that there is a positive association between food energy density and body would be of great interest to identify weight. A nutritional pattern with low energy density can help to main - the factors that influence weight tain or reduce body weight. The DGE concludes that measures to con - gain, as well as successful weight trol weight should consider food energy density. loss and weight maintenance. It Keywords: energy density, body weight, overweight, , weight might then be possible to infer pos - loss sible methods for treatment or pre - vention. At the first glance, it is quite clear how to lose weight: Energy in - take must be less than energy ex - Introduction and objective described in the nutritional reports of penditure. There has been much de - the German Nutrition Society (DGE); bate about the best way to reach this Changes in the living conditions in they have been very rapid and have goal. For decades, there has been a Germany have led to a marked de - taken place within only a few gen - great deal of discussion and research crease in physical activity. However, erations. A wide variety of relatively on changes in the composition of nutrition has not been adapted to the cheap and tasty foods are now avail - food with respect to the content of resulting decrease in energy require - able – everywhere and at any time. the energy sources , ments. In parallel to these changes in Many of these are of high energy and . However, this approach lifestyle and working environment, density. It is becoming increasingly could be incomplete or misleading if there has been a fundamental change difficult to achieve a long-term en - the energy density is ignored [3]. in nutritional behaviour and food ergy balance – particularly for con - culture. These diverse changes are sumers with inadequate knowledge The present statement presents the of the composition and preparation principle for the calculation and as - of foods [1]. sessment of the energy density of foods. Current scientific knowledge This has lead to a high prevalence of on the link between food energy den - Citation: overweight in the population. This sity and body weight is described Bechthold A (2014) Food energy frequently starts in children and and evaluated. For this purpose, a lit - density and body weight. A scien - adolescents and is particularly erature search was carried out in tific statement from the DGE. Er - marked in socially disadvantaged PubMed for meta-analyses and sys - nahrungs Umschau 61(1): 2–11 families. The increase in weight con - tematic reviews. In addition, for the This article is available online: tinues in adults and is affecting more period between 1 May 2011 (end of DOI 10.4455/eu.2014.002 and more people. As a consequence, the search period for the most mod - people of normal weight in Ger - ern available meta-analysis) and 25

2 Ernaehrungs Umschau international | 1/2014 June 2013, a search was performed Most natural foods of plant origin for intervention and cohort studies exhibit low energy density and high Definitions (search terms: [“energy density” OR density – the exceptions are Energy density is defined as the “caloric density” OR “energy dense”] plant oils and nuts. Because of their energy content (in kcal or kJ) per AND [“body weight” OR “body mass high content, drinks and fluid unit weight (e.g. g or 100 g) food. index” OR obes* OR overweight OR dishes – such as soups – exhibit adiposity]; Limits: ; Field: lower energy density than many is the ratio of es - Title / Abstract). v Table 2 sum - “solid” foods and dishes. This is il - sential to energy in the marises the selected studies that were lustrated in v Figure 1, with the en - food. This is defined as the quan - used in this statement to evaluate ergy density of selected foods and tity of nutrient (e.g. in mg) per the available data. dishes. unit energy (e.g. kJ or MJ).

Energy density of foods Calculation of the mean and dishes energy density of food on call (underreporting, see the section on “Method to determine the energy Foods or dishes of low energy den - the basis of food consump - density of food”, p. 4). Calculations sity provide less energy per unit tion in Germany of the energy density on the basis of weight than those with high energy Energy density of food for consumption data from agricultural density. For the same amount of en - adults, depending on age and statistics and income and consump - ergy, a person can consume a larger gender tion samples (potential overestima - portion of a food or dish of low en - tion of the true consumption) give ergy density than of one with a high The National Nutrition Survey II lower values for the mean energy energy density. (NVS II) provides representative data density (women ca. 1.4 kcal/g, men on food consumption and nutri - ca. 1.8 kcal/g) [7]. The energy density of foods and tional behaviour for the German- dishes, or diets, is largely dependent speaking population. In the context Energy density of food, on their fat and water content [4]. If of NVS II, a total of 19,329 men and depending on lifestyle and a food is rich in water (provides no women aged 14–80 years were sur - nutritional knowledge energy) or in fibre (low energy con - veyed throughout Germany be - tent of ca. 2.3 kcal/g), it generally tween November 2005 and January National Nutrition Survey II (2012) exhibits low energy density. Vegeta - 2007. On the basis of two 24-hour describes the evaluation of the 24- bles and fruit are the best example of recalls, weighted data were available hour recall data from 6,817 partici - this. In contrast, foods that are rich for 10,215 adults (19–64 years) pants in the NVS II, aged 19 to 64 in fat usually exhibit high energy (v Table 1). Drinks were not consid - years for different population density, as fat is the nutrient with ered in the calculation of energy den - groups. This gave the following re - the highest energy density (fat, 9 sity. The median energy density was sults for the food energy density kcal [37 kJ]; , 7 kcal [29 kJ]; 1.7 kcal/g for women and 2 kcal/g (drinks were excluded from the cal - carbohydrate, 4 kcal [17 kJ]; pro - for men [6]. culation) [8]: tein, 4 kcal [17 kJ] – each per g). However, foods rich in carbohydrate When considering these data, it is – For women and men who engage can also exhibit high energy density, important to remember that partic - in sport, the median food energy if the water content is low – e. g. ipants may underreport their own density is lower (1.64 kcal/g and white bread. food consumption in a 24-hour re - 1.94 kcal/g, respectively) than for

19–24 years 25–34 years 35–50 years 51–64 years overall n P50 n P50 n P50 n P50 n P50 women 486 1.88 852 1.71 2 648 1.71 1 740 1.58 5 726 1.70 men 469 2.17 614 2.08 1 946 2.03 1 460 1.92 4 489 2.02

Tab. 1: Median values (P50) for food energy density [kcal/g] by gender and age (data from NVS II [6])

Ernaehrungs Umschau international | 1/2014 3 DGE | Statement

those who do not engage in sport price per weight or portion). The rel - this gives a variable that shifts the (1.73 kcal/g and 2.02 kcal/g, re - atively low prices of foods of high association between energy density spectively). energy density may be one reason and weight increase in the popula - for the high prevalence of over - tion in the direction of no correla - – For female and male smokers, the weight in the population, particu - tion. Moreover, the intra-individual median food energy density is larly for consumers of low socioeco - between-day variance may then be higher (1.80 kcal/g and 2.11 nomic status [9], whose risk of obe - greater than the inter-individual kcal/g, respectively) than for fe - sity is increased [13]. Conversely, variance if the energy density of male and male non-smokers (1.63 food of high quality frequently costs foods including drinks is calculated. kcal/g and 1.93 kcal/g, respec - more per kcal and is consumed by tively). persons with a higher level of educa - However, the energy supply from – For women and men who take tion [14]. drinks cannot be neglected as an im - food supplements, the median food portant factor in the development of energy density is lower (1.61 In a randomised controlled study in overweight. It should be charac - kcal/g and 1.92 kcal/g, respec - two supermarkets in Manhattan, it terised and used as a covariate in risk tively) than for women and men was established that cheap offers assessment. According to JOHNSON et who take no supplements (1.70 (50 % price discount) of vegetables al. (2009) [16], standardisation of kcal/g and 2.01 kcal/g, respec - and fruit (foods of low energy den - these methodological aspects would tively). sity) increased the sales and con - facilitate the interpretation of the sci - sumption of these foods [15]. entific data to develop evidence-based – If women and men know more measures for overweight prevention. about nutrition, their median en - ergy density is lower (1.62 kcal/g Another critical aspect in the deter - and 1.85 kcal/g, respectively) than Link between energy mination of food energy density and for women and men who know density and body weight its correlation with body weight is little about nutrition (1.74 kcal/g underreporting. In many cases, nu - and 2.00 kcal/g, respectively). Method to determine food tritional data are based on self-re - energy density porting by the participants; the in - – For women with very good or The energy density of food can be de - formation on energy supply is less good cooking skills, the food en - termined by various methods. For reliable than the recording of other ergy density is lower (1.65 kcal/g) example, it can be exclusively calcu - nutritional factors. Particularly than for women with little or no lated on the basis of food consumed overweight persons tend to underes - cooking skills (1.81 kcal/g). without drinks, on the basis of food timate their consumption of high consumed including energy contain - energy foods and thus their energy – Women and men who were not ing drinks, or on the basis of all food consumption [17–19]. Moreover, born in Germany have a lower consumed, including all drinks. there is also evidence that underre - mean energy density (1.58 kcal/g porting in the overweight is particu - and 1.87 kcal/g, respectively) than JOHNSON et al. (2009) [16] proposed larly common for foods of high fat women and men born in Germany the hypothesis that the inclusion of and content, i. e. generally (1.69 kcal/g and 2.00 kcal/g). drinks in the calculation of food en - those of high energy density [20– ergy density attenuates the recognis - 22]. In addition, self-reported data Energy density and food able effect of energy density on body on body weight tend to underesti - prices weight. They postulate that studies mate the actual value and the extent on the correlation between energy of underreporting is proportional to In Germany and in other countries, density and the risk of weight in - the overweight of the individual [23, foods of high energy density are rel - crease should be based on the energy 24]. atively cheap [9–12]. In other words, density of foods without drinks. foods of high energy density provide This is because their systematic eval - This putative underreporting could energy cheaply, while foods of lower uation of the studies showed that the lead to an underestimate of the cor - energy density cost more per unit effect of energy density on weight relation between energy density and energy ( J/kcal). It is therefore prob - increase is due to changes in the body weight. For this reason, the fol - able that foods of high energy den - composition of foods and not of the lowing results must be regarded as a sity are mainly consumed when in - drinks consumed. If the energy den - conservative estimate – the true ef - come is low (based on a selection by sity including drinks is calculated, fect size could be greater. (continued p. 7)

4 Ernaehrungs Umschau international | 1/2014 oil clarified butter high energy hazel nuts density chips (> 2.25– , white nougat cream 2.75 croissant kcal/g) pralines parmesan, min. 45 % fat in the dry mass liquorice salami camembert, min. 60 % fat in the dry mass cornflakes cereal edamer cheese, min. 45 % fat in the dry mass French fries hamburger camembert cheese, min. 45 % fat in the dry mass cheeseburger jam edamer cheese, min. 30 % fat in the dry mass bread inter- chicken , boiled mediate pizza salami energy schnitzel, coated with bread crumbs and fried density /pork, raw mince (1–2.25 whole grain bread salmon kcal/g) ham sausage doner kebab pork filet, fried (prepared without fat) noodles (egg-free), boiled , boiled rock salmon, lightly boiled pikeperch, lightly boiled , broad, tinned sole, lightly boiled rice pudding cod, lightly boiled boiled potatoes low , green, lightly boiled , 3.5 % fat energy cow's milk, 3.5 % fat density (< 1–1.5 vegetable stew kcal/g) yogurt, 1.5 % fat cow's milk, 1.5 % fat mangel-wurzel lamb's iceberg lettuce lettuce non-alcoholic and alcoholic drinks advocaat whisky milk cocoa, 3.5 % fat sect white apple juice juice [kcal/g] beer lemonade coffee, tea (unsweetened) water 0123456789

Fig. 1: Energy density [kcal/g] of examples of foods and dishes. The values range from 0 kcal/g for water to 9 kcal/g for fat or oil (Source: DGExpert Version 1.3.0.1). Classified into high, intermediate or low energy density by the WORLD CANCER RESEARCH FUND (2012) [5]

Ernaehrungs Umschau international | 1/2014 5 DGE | Statement ; ) ) e l ) ) y : c a t 4 ) 6 i n s c 2 1 e e . n e . k n n d e v , 0 0 i i , , e ) g e e 9 t ) ) v r = 4 e g n = e c 6 7 3 i e , w o s : n 0 o t e ) t f b d I : w 7 9 p . j 2 t k p r e a . . t s e . 8 n d ; C 1 e r b e n n ; e s d e e 2 2 i - a b t ( l 3 0 o c 5 e o t ( ( o a 4 r . b e w i l 9 9 t : u a o n 4 7 p t 3 n d 1 % s s a f 2 = . h b 9 5 1 3 0 d . o i r ( e t n e 6 o ( s n 1 f l 0 m e 5 J i 3 6 1 5 5 5 0 h o d i n i o r b . . . . . 1 t m ) i 9 a – i s n f o 5 k t – c 9 . 0 e i e . t a 3 2 1 0 0 . v ( s o 3 8 1 n o l t t 6 t n n 0 s c c . a r – – – 0 i r e i e 0 1 c i 1 s e 1 f h h 0 n o e = = 6 s 3 . e ( r i , i . ) ) ) c = e 0 = t g g r g t n < y l p s 0 y d . 0 ) i i 0 l r o b b b p p l . s e a k n o o n o p – s 0 n e e i – a l i b i p o , , , ; ; p 0 p c r s n ) f o : t ; a d c ) ) ) : ) ) : n i , y ; u r s ; : w w I r ) p ) = a I o a r a 1 ) t ) t o 4 4 4 ) 3 4 ) e a t l f e o i . y o g d u 9 C s s f C y y d 8 j 5 t s s e n 6 3 3 0 0 8 5 e h p s - t 0 s d i e - n ...... 5 . n r t l v a e d d e e 3 0 t t o . ; y a i i r n 1 ) ) d n . . a l t o 3 3 1 7 1 2 6 l y a s t % o o b i u ( % 2 r 1 ( ( ( ( ( ( ( n e e a o i b a 1 1 e m g e D D ( u u t i t o b b o s n ( ( t t j K 1 c r o l 5 5 r s 9 v s S S . 4 7 6 5 2 1 3 5 q s n m i a o . h o e a d . ( ( . t a 9 9 s t : d d d t 8 u r 2 t 0 1 8 3 d e 3 9 7 u l = i j 6 i ( ( a p s y s n v n j . . . 0 . . . 2 e r e n n n – 6 d 0 e s t n n i r J u l 1 d e . n . u l o d 4 3 1 2 1 2 3 1 d d w a a a a e d j 1 4 7 a a o e d l s k – a c o – – – 3 – u – – – 4 – a s u u i t e e e o r 0 1 1 d p t u e ; o a ) ) . . . x ) ) ) ) d ) s ) D D D D ) ) ) ) ) h ) t s a h o e E a b c c c t c R m E a s a E a p a a m b a c f a E 0 c b m a ( 0 c e ( 0 r i a n C ; s y n A h h 1 t t e r i c c o 1 c l d G i r r c i e 0 t a t - o a a n D p i t s a 2 u e e r e s x d e s s s r 0 q e e i y u e m j e u 1 p s e e a f f e s d d ) r r d f i t 0 q h y i 8 o e u s n s a l u u b M l t c 2 l 0 - d t t y a h y r y c a a l ( n s t s a a 0 o r ) e a l c a e n a o r r l t ) t t n n i r i 2 i r e r i t o h g n n e e t f t t h h s t g / e o b A t t r 0 i - % e h J i a e f a i i l t g g l s ( l l - e E r l k i i 8 / o o h r u h a g ] n e ( a t t t d t b e e i s o t a 9 a c c t N - u i 7 e i i q d ) I e a f s c e p e 1 t t e d d w f w n s n m 2 i e L r k r w o : a a y [ m e r t a o e o M n y e o w y y y e s t m i t f D t r d s I t e t t s o b e c e h m m i a w d d d E r f i t m a i p c u y t u n t u e e n e d r a d t o o o M o j w n n e i u i d t t i e - M P s d e d a u o b b B b e s s S v p d t n u t y 2 p p n D o y y o t a e e o a n n n n a 1 s 1 ∆ M s S ∆ i s E i ∆ ∆ s i J r u m r ( i b o f b = d n d Q a n F c i a F ) y l y l y ; t o y t p i i t k b d d d n g l s p s r a n i n n a o e f y u t n r e l e a a u o s o e t , f e , , n p m t t t q t t n e , n n d p m o l h h h n s D h o , o o e u a n s s i i r g g g e E f c y e g w i i i i s t t i n o o e o i i s r o t i t t l e e e l f m g t t e s s o t m d = a a n i r t y n u o w w o w f f s b o a t o w o t e l f i r e h e r i c n p p a r r i , y y y y y h u i o ; t g t I r d d n e t i t i c r d d d d d t f d m m y l l u e u n f e c e t i o o o o o u a M n a o a o y i n a d c v b f b n c O v b w c b s a ( m B b s n n e e t e n d w e t t y n r h n e t o e g o w d r i i t r r n o t h b o c r u n r t l i w c h e o o d a a i o t o i t t e , t n n s n l h n g m p d l i h n l y p h a t u k d r - e o o w a e o i f n o t o a r t o i g f i ) i ( ( o n 4 i a Q c r c s o i s t s v u o t w t = o d f c h r i 2 F w e e o e k d d n c n a a t n l n y r t n F l i r , d g l l n e n e o o o D ) D l o D e o d i D a i o i u r r r e e e t t t u g r h E E r w o o t E r o d t e E c t t f f r u , o s h y u u l n c c c d o p s d s t r Q ; n f f f l o w a w w g o o w o o r u w o x l u k h u F r r x o o o o o c t r h o d c t o o h h h o s e a o o l m t p F n l - l t l e l c t t t e r c e o i e o c c s t i i i d s o x r r ) 4 r z ) n ) D D D D e ) ) ) ) e e i d a r o n n n e s w d E p e E E v E i a b r f w f c r w E f m 2 o i c b s i a t n i h r t o s ) ) d s f h s n n n n p d h o a e o o o a t i i c n u e n t ( t s - n s a m s s n n r w a n o o s h n k k s i e t a i o w r t y e e e e s i k v v t e e a m v i r n o t d e e e e y r e l b a e a g o l a e o 9 e r w w y w e d 7 t t t d o u . b w y m u l e n o 2 2 2 n a F i d o a n 1 b 1 1 ( D c 4 t 4 ( a 6 = r v a I l e l d i M n e t y B a l h h l t r - ; - t 7 l a s g r s . o o g i t t c f a 3 r e i 8 n e n n o = n i v 2 2 p n i e y y n 3 r m i e n v w 0 6 e l i d d e , c l n e e ) D m d c 7 n m e s d u u f t l 1 , s g m o i g S o s t t e i t e t o o a r a n 9 1 l l s s o t a d i t o i ; c o w ) l , o , c t 1 u o , r r a s n m w d d n n o t d n a f 8 u e r r e e a d d r 2 e o . t d e n n l . h e h n a t c a a e d o p p o r 4 n a a d h r n 2 a u e g m i e n n w ) ) i m , h d a e n d d r p g y f f l s + ) 3 8 p i s e , s e r + i r a d t n n i i t s t s w r r e 9 2 4 = 6 o d r h a a n 8 e o w n . h n 8 i y n o o w . a c r . w f a o P e m c n n n h n / / a 7 g o d r n n 4 s e e ( i t 1 i c y m h e e e e ) i n d d p 2 n l e e e u t y v y s 3 e i s + i 3 r s i e e e r r t ; e o n n 3 v w e t c o I m y % e s d I ) l l i d w 7 l v d d a a c s w w w o 1 4 i t m l l . d . , - r t t t o u d l a i i u n g 7 t r d 2 M e a M 6 t e e e e a 4 2 9 n i k n c d d n o h h a r 5 n m 8 B m i B % u b b 4 ( b a c S c ( a ( 5 c 8 a ( a a p 1 a ( + p c g d 5 u 5 4 l t . 9 s a l 0 n = a y y e . o s c I i d d i a w w h e t i t c e e u u C n c n d s i i i e d i - t t l e f e n v v v s s = i u s s i c s s a i t - e e o t % d e e e s s s r r n n i i c ) b d d s u s n l y t o o p y e 5 d d t c c l e e i i c o r o d i i n s d s s i y i d u u p t t r a 9 t t 1 i i o e t e t t s t n t c u l ( T n n n r a a , s s l r h n s t o a m m e e i a d s e s r t t 6 e o o o y l - d m m r s v v r r o o i e r v c p t g 1 h t i a r r e e 7 d t n r l e o o h d d t o t t o n d e e t l e 8 6 1 c u d n u h h u i s s n n e t t c t a u c t f f f n d o o o y y o a a t p n n n n h a i s s r s i r m S a o c i ( o o i c c a 6 P r c a = = h ) b l C ∆ r A : a L L 2 e I . Y M 2 2 9 2 b A , 1 N 1 1 0 1 r C a 1 O S 0 0 0 0 N T o 0 S R E 2 2 2 2 O y - 2 h N O S S . . . . . t Z l l l l l A d K N ] ] ] ] ] E N L L a a a a a u u Y R I E 9 6 8 6 5 H t A E t t t t t A 2 1 2 2 2 O M e S ( J [ W R P [ e [ e e e [ [

6 Ernaehrungs Umschau international | 1/2014 (Continuation from p. 4) Results of epidemiological children?” The results of the studies dence-based systematic reviews pre - studies were converted to correlation coeffi - pared with the support of the Nutri - cients without adjustment. The cor - tion Evidence Library (NEL) of the In order to evaluate the evidence for relation estimate was then 0.06 USDA and up-dated by PÉREZ -E S- the correlation between nutritional (95 %-confidence interval [95 %-CI] CAMILLA et al. (2012) [26] with the energy density and body weight, a 0.01–0.11; p = 0.013), with hetero - inclusion of studies published from meta-analysis has been performed geneity between the studies. After January 1980 to May 2011. [25] on six prospective studies. These adjustment for internal biases (study studies had also been included in a quality), the studies were compara - The 17 studies included had between systematic review in 2009 [16]. Five ble and the pooled correlation was 23 and 89 432 adults and investi - of these studies were also evaluated then 0.14 (95 %-CI -0.06– 0.34; p = gated the relationship between en - in a recent systematic review [26] of 0.16). After adjustment for both in - ergy density and weight loss in the 17 interventional and cohort studies ternal and external biases (adapta - overweight or obese . Seven of with adults and 6 cohort studies tion to the specified targets for the these studies were randomised con - with children and adolescents. meta-analysis), the pooled correla - trolled intervention trials (RCTs) and tion between energy density and the one involved a non-controlled inter - In their narrative systematic review, change in the weight of body fat in vention. Nine studies were cohort JOHNSON et al. (2009) [16] stated that children was 0.17 (95 %-CI -0.11– studies on the correlation between most prospective observational stud - 0.45; p = 0.24). Thus, the studies energy density and body weight sta - ies indicated a positive association were comparable after these adjust - tus or maintenance in normal between energy density and obesity ments, but the association was no weight, overweight and obese in adults and children, although longer statistically significant. The adults. The methods used to calcu - there were considerable differences correlation coefficient was increased late energy density were different, or, between the individual studies with in comparison to the non-adjusted in some cases, unspecified. In addi - respect to design and quality. The analysis; according to WILKS et al., tion, the methods to reduce energy differences included the age of the this indicates that the energy density density in the interventions also dif - participants, the follow-up observa - is possibly an important determi - fered (e. g. nutritional advice, provi - tional period (between 9 months and nant of excessive weight increase. sion of foods of lower energy den - 7 years), whether the energy density They called on decision makers to sity). Four of the seven RCTs found was incorporated in the statistical carry out interventions to reduce en - significantly greater weight loss analysis as a continuous or categor - ergy density, in order to reduce over - with reduced energy density (calcu - ical variable, the calculation of the weight in children, as well as draw - lated with foods without drinks). energy density (food without drinks, ing the attention of consumers to the One RCT found that a snack of high food and all drinks, or food and en - importance of reduced energy den - energy density together with meals ergy containing drinks, see the sec - sity [25]. led to weight gain, but that a snack tion on “Method to determine food of low energy density had no effect. energy density”, p. 4), the determi - In the 2010 Dietary Guidelines for Two RCTs found no difference in nation of body weight status (e. g. Americans, the Dietary Guidelines weight loss between nutrition with body weight or weight of body fat), Advisory Committee (DGAC) of the high versus low energy density. The as well as adjustment for con - US Department of Agriculture prospective cohort studies found a founders. For this reason, JOHNSON et (USDA) indicated that the total en - consistent positive association be - al. were unable to calculate an over - ergy intake is the decisive nutritional tween low energy density and all effect size [16]. factor for body weight control and lower weight increase or BMI, WILKS et al. (2011) [25] applied an that it is easier to control body better weight maintenance and/ adapted meta-analysis method, that weight with food of lower energy or weight loss. allows adjustment for differences in density. They considered that there is study design and quality by using a strong and consistent evidence that Six prospective cohort studies in - formal transparent process of incor - energy density is positively associ - cluded between 48 and 2,275 nor - poration of expert opinions (bias-ad - ated with obesity in children and mal weight and overweight chil - justment meta-analysis). The key that a nutritional pattern of rela - dren and adolescents and follow- question in their meta-analysis was tively low energy density can im - up periods of one to twelve years; as follows: ”Is the energy density prove weight loss and weight main - they also calculated energy density (excluding drinks) associated with tenance in adults [27]. This DGAC in various ways. Four of these six changes in the weight of body fat in evaluation was based on the evi - studies found a positive association

Ernaehrungs Umschau international | 1/2014 7 DGE | Statement

between energy density and obesity; Discussion and conclusions The strategy to reduce nutritional one study found no association and energy density is to increase the con - one an inverse association. The weight of scientific evidence in - sumption of foods with high levels dicates that there is a positive corre - of water and fibre – such as vegeta - lation between food energy density Overall, PÉREZ -E SCAMILLA et al. (2012) bles and fruit – and to reduce the [26] confirmed the results of the and body weight. A nutritional pat - consumption of foods with high lev - DGAC (2010) [27] and concluded tern with low energy density can els of fat or added sugar, as well as that there is strong and consistent have a positive effect on changes in energy containing drinks (alcoholic evidence from interventional and body weight. drinks, juices and nectars, sugared prospective cohort studies for a pos - soft drinks). A nutritional pattern itive association between energy den - The energy density of the food con - with lower energy density is thus sity and body weight and that nu - sumed is an important determinant also one with high nutrient density, trition with relatively low energy of the total energy intake. Experi - that is high nutritional value. A density improves weight loss and mental studies show that a low food healthy nutrition pattern with low maintenance. For children and ado - energy density leads to lower energy energy density includes the con - lescents, there is moderately strong intake during ad libitum nutrition in sumption of low quantities of foods evidence from longitudinal studies both adults and children [30–41]. of high energy density, such as rape for a positive association between Short term studies in adults have oil or nuts. The orientation for the energy density and obesity [26]. shown that the consumption of selection of foods can be provided by foods with lower energy density the three dimensional food pyramid, A pilot study was published after leads to increased satiation [31, 40]. which classifies foods in accordance these systematic reviews and meta- The acute regulation of satiation and with their nutritional physiological analysis. It had a randomised con - hunger is primarily determined by quality, incorporating the energy trolled design and lasted for 12 the volume of food, so that the en - density as a criterion for evaluation weeks. Lifestyle intervention was in ergy intake at constant satiation [54]. the form of instructions on nutrition volume is primarily dependent on with a) low energy density, b) low the energy density in this volume Selection of healthy foods with con - energy and fat content or c) low en - [3, 42, 43]. In children and adoles - sideration of energy density does ergy density with low energy and fat cents, the scientific data indicates not mean then that foods of high content. The effects of these inter - that the consumption of energy energy density are excluded in prin - ventions were measured on the qual - dense foods can lead to passive con - ciple. Moreover, simple replacement ity of nutrition and weight loss in 44 sumption of excessive energy [36, of foods of high energy density overweight adults (BMI 34.8 ± 4.8). 44–46]. with those of low energy density is The instruction on nutrition with not sensible – unless they belong to low energy density (a) enhanced the The high frequency of overweight is the same product group, e. g. consumption of fruit and increased influenced in a complex manner by sausages. What is important is that weight loss in comparison to the many factors [47]. Many studies foods of low and intermediate en - other instructions [28]. show that one of these factors is a ergy density should be the basis of high consumption of foods of high daily nutrition and that consump - In another 12-week randomised in - energy density. Scientific societies tion of foods of high energy density terventional study, 157 overweight and health organisations throughout should be limited. One criticism of participants (BMI 31.8 ± 2.2) in a the world recommend that energy the concept of energy density is that weight reduction program (Weight density should be reduced for weight the roles of different high density Watchers) were given a nutritional control – both for adults and for foods must be differentiated. Plant plan with individual advice on either: children [48–53]. oils and nuts are energy dense, but a) low energy density, b) low gly - are nevertheless of value for nutri - caemic index, or c) control of the The DGE also concludes that meas - tional physiology. Fat and sugar are portion size. The effects were then ures for weight control should con - often added during the preparation examined, including body weight sider food energy density. If food en - of products such as crisps, pastries and composition. All methods led to ergy density is lower, the energy in - and sweets. These are energy dense, a loss in body weight and body fat, take is less when large quantities of but have very low nutrient density. although the differences between the food are eaten. This can help to in - The concept of energy density does three groups were not significant crease compliance with nutritional not cover this aspect adequately and [29]. recommendations. it must be examined how this as -

8 Ernaehrungs Umschau international | 1/2014 pect can be integrated into concept density. This demonstrates the im - Strategy for Weight Management. Journal of of energy density. portance of active nutritional and the American Dietetic Association 195: 98– consumer education [60]. It is not 103 In comparison to many solid foods, yet conclusively clear and has to be 5. World Cancer Research Fund (WCRF UK). energy containing drinks, such as further investigated whether Energie density: finding the balance for can - sugared soft drinks, have a relatively changes in the price structure of cer prevention. London (2012), URL: www. low energy density ( v Figure 1). foods can influence food selection wcrf-uk.org/PDFs/EnergyDensity.pdf However, the energy and sugar sup - and behaviour as desired, that 6. Krems C. Ergebnisse der Nationalen Ver- plied by sugared drinks, juices and means support the selection and zehrsstudie II zur Energiedichte bei Erwach - nectars, as well as alcoholic drinks, consumption of less energy dense senen. Persönliche Mitteilung vom 17. Mai should not be neglected. The con - foods and, in general, the selection of 2013. Max Rubner-Institut, Bundesfor- sumption of sugared drinks is an healthy foods [9, 61]. schungsinstitut für Ernährung und Lebens - important factor in the development mittel, Karlsruhe (2013) of overweight and type 2 diabetes 7. Erbersdobler H (2005) Die Energiedichte, eine [55]. Even a higher consumption of Thanks to the following colleagues for vernachlässigte Größe? Ernährungs Um - fruit juices (as opposed to fruit) is critically examining this manuscript: schau 52: 136–139 associated with a higher risk for type Prof. Dr. Thomas ELLROTT , Prof. Dr. Hel - 8. Krems C, Walter C, Heuer T, Hoffmann I. 2 diabetes mellitus. Consumption of mut ERBERSDOBLER , Prof. Dr. Helmut Lebensmittelverzehr und Nährstoffzufuhr – high levels of fruit juice (in contrast HESEKER , Prof. Dr. Anja KROKE , Dr. Eva Ergebnisse der Nationalen Verzehrsstudie II. to fruit) is associated with an in - LESCHIK -B ONNET , Prof. Dr. Hildegard In: Deutsche Gesellschaft für Ernährung e. V. creased risk of type 2 diabetes [56]. PRZYREMBEL , Prof. Dr. Matthias B. (DGE) (Hg). 12. Ernährungsbericht 2012. In comparison to similar solid foods, SCHULZE , Prof. Dr. Peter STEHLE , Prof. Dr. Bonn (2012), S. 40–112 high energy drinks presumably Gertrud Winkler. 9. Westenhöfer J (2013) Energy density and the cause less satiation, which tends to cost of foods in Germany. Ernaehrungs Um - increase energy intake [57–59]. It is schau international 60: 30–35 still unclear how drinks should best 10. Drewnowski A (2010) The cost of US foods be considered in studies on the cor - Deutsche Gesellschaft für Ernährung e. V. as related to their nutritive value. Am J Clin relation between energy density and Referat Wissenschaft Nutr 92: 1181–1188 Dipl. oec. troph. Angela Bechthold body weight [26]. It may neverthe - 11. Monsivais P, Drewnowski A (2007) The Ris - Godesberger Allee 18, 53175 Bonn less be concluded that energy density E-Mail: [email protected] ing Cost of Low-Energy-Density Foods. Am is a useful concept in the evaluation Assoc 107: 2071–2076 of foods aside from drinks, if nutri - Conflict of Interest 12. Darmon N, Briend A, Drewnowski A (2004) ent density is also considered. It is The author declares that there is no conflict of Energy-dense diets are associated with lower interest according to the guidelines of the In - generally true that drinks should diet costs: a community study of French ternational Committee of Medical Journal Edi - only make up a small part of the tors. adults. Public Health Nutrition 7: 21–27 total energy supply. In other words, 13. Lampert T, Kroll LE, von der Lippe E et al. energy-free drinks such as water and (2013) Sozioökonomischer Status und unsweetened tea should be preferred. Gesundheit. Bundesgesundheitsbl 56: 814– 821 As tasty energy dense foods are References 14. Monsivais P, Drewnowski (2009) Lower-En - cheap and almost always available, ergy-Density Diets Are Associated with it is difficult today for many con - 1. Heseker H. Ernährungssituation in Deutsch - Higher Monetary Costs per Kilocalorie and sumers – particularly those of low land. In: Deutsche Gesellschaft für Ernäh- Are Consumed by Women of Higher Socioeco - socioeconomic status – to adapt their rung e. V. (DGE) (Hg). 12. Ernährungsbericht nomic Status. J Am Diet Assoc 109: 814– daily nutrition to their individual re - 2012. Bonn (2012), S. 19–136 822 quirements. As shown by the data 2. Mensink GBM, Schienkiewitz A, Haften - 15. 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DOI: 10.4455/eu.2014.002