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ORIGINAL ARTICLE
Food sources of energy and nutrients in Finnish girls and boys 6�8 years of age � the PANIC study Aino-Maija Eloranta
1 * $ , Taisa Venäläinen
1,2$ , Sonja Soininen
1,3,4 , Henna Jalkanen
1 ,
Sanna Kiiskinen 1 , Ursula Schwab
2,5 , Timo A. Lakka
1,6,7 and Virpi Lindi
1
1 Department of Physiology, Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland;
2 Department of Clinical Nutrition, Institute of Public Health and Clinical Nutrition, School of Medicine, University of
Eastern Finland, Kuopio, Finland; 3 Social and Health Center, City of Varkaus, Finland;
4 Institute of Dentistry, School of
Medicine, University of Eastern Finland, Kuopio, Finland; 5 Department of Internal Medicine, Institute of Clinical
Medicine, Kuopio University Hospital, Kuopio, Finland; 6 Kuopio Research Institute of Exercise Medicine, Kuopio, Finland;
7 Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland
Abstract
Background: Data on food sources of nutrients are needed to improve strategies to enhance nutrient intake among girls and boys in Western countries.
Objective: To identify major food sources of energy, energy nutrients, dietary fibre, and micronutrients, and to study gender differences in these food sources among children.
Design: We assessed food consumption and nutrient intake using 4-day food records in a population sample of Finnish girls (n �213) and boys (n �217) aged 6�8 years from the Physical Activity and Nutrition in Children Study. We calculated the percentual contribution of 55 food groups for energy and nutrient intake
using the population proportion method.
Results: Low-fibre grain products, skimmed milk, and high-fibre bread provided almost 23% of total energy intake. Skimmed milk was the top source of protein (18% of total intake), vitamin D (32%), potassium (20%),
calcium (39%), magnesium (17%), and zinc (16%). Vegetable oils (15%) and high-fat vegetable oil�based spreads (14%) were the top sources of polyunsaturated fat. High-fibre bread was the top source of fibre (27%)
and iron (12%). Non-root vegetables were the top source of folate (14%) and vitamin C (22%). Sugar-
sweetened beverages provided 21% of sucrose intake. Pork was a more important source of protein and
sausage was a more important source of total fat and monounsaturated fat in boys than in girls. Vegetable
oils provided a higher proportion of unsaturated fat and vitamin E among boys, whereas high-fat vegetable
oil�based spreads provided a higher proportion of these nutrients among girls. Conclusion: Commonly recommended foods, such as skimmed milk, high-fibre grain products, vegetables, vegetable oil, and vegetable oil�based spreads, were important sources of several nutrients, whereas sugar- sweetened beverages provided the majority of sucrose intake among children. This knowledge can be used in
improving health among children by dietary interventions, nutrition education, and health policy decision making.
Keywords: food sources; energy; nutrients; vitamins; minerals; children; gender differences
Received: 31 May 2016; Revised: 16 August 2016; Accepted: 16 August 2016; Published: 30 September 2016
C hildren in Western countries fail to meet recom-
mendations for many nutrients that are important
for their health, growth, and development (1).
For example, the intakes of saturated fat (SFA), sucrose,
and salt are higher and the intakes of vitamin D, iron,
and dietary fibre as well as unsaturated-to-saturated
fatty acid ratio are lower than recommended among
children in many Western countries, including Finland
(2, 3).
Health promotion messages and nutrition counselling
can be made more concrete and easier to adopt if they are
based on food consumption rather than nutrient intake.
Therefore, recent dietary guidelines, for example in Nordic
countries, emphasise healthy dietary choices at food rather
than nutrient level (4, 5). Consequently, it is important to
have precise data on food sources of nutrients to better
design strategies to enhance diet quality in different age
groups.
$ These authors contributed equally to this work.
research food & nutrition �
Food & Nutrition Research 2016. # 2016 Aino-Maija Eloranta et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any
purpose, even commercially, provided the original work is properly cited and states its license.
1
Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444 (page number not for citation purpose)
There are few studies on the food sources of nutrients in
children and most of them have reported the sources of
only one or few nutrients (6�9). Milk products have been found to be among the main sources of energy, protein,
and SFA among children in Europe (6, 8, 10) and the USA
(11�13). Sugar-sweetened beverages have also been ob- served to be a major source of energy and refined
carbohydrates among US children (13, 14). In a Swedish
study, girls obtained more sucrose from sweets and
chocolate, whereas boys received more sucrose from
sugar-sweetened beverages (8). With the exception of the
Swedish study (8), there are limited data on differences in
the food sources of nutrients among girls and boys (11).
To provide detailed information on food sources of
nutrients for health promotion and dietary counselling to
correct the observed shortcomings in nutrient intake
among children, we investigated the main food sources
of energy, energy nutrients, dietary fibre, vitamins, and
minerals among Finnish children 6�8 years of age. We also studied the gender differences in food sources of
energy and these nutrients.
Methods
Study population
The present analyses are based on the baseline data of the
Physical Activity and Nutrition in Children (PANIC)
study, which is an ongoing physical activity and dietary
intervention study in a population sample of primary
school children from the city of Kuopio, Finland. We
invited 736 children 6�8 years of age who were registered for the first grade in 16 primary schools, selected out of all
26 primary schools of Kuopio, in 2007�2009. We received the contact information of the children’s principal custo-
dians from the city of Kuopio and sent them the invitation
letters by mail. Of 736 invited children, 512 (70%)
participated in the baseline examinations that were con-
ducted in 2007�2009. The participants did not differ in sex distribution, age, or body mass index standard deviation
score (BMI-SDS) from all children who started first grade
in primary schools of Kuopio in 2007�2009 based on available school health examination data. Complete diet-
ary data were available for 430 children (213 girls and 217
boys) who were included in the analyses. These children did
not differ in sex distribution, age, or BMI-SDS from those
82 children who had incomplete data and were excluded.
The PANIC study protocol was approved by the research
ethics committee of the Hospital District of Northern
Savo. All participating children and their parents gave
informed written consent.
Assessments
We assessed food consumption and nutrient intake by
food records administered by the parents on 4 predefined
consecutive days that included either consecutive 2
weekdays and 2 weekend days (99.5%) or consecutive 3
weekdays and 1 weekend day (0.5%). A clinical nutri-
tionist instructed the parents to record all food and
drinks consumed by their child at home, at school, in
afternoon care, and elsewhere outside home using house-
hold or other measures, such as tablespoons, decilitres,
and centimetres, in person at the first study visit. The
parents were instructed to report the recipes of mixed
dishes and the brands and the contents of food products.
A clinical nutritionist reviewed the food records with the
parents at the second study visit and completed the
records using a picture booklet of portion sizes (15).
Moreover, a clinical nutritionist asked the catering
company about the details of food and drinks, such as
menus, cooking fat, and spread on bread, served at
schools and in afternoon care. All prepared foods and
mixed dishes were disaggregated into ingredients accord-
ing to the recipes used. We analysed food consumption
and nutrient intake using The Micro Nutrica† dietary
analysis software, version 2.5 (The Social Insurance
Institution of Finland), that uses Finnish and interna-
tional data on the nutrient compositions of foods (16).
A clinical nutritionist also updated the software by
adding new food items and products with their precise
nutrient content received from the producers. Vitamin
and mineral supplements were not included in these
analyses. Food records that contained B4 days, con-
tained inconsecutive days, did not include weekdays and
weekend days, or lacked essential information for dietary
analysis even after the review were excluded from the
analyses. We estimate that 26% of girls and 24% of boys
may have underreported their total energy intake in the
food records when comparing it with energy expenditure
estimated by basal metabolic rate and using the cut-offs
for underreporting suggested by Torun et al. (17).
Foods consumed were divided into 55 food groups
each of which included foods of similar nutrient compo-
sition and type of consumption (Table 1). We divided
bread, breakfast cereals, and grain products into six food
groups based on their fibre content. Bread, breakfast
cereals, and grain products with at least 5% of fibre were
considered high-fibre products. Meat products were
divided into seven groups and fish was separated from
shellfish and fish products. Fats and fat products were
divided into five groups based on the amount and the
quality of fat. Milk, sour milk products, and cheese were
divided into six groups based on their fat content. Milk
and sour milk products with B1% of fat were considered
low-fat products. Cheese was defined low-fat cheese if it
contained no more than 17% of fat. Ice creams and
puddings were included in the same group. Sweetened
beverages were divided into artificially sweetened and
sugar-sweetened beverages. Energy drinks formed one
group.
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Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444
Table 1. Contents and median intakes (interquartile range) of the food groups in girls and boys
Food groups Contents
All children (n �430),
median (interquartile
range)
Girls (n �213),
median
(interquartile range)
Boys (n �217),
median (interquartile
range)
High-fibre bread Rye bread, crisp bread, wholegrain bread
(fibre ]5%)
37.5 (22.5, 59.0) 36.5 (21.1, 58.9) 37.5 (22.5, 59.0)
Low-fibre bread White bread, white rolls (fibre B5%) 22.0 (7.5, 40.1) 22.3 (7.5, 37.5) 21.7 (7.5, 45.0)
High-fibre breakfast cereals Mueslis, breakfast cereals (fibre ]5%) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.0 (0.0, 4.1)
Low-fibre breakfast cereals Breakfast cereals (fibre B5%) 0.0 (0.0, 7.5) 0.0 (0.0, 7.5) 0.0 (0.0, 6.6)
High-fibre grain products Wholegrain pasta, rice, oatmeal (fibre
]5%)
9.6 (0.0, 24.1) 9.4 (0.0, 23.5) 10.5 (0.0, 24.9)
Low-fibre grain products White pasta, rice, flours (fibre B5%) 70.7 (45.0, 104.7) 71.8 (46.2, 100.4) 69.1 (42.6, 108.5)
Sweet pastry Biscuits, cookies, cakes, pastries 0.0 (0.0, 6.8) 0.0 (0.0, 6.6) 0.0 (0.0, 7.1)
Potato Potatoes 70.7 (44.7, 101.2) 68.3 (43.6, 100.4) 75.0 (48.3, 101.9)
Root vegetables Carrot, beetroot, turnip 14.9 (3.8, 30.2) 16.9 (5.3, 31.6) 12.5 (1.7, 28.2)
Non-root vegetables Green leafy vegetables, cabbages,
cucumber, peppers, tomatoes, onions
68.3 (40.0, 103.9) 68.3 (43.1, 103.9) 68.3 (39.0, 104.8)
Legume and nut Peas, beans, nuts, almonds, seeds 0.0 (0.0, 2.4) 0.0 (0.0, 2.2) 0.0 (0.0, 2.5)
Mushroom Mushrooms 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Vegetable products Ready-made vegetable products 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Fruit Fruit and fruit purées 73.8 (33.6, 121.1) 75.8 (40.5, 126.8) 70.0 (27.5, 117.7)
Berry Berries and berry purées 9.0 (0.0, 25.4) 9.9 (0.0, 28.2) 8.3 (0.0, 23.4)
Jam Jams, marmalades 0.9 (0.0, 7.7) 1.6 (0.0, 8.0) 0.0 (0.0, 7.4)
Pork Pork 29.5 (15.7, 46.8) 27.8 (13.8, 42.6) 32.6 (16.7, 56.5)**
Beef Beef 13.5 (0.0, 29.0) 12.0 (0.0, 27.9) 14.5 (0.0, 30.5)
Sausage Frankfurter, balkan, salami, ham sausage 15.0 (3.5, 31.8) 11.8 (0.0, 25.3) 18.0 (6.9, 34.6)**
Poultry Chicken, turkey 10.3 (0.0, 24.5) 10.3 (0.0, 22.9) 10.0 (0.0, 27.2)
Game Hare, moose, willow grouse 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Lamb and other meat Lamb, horse, reindeer 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Organ meats Liver, kidney, tongue 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Fish Fresh fish 0.0 (0.0, 18.5) 0.0 (0.0, 17.1) 0.0 (0.0, 23.9)
Shellfish Shellfish 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Fish products Salted fish, smoked fish, canned fish, roe
paste
0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Egg Eggs 10.0 (5.7, 19.1) 9.8 (5.8, 18.6) 10.9 (5.6, 19.6)
High-fat vegetable oil�based spreads Vegetable oil�based spreads
(fat 60�80%)a 5.0 (1.3, 10.3) 5.0 (1.5, 10.6) 4.5 (1.3, 9.9)
Low-fat vegetable oil�based spreads Low-fat vegetable oil�based spreads
(fat B60%) a
0.0 (0.0, 5.3) 0.0 (0.0, 5.0) 0.0 (0.0, 6.1)
Vegetable oil Vegetable oils, vegetable oil�based salad
dressings
2.9 (1.2, 5.5) 2.5 (1.1, 5.0) 3.1 (1.2, 6.3)
Butter and butter-based spreads Butter, butter-based spreads 3.0 (0.9, 7.9) 2.9 (1.0, 6.9) 3.1 (0.8, 10.1)
Shortenings and other added fats Shortenings, lard, coconut fat 5.1 (2.7, 8.5) 5.1 (2.7, 8.6) 5.2 (2.7, 8.6)
Skimmed milk Milk, a
organic milk (fat B1%) 371.7 (88.8, 602.8) 356.4 (91.4, 587.5) 421.2 (87.5, 633.8)
Fat-containing milk Milk, a
organic milk, farm milk (fat ]1%) 95.8 (33.1, 264.4) 93.4 (31.2, 253.7) 102.6 (36.6, 301.7)
Low-fat sour milk products Yoghurts, sour milk (fat B1%) 0.0 (0.0, 9.9) 0.0 (0.0, 13.3) 0.0 (0.0, 8.9)
Sour milk products Yoghurts, sour milk (fat ]1%) 66.9 (25.0, 125.0) 65.0 (25.0, 114.4) 75.0 (25.0, 142.6)
Low-fat cheese Cheese, cottage cheese, processed
cheese, fromage frais (fat 517%)
2.5 (0.0, 10.0) 4.2 (0.0, 12.0) 0.6 (0.0, 9.0)*
Cheese Cheese, processed cheese, blue cheese,
fromage frais (fat �17%)
4.2 (0.0, 10.1) 3.8 (0.0, 9.3) 5.0 (0.0, 11.2)
Ice cream and pudding Ice creams, puddings 17.5 (0.0, 37.9) 16.3 (0.0, 40.9) 18.8 (0.0, 37.5)
Cream and other dairy products Cream, sour cream, double cream, soya-,
rice-, and oat-based milks and creams
10.6 (2.9, 20.0) 11.2 (3.8, 19.9) 10.4 (1.6, 20.2)
Food sources of energy and nutrients
Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444 3 (page number not for citation purpose)
Statistical methods
Data were analysed using the SPSS for Windows software,
Version 21.0 (IBM Corp. IBM SPSS Statistics for Windows,
Armonk, NY). We compared differences in food con-
sumption between genders by the Mann�Whitney U-test. The differences between genders with p-value B0.05 were
considered statistically significant. We calculated the
contribution of each food group to the intakes of total
energy, energy nutrients, dietary fibre, and selected
vitamins and minerals using the population propor-
tion method as defined by Krebs-Smith et al. (18). The
percentage contribution of each food group to the intakes
of total energy, energy nutrients, dietary fibre, and selected
vitamins and minerals was estimated by summing the
amount of a particular nutrient from the particular food
group for all children and dividing this value by the sum of
the nutrient from all foods for all children. The food
sources of nutrients were ranked and top 10 sources were
reported for all children, and for girls and boys separately.
Results
The medians (interquartile ranges) of the consumption of
food groups in girls and boys are presented in Table 1.
Boys consumed more pork, sausage, water and other
drinks, and salt and less low-fat cheese than girls.
Food sources of energy, energy nutrients, and dietary fibre
Several food groups contributed almost similarly to the
intake of energy, the two main sources being low-fibre
grain products and skimmed milk in girls and boys
(Table 2). Skimmed milk was the main source of protein
in girls and boys, followed by fat-containing milk in girls
and pork in boys. The main source of total fat was high-fat
vegetable oil�based spreads, followed by shortenings and other added fats among girls and sausage among boys.
The top two sources of SFA were cream and other
dairy products and fat-containing milk in girls and fat-
containing milk and butter and butter-based spreads in
boys. The main source of monounsaturated fatty acids
(MUFA) was high-fat vegetable oil�based spreads in girls and boys, followed by shortenings and other added fats
among girls and by sausage among boys. The main source
of polyunsaturated fatty acids (PUFA) was high-fat
vegetable oil�based spreads followed by vegetable oil in girls and vegetable oil followed by high-fat vegetable oil� based spreads in boys. Low-fibre grain products were the
major source of carbohydrates, followed by skimmed milk
in girls and boys. Sugar-sweetened beverages and sugar
and honey were the major sources of sucrose in both girls
and boys. High-fibre bread was the major source of dietary
fibre, followed by fruit and low-fibre grain products in girls
and boys.
Table 1. (Continued )
Food groups Contents
All children (n �430),
median (interquartile
range)
Girls (n �213),
median
(interquartile range)
Boys (n �217),
median (interquartile
range)
Coffee Coffee 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Tea Tea 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Artificially sweetened beverage Carbonated and non-carbonated
artificially sweetened beverages
0.0 (0.0, 50.0) 0.0 (0.0, 0.0) 0.0 (0.0, 56.7)
Sugar-sweetened beverage Carbonated and non-carbonated sugar-
sweetened beverages
100.0 (43.4, 200.3) 87.5 (42.5, 200.0) 125.0 (50.0, 225.0)
Fruit juice Natural fruit juices 1.4 (0.0, 50.0) 1.5 (0.0, 50.0) 0.8 (0.0, 50.0)
Energy drink Energy drinks 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)
Water and other drinks Water, mineral water, sport drink, mulled
wine, berry fool
187.2 (108.2, 319.8) 163.4 (90.1, 277.8) 206.0 (121.6, 350.0)**
Sugar and honey Table sugar, baking sugar, honey, syrup 7.7 (4.2, 13.3) 7.7 (4.1, 13.3) 7.4 (4.4, 13.3)
Candy Sweets, chewing gums 12.5 (2.0, 31.1) 12.0 (2.0, 26.8) 15.0 (0.0, 37.5)
Chocolate and hot chocolate
powder
Chocolate, hot chocolate powder 5.3 (0.2, 14.1) 5.0 (0.5, 12.5) 6.0 (0.0, 16.2)
Ready meal Hamburgers, pizzas, nuggets 0.0 (0.0, 10.0) 0.0 (0.0, 5.6) 0.0 (0.0, 15.0)
Salt Recipe and table salt 2.2 (1.8, 2.8) 2.1 (1.7, 2.6) 2.4 (1.9, 3.0)***
Condiments and sauces Ketchup, mustard, soy sauce, chilli sauce,
barbeque sauce
3.9 (0.4, 12.0) 4.0 (0.5, 13.0) 3.8 (0.3, 11.1)
Salty snacks Popcorn, potato crisps, nachos, crackers,
tacos
0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.0 (0.0, 3.9)
a Fortified with vitamin D.
*pB0.05 for difference between girls and boys. **pB0.01 for difference between girls and boys. ***pB0.001 for difference between girls and boys.
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Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444
Table 2. Dietary sources of energy, energy nutrients, and dietary fibre in all children, girls, and boys
All (n �430) Girls (n �213) Boys (n �217)
Rank a
Food group % of intake % of intake % of intake
Energy
1 Low-fibre grain products 9.4 9.5 9.4
2 Skimmed milk 7.6 7.5 7.7
3 High-fibre bread 5.5 5.7 5.4
4 Fat-containing milk 5.4 5.4 5.3
5 Sour milk products 4.5 4.3 4.6
6 Candy 4.4 4.3 4.6
7 Low-fibre bread 4.0 4.0 4.0
8 Pork 3.7 3.4 3.9
9 Sugar-sweetened beverage 3.3 3.2 3.4
10 Potato 3.3 3.3 3.2
Protein
1 Skimmed milk 18.3 18.2 18.4
2 Pork 9.2 8.7 9.7
3 Fat-containing milk 9.2 9.4 9.0
4 Low-fibre grain products 6.5 6.6 6.4
5 Beef 5.8 5.9 5.7
6 High-fibre bread 5.0 5.1 4.8
7 Poultry 4.6 4.8 4.4
8 Sour milk products 4.3 4.2 4.3
9 Sausage 3.7 3.1 4.2
10 Low-fibre bread 3.6 3.6 3.6
Total fat
1 High-fat vegetable oil�based spreads 9.1 10.0 8.4
2 Shortenings and other added fats 8.1 8.6 7.7
3 Sausage 7.2 6.2 8.0
4 Pork 6.9 6.5 7.2
5 Butter and butter-based spreads 6.6 6.3 6.8
6 Vegetable oil 6.5 6.2 6.8
7 Fat-containing milk 5.4 5.3 5.4
8 Cream and other dairy products 5.3 5.8 4.8
9 Chocolate and hot chocolate powder 5.0 4.6 5.3
10 Ice cream and pudding 4.8 5.3 4.4
Saturated fatty acids
1 Fat-containing milk 8.8 8.7 8.9
2 Cream and other dairy products 8.3 9.2 7.5
3 Butter and butter-based spreads 7.9 7.7 8.1
4 Shortenings and other added fats 7.9 8.3 7.5
5 Ice cream and pudding 7.2 7.9 6.6
6 Chocolate and hot chocolate powder 7.0 6.5 7.4
7 Sausage 6.8 5.8 7.6
8 High-fat vegetable oil�based spreads 6.6 7.3 6.0
9 Pork 6.2 5.9 6.5
10 Cheese 6.2 5.5 6.8
Monounsaturated fatty acids
1 Vegetable oil�based spreads 12.2 13.4 11.2
2 Sausage 9.6 8.3 10.7
3 Vegetable oil 9.3 8.9 9.6
4 Pork 9.0 8.4 9.4
5 Shortenings and other added fats 8.5 9.0 8.1
Food sources of energy and nutrients
Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444 5 (page number not for citation purpose)
Table 2. (Continued )
All (n �430) Girls (n �213) Boys (n �217)
Rank a
Food group % of intake % of intake % of intake
6 Butter and butter-based spreads 5.3 5.0 5.7
7 Chocolate and hot chocolate powder 4.8 4.4 5.0
8 Cream and other dairy products 4.0 4.3 3.8
9 Ice cream and pudding 3.5 3.8 3.2
10 Fat-containing milk 3.2 3.2 3.3
Polyunsaturated fatty acids
1 Vegetable oil 15.0 14.1 15.8
2 High-fat vegetable oil�based spreads 13.8 14.8 12.9
3 Shortenings and other added fats 11.0 11.9 10.2
4 Sausage 5.9 5.1 6.6
5 Pork 5.9 5.5 6.2
6 Low-fat vegetable oil�based spreads 5.5 4.9 6.0
7 Salty snacks 5.5 5.7 5.2
8 Low-fibre grain products 4.2 4.2 4.1
9 High-fibre bread 3.4 3.5 3.3
10 Butter and butter-based spreads 3.2 2.8 3.5
Carbohydrates
1 Low-fibre grain products 14.8 14.8 14.8
2 Skimmed milk 8.5 8.3 8.7
3 Candy 8.3 7.9 8.7
4 High-fibre bread 8.0 8.2 7.9
5 Sugar-sweetened beverage 6.1 5.9 6.2
6 Low-fibre bread 5.7 5.6 5.7
7 Potato 5.5 5.6 5.4
8 Sour milk products 5.2 4.9 5.4
9 Fruit 5.0 5.5 4.5
10 Sugar and honey 4.5 4.7 4.3
Sucrose
1 Sugar-sweetened beverage 21.2 20.5 21.7
2 Sugar and honey 17.5 18.4 16.6
3 Sour milk products 14.5 13.6 15.3
4 Candy 9.7 9.2 10.1
5 Chocolate and hot chocolate powder 8.0 7.4 8.5
6 Ice cream and pudding 6.4 6.8 6.0
7 Fruit 6.2 6.8 5.6
8 Sweet pastry 2.4 2.2 2.6
9 Fruit juice 2.4 2.1 2.6
10 Low-fibre breakfast cereals 2.0 2.2 1.9
Dietary fibre
1 High-fibre bread 27.1 27.1 27.2
2 Fruit 11.7 12.4 11.0
3 Low-fibre grain products 10.9 10.7 11.0
4 High-fibre grain products 8.3 7.7 8.7
5 Potato 8.1 8.1 8.1
6 Low-fibre bread 7.5 7.1 7.8
7 Non-root vegetables 6.0 6.3 5.6
8 Berry 3.6 3.7 3.5
9 Root vegetables 3.3 3.7 3.0
10 High-fibre breakfast cereals 2.0 1.8 2.2
a Rank for all children.
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Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444
Food sources of vitamins
Skimmed milk and fat-containing milk were the most
important sources of vitamin D, followed by high-fat
vegetable oil�based spreads among girls and by fish among boys (Table 3). The main source of vitamin E was
high-fat vegetable oil�based spreads followed by vegeta- ble oil in girls and vegetable oil followed by high-fat
vegetable oil�based spreads in boys. The main sources of folate were non-root vegetables and potato in girls and
boys. Non-root vegetables were the main source of
vitamin C, followed by sugar-sweetened beverages among
girls and boys.
Food sources of minerals
Sodium was mainly obtained from salt among girls and
boys (Table 4). The main source of potassium was
skimmed milk, followed by potato in girls and fat-
containing milk in boys. Skimmed milk and fat-containing
milk provided the majority of calcium intake in girls
and boys. High-fibre bread was the main source of iron,
followed by low-fibre grain products in girls and boys.
The main sources of magnesium were skimmed milk and
high-fibre bread in girls and boys. Similarly, skimmed
milk was the main source of zinc, followed by high-fibre
bread among girls and boys.
Discussion
Our study in a population sample of girls and boys 6�8 years of age provides new information on the top food
sources of energy, energy nutrients, dietary fibre, and
several vitamins and minerals among primary school
children. Previous studies have mainly focused on the
sources of one or few nutrients (9, 19�21), and only few studies have compared the food sources of nutrients
among girls and boys (8, 11).
Milk products have been observed to be among the
main sources of energy, protein, and SFA among
children in Western countries (6, 8, 10�13). However, most of the previous studies have not analysed the
contribution of milk products of different fat contents
to the intake of nutrients. We found that skimmed milk
was among the top sources of energy, protein, carbohy-
drates, vitamin D, folate, potassium, calcium, magne-
sium, and zinc. Fat-containing milk provided a lower
proportion of all these nutrients than skimmed milk.
This finding is due to the higher consumption of
skimmed milk than fat-containing milk in the present
study sample that is in line with the results of previous
studies in Finnish children (1, 22). However, we observed
that fat-containing milk was the highest source of SFA
among children. Since milk is commonly consumed in
large quantities among children, the consumption of fat-
containing milk easily leads to an excessive intake of
SFA. Because milk is an important source of several
nutrients among children, sufficient intake of these
nutrients from other sources should be assured among
children who do not drink milk regularly.
Bread has been reported to provide 20�45% of the intake of dietary fibre among Finnish children (6) and
European adolescents (23). We found that high-fibre bread
was among the top sources not only for dietary fibre but
also for iron, magnesium, and zinc. However, low-fibre
grain products were the top source of energy and
carbohydrates among children. These findings are ex-
plained by a higher density of dietary fibre and minerals
but a lower consumption of high-fibre grain products than
those of low-fibre grain products. Enhancing the use of
high-fibre grain products at the expense of low-fibre grain
products could be effective in improving the intake of
several nutrients among children.
Previous studies have reported that sugar-sweetened
beverages provide a considerable amount of energy and
refined carbohydrates among children (8, 13, 14). In line
with those findings, sugar-sweetened beverages were the
top source of sucrose in children in this study, providing
one-fifth of total sucrose intake. They were also the ninth
most common source of energy and the fifth most
common source of carbohydrates. The reduction in the
consumption of sugar-sweetened beverages among
children would markedly decrease their total intake of
sucrose, which is currently higher than recommended
(1, 24). Moreover, we found that sugar and honey
provided almost 18% of the total sucrose intake in
children. In this study, the food group of sugar and honey
included all sugar used at home in baking, cooking, and as
table sugar, and the dietary analysis software was unable
to analyse sugar from recipes and sugar as such separately.
This led to overestimation of sugar and honey as a source
of sucrose at the expense of other food groups and needs
to be acknowledged when comparing the dietary sources
of sucrose in this study with those of other studies.
Previous studies have shown that the daily intake of
vitamin D from food is around 6 mg in Finland (24�26) and even lower in the most Western countries (2, 3, 27).
Products fortified with vitamin D have been reported to
be major food sources of vitamin D in children across
Europe and USA (10, 26�28). Whereas products fortified with vitamin D are available to a lesser extent in many
other countries, in Finland most of the liquid dairy
products and vegetable oil-based spreads have been
fortified with vitamin D since 2003. In line with this, we
found that the top sources of vitamin D among children
were skimmed milk, fat-containing milk, and high-fat
vegetable oil�based spreads that together contributed more than a half of the total intake of vitamin D. The
level of fortification was increased in 2010, after the data
collection of this study, in both liquid dairy products and
fat spreads. Therefore, we suggest that the fortified
products are even more abundant sources of vitamin D
in Finnish children at the moment. Moreover, because
Food sources of energy and nutrients
Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444 7 (page number not for citation purpose)
skimmed milk was among the top sources of several
vitamins and minerals, and high-fat vegetable oil�based spreads were among the top sources of MUFA, PUFA, and
vitamin E, these products are not only good sources of
vitamin D but also important sources of other nutrients
among children.
Table 3. Dietary sources of selected vitamins in all children, girls, and boys
All (n �430) Girls (n �213) Boys (n �217)
Rank a
Food group % of intake % of intake % of intake
Vitamin D
1 Skimmed milk b
31.9 32.0 31.8
2 Fat-containing milk b
16.1 16.7 15.6
3 High-fat vegetable oil�based spreadsb 11.1 12.2 10.1
4 Fish 9.7 8.4 10.8
5 Low-fat vegetable oil�based spreadsb 6.5 6.0 6.9
6 Shortenings and other added fats 6.3 6.7 6.0
7 Fish products 3.0 2.8 3.1
8 Egg 2.9 3.1 2.7
9 Pork 2.5 2.4 2.6
10 Butter and butter-based spreads 1.5 1.3 1.7
Vitamin E
1 Vegetable oil 14.1 13.1 15.1
2 High-fat vegetable oil-based spreads 12.8 13.5 12.2
3 Non-root vegetables 5.4 5.8 5.0
4 High-fibre bread 5.2 5.4 5.1
5 Low-fat vegetable oil�based spreads 5.1 4.4 5.6
6 Shortenings and other added fats 4.4 4.4 4.4
7 Fruit 4.1 4.6 3.7
8 Low-fibre bread 3.9 4.0 3.8
9 Egg 3.8 3.9 3.6
10 Butter and butter-based spreads 3.1 2.7 3.4
Folate
1 Non-root vegetables 13.5 14.4 12.7
2 Potato 11.5 11.5 11.5
3 Skimmed milk 9.3 8.9 9.7
4 Sour milk products 6.5 6.2 6.8
5 High-fibre bread 6.0 6.2 5.8
6 Fruit 5.8 6.3 5.3
7 Fat-containing milk 4.5 4.4 4.6
8 Low-fibre grain products 3.9 3.7 4.0
9 Low-fibre bread 3.8 3.6 4.0
10 Egg 3.3 3.3 3.3
Vitamin C
1 Non-root vegetables 22.3 23.1 21.4
2 Sugar-sweetened beverage 18.4 17.3 19.5
3 Fruit 14.4 15.9 12.9
4 Fruit juice 13.6 12.6 14.5
5 Berry 10.5 10.3 10.7
6 Potato 7.2 7.0 7.3
7 Skimmed milk 4.9 4.6 5.2
8 Fat-containing milk 2.4 2.3 2.5
9 Root vegetables 2.0 2.1 2.0
10 Sour milk products 0.9 0.8 1.0
a Rank for all children.
b Fortified with vitamin D.
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Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444
Table 4. Dietary sources of selected minerals in all children, girls, and boys
All (n �430) Girls (n �213) Boys (n �217)
Rank a
Food group % of intake % of intake % of intake
Sodium
1 Salt 37.8 37.9 37.7
2 High-fibre bread 8.2 8.6 7.9
3 Skimmed milk 6.9 6.9 6.9
4 Sausage 6.6 5.8 7.3
5 Low-fibre bread 4.8 4.8 4.8
6 Pork 4.1 3.7 4.4
7 Fat-containing milk 3.2 3.3 3.1
8 Condiments and sauces 3.2 3.4 3.0
9 Ready meal 2.1 1.9 2.2
10 Low-fibre breakfast cereals 1.8 1.9 1.7
Potassium
1 Skimmed milk 20.4 19.9 20.9
2 Potato 9.7 9.9 9.5
3 Fat-containing milk 9.7 9.7 9.6
4 Non-root vegetables 6.9 7.3 6.6
5 Fruit 6.3 6.8 5.8
6 Sour milk products 5.4 5.1 5.6
7 High-fibre bread 5.0 5.0 5.0
8 Sugar-sweetened beverages 2.9 2.8 3.0
9 Low-fibre grain products 2.8 2.8 2.8
10 Pork 2.8 2.6 3.0
Calcium
1 Skimmed milk 38.9 38.6 39.2
2 Fat-containing milk 19.5 19.9 19.2
3 Sour milk products 8.6 8.3 8.8
4 Cheese 5.3 4.6 5.9
5 Low-fat cheese 4.8 5.3 4.4
6 Ice cream and pudding 2.5 2.7 2.4
7 Chocolate and hot chocolate powder 1.9 1.7 2.0
8 Low-fat sour milk products 1.9 1.9 1.8
9 Candy 1.6 1.5 1.6
10 Non-root vegetables 1.5 1.6 1.4
Iron
1 High-fibre bread 12.4 12.7 12.0
2 Low-fibre grain products 9.3 9.4 9.2
3 Potato 6.2 6.3 6.0
4 Low-fibre bread 5.9 5.8 6.0
5 High-fibre grain products 5.9 5.7 6.1
6 Pork 5.4 5.1 5.6
7 Beef 4.2 4.3 4.2
8 Egg 3.7 3.9 3.6
9 Candy 3.7 3.5 3.9
10 Non-root vegetables 3.6 3.9 3.4
Magnesium
1 Skimmed milk 16.7 16.4 17.1
2 High-fibre bread 11.7 11.9 11.6
3 Fat-containing milk 7.7 7.8 7.7
4 Potato 6.6 6.6 6.5
5 Fruit 5.0 5.4 4.6
Food sources of energy and nutrients
Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444 9 (page number not for citation purpose)
Potato was among the top 10 sources of energy,
carbohydrates, dietary fibre, folate, vitamin C, potassium,
iron, and magnesium in our study sample. Although
potato is not particularly rich in these nutrients (16, 29),
high consumption of potato in Finland makes it as a
good source of several nutrients. On the contrary,
although the consumption of vegetables and fruit was
relatively low among children in this study, they con-
tributed markedly to the intakes of dietary fibre, vitamin
E, folate, and vitamin C and to a lesser extent to the
intakes of several minerals. This is due to the high density
of these nutrients in vegetables and fruit (29).
Fish and fish products were among the top 10 sources
of vitamin D in our study. However, fish did not
markedly contribute to the intakes of any other nutrients,
although it is high in protein and several minerals, such
as calcium and potassium, and some fish species provide
a considerable amount of PUFA (29). This finding is
explained by the low consumption of fish among children
in our study, which is in line with a previous report
among Finnish children (1, 24).
In one previous study, meat provided more total and
SFA in boys than in girls among 15-year-old adolescents,
but the differences between genders were smaller among
9-year-old children (8). We also found that meat and
sausages covered a slightly higher proportion of the
intake of protein, fat, and sodium in boys than in girls.
Moreover, vegetable oils provided a higher proportion of
PUFA and vitamin E among boys, whereas high-fat
vegetable oil�based spreads provided a higher proportion
of these nutrients among girls. However, the rankings of
most sources of nutrients did not differ between girls and
boys. One explanation for the minor differences between
girls and boys can be that our study sample consisted of
primary school children who are provided a free-of-
charge school meal every school day which may equalise
food consumption between genders at this age. In
addition, most of the gender differences in the sources
of nutrients may not appear before adulthood (30).
A major strength of this study is the large population-
based sample of Finnish primary school children. An-
other strength is that food consumption and nutrient
intake were assessed by 4-day food records that were
reviewed by a clinical nutritionist together with the family
at return and analysed using a carefully updated nutrition
database. A limitation of this study is that the grouping of
food items was based on the judgement of a clinical
nutritionist which could have had an influence on the
rankings. If no detailed information was available, stan-
dard recipes were used for foods prepared at home, which
could have led to either underestimation or overestima-
tion of the intake of certain nutrients at an individual
level. However, at group level this might have a minor
effect only.
This study provides comprehensive data on the main
food sources of nutrients among primary school girls and
boys. Foods that are commonly recommended to be inclu-
ded in a healthy diet, such as skimmed milk, high-fibre
grain products, vegetables, vegetable oil, and vegetable
oil-based spreads, had a major contribution to the intake
Table 4. (Continued )
All (n �430) Girls (n �213) Boys (n �217)
Rank a
Food group % of intake % of intake % of intake
6 Low-fibre grain products 4.8 4.9 4.7
7 High-fibre grain products 4.6 4.4 4.7
8 Low-fibre bread 4.3 4.2 4.4
9 Non-root vegetables 4.2 4.5 4.0
10 Sour milk products 3.9 3.7 4.1
Zinc
1 Skimmed milk 16.2 16.1 16.3
2 High-fibre bread 9.8 10.1 9.5
3 Pork 9.0 8.6 9.4
4 Fat-containing milk 7.8 8.0 7.7
5 Beef 7.4 7.6 7.3
6 Low-fibre grain products 4.9 5.0 4.7
7 Low-fibre bread 4.0 3.9 4.0
8 Sour milk products 3.8 3.7 3.9
9 High-fibre grain products 3.8 3.7 4.0
10 Sausage 3.4 2.9 3.9
a Rank for all children.
Aino-Maija Eloranta et al.
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Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444
of several health-promoting nutrients, whereas sugar-
sweetened beverages provided the majority of sucrose
intake. This knowledge can be used in improving
health among children by dietary interventions, nutrition
education, and health policy decision making.
Acknowledgements
We are grateful to all voluntary subjects and their families
participating in the PANIC study. We are also gratefully indebted
to the research team for the skilful contribution in performing the
study. The PANIC study was financially supported by grants from
the Ministry of Social Affairs and Health of Finland, the Ministry
of Education and Culture of Finland, the Finnish Innovation Fund
Sitra, the Social Insurance Institution of Finland, the Finnish
Cultural Foundation, the Juho Vainio Foundation, the Foundation
for Paediatric Research, the Paavo Nurmi Foundation, the Paulo
Foundation, the Diabetes Research Foundation, state research
funding from the Research Committee of the Kuopio University
Hospital Catchment Area, Kuopio University Hospital EVO fund-
ing, and the city of Kuopio.
Conflict of interest and funding
The authors declare that there is no conflict of interest.
References
1. Eloranta A, Lindi V, Schwab U, Kiiskinen S, Kalinkin M,
Lakka HM, et al. Dietary factors and their associations with
socioeconomic background in Finnish girls and boys 6�8 years of age: the PANIC study. Eur J Clin Nutr 2011; 65: 1211�18.
2. Lambert J, Agostoni C, Elmadfa I, Hulshof K, Krause E,
Livingstone B, et al. Dietary intake and nutritional status
of children and adolescents in Europe. Br J Nutr 2004; 92:
S147�211. 3. Elmadfa I, Meyer AL, Nowak V, Hasenegger V, Putz P,
Verstraeten R, et al. European Nutrition and Health Report
2009. Ann Nutr Metab 2009; 55: 1�40. 4. Nordic Council of Ministers (2014). Nordic nutrition recom-
mendations, integrating nutrition and physical activity. Copen-
hagen, Denmark: Nordic Council of Ministers.
5. National Nutrition Council (2014). Finnish nutrition recom-
mendations. Helsinki, Finland: National Nutrition Council.
(in Finnish)
6. Kyttälä P, Ovaskainen M, Kronberg-Kippilä C, Erkkola M,
Tapanainen H, Tuokkola J, et al. The diet of Finnish pre-
schoolers. Helsinki, Finland: Publications of the National
Public Health Institute; 2008. (in Finnish)
7. Erkkola M, Kronberg-Kippilä C, Kyttälä P, Lehtisalo J,
Reinivuo H, Tapanainen H, et al. Sucrose in the diet of
3-year-old Finnish children: sources, determinants and impact
on food and nutrient intake. Br J Nutr 2009; 28: 1209�17. 8. Patterson E, Wärnberg J, Kearney J, Sjöström M. Sources of
saturated fat and sucrose in the diets of Swedish children and
adolescents in the European Youth Heart Study: strategies for
improving intakes. Public Health Nutr 2010; 13: 1955�64. 9. Cribb VL, Northstone K, Hopkins D, Emmett PM. Sources of
vitamin A in the diets of pre-school children in the Avon longi-
tudinal study of parents and children (ALSPAC). Nutrients
2013; 13: 1609�21. 10. Royo-Bordonada MA, Gorgojo L, de Oya M, Garcés C,
Rodrı́guez-Artalejo F, Rubio R, et al. Food sources of nutrients
in the diet of Spanish children: the four provinces study. Br J
Nutr 2003; 89: 105�14. 11. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary
sources of nutrients among US children, 1989�1991. Pediatrics 1998; 102: 913�23.
12. Stroehla BC, Malcoe LH, Velie EM. Dietary sources of
nutrients among rural native Americans and white children. J
Am Diet Assoc 2005; 105: 1908�16. 13. Keast DR, Fulgoni VL, Nicklas TA, O’Neil CE. Food sources
of energy and nutrients among children in the United States:
National health and nutrition examination survey 2003�2006. Nutrients 2013; 5: 283�301.
14. Reedy J, Krebs-Smith SM. Dietary sources of energy, solid
fats, and added sugars among children and adolescents in the
United States. J Am Diet Assoc 2010; 110: 1477�84. 15. Paturi M, Nieminen R, Reinivuo H, Ovaskainen ML, editors.
Picture book of food portion sizes. Helsinki, Finland: Publica-
tions of the National Public Health Institute; 2006.
16. Rastas M, Seppänen R, Knuts LR, Hakala P, Karttila V.
Nutrient composition of foods. Helsinki, Finland: Publications
of the Social Insurance Institution; 1997.
17. Torun B, Davies PS, Livingstone MB, Paolisso M, Sackett R,
Spurr GB. Energy requirements and dietary energy recommen-
dations for children and adolescents 1 to 18 years old. Eur J
Clin Nutr 1996; 50: S37�81. 18. Krebs-Smith SM, Kott PS, Guenther PM. Mean proportion
and population proportion: two answers to the same question?
J Am Diet Assoc 1989; 89: 671�6. 19. Slining MM, Mathias KC, Popkin BM. Trends in food
and beverage sources among US children and adolescents:
1989�2010. J Acad Nutr Diet 2013; 113: 1683�94. 20. Vandevijvere S, Michels N, Verstraete S, Ferrari M, Leclercq C,
Cuenca-Garcı́a M, et al. Intake and dietary sources of haem and
non-haem iron among European adolescents and their associa-
tion with iron status and different lifestyle and socio-economic
factors. Eur J Clin Nutr 2013; 67: 765�72. 21. Campbell KJ, Hendrie G, Nowson C, Grimes CA, Riley M,
Lioret S, et al. Sources and correlates of sodium consumption in
the first 2 years of life. J Acad Nutr Diet 2014; 114: 1525�32. 22. Mäki P, Hakulinen-Viitanen T, Kaikkonen R, Koponen P,
Ovaskainen ML, Sippola R, et al. Child health � results of the LATE-study of growth, development, health, health behavior
and growth environment. Helsinki, Finland: National Institute
for Health and Welfare; 2010.
23. Lin Y, Huybrechts I, Vereecken C, Mouratidou T, Valtueña J,
Kersting M, et al. Dietary fiber intake and its association with
indicators of adiposity and serum biomarkers in European
adolescents: the HELENA study. Eur J Nutr 2015; 54: 771�82. 24. Kyttälä P, Erkkola M, Kronberg-Kippilä, Tapanainen H,
Veijola R, Simell O, et al. Food consumption and nutrient
intake in Finnish 1�6-year-old children. Public Health Nutr 2010; 13: 947�56.
25. Hoppu U, Lehtisalo J, Tapanainen H, Pietinen P. Dietary habits
and nutrient intake of Finnish adolescents. Public Health Nutr
2010; 13: 965�72. 26. Soininen S, Eloranta AM, Lindi V, Venäläinen T, Zaproudina
N, Mahonen A, et al. Determinants of serum 25-hydroxyvitamin
D concentration in Finnish children: the Physical Activity and
Nutrition in Children (PANIC) study. Br J Nutr 2016; 115(6):
1080�92. 27. Black LJ, Walton J, Flynn A, Kiely M. Adequacy of vitamin D
intakes in children and teenagers from the base diet, fortified
foods and supplements. Public Health Nutr 2014; 17: 721�31.
Food sources of energy and nutrients
Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444 11 (page number not for citation purpose)
28. Berner LA, Keast DR, Bailey RL, Dwyer JT. Fortified foods are
major contributors to nutrient intakes in diets of US children
and adolescents. J Acad Nutr Diet 2014; 114: 1009�22. 29. Fineli, Finnish food composition database. Helsinki, Finland:
National Institute for Health and Welfare, Nutrition Unit.
Release 16. Available from: http://www.fineli.fi [cited 18 May
2015].
30. Helldán A, Raulio S, Kosola M, Tapanainen H, Ovaskainen
ML, Virtanen S. The National FINDIET 2012 Survey. Helsinki,
Finland: National Institute for Health and Welfare; 2013.
(in Finnish)
*Aino-Maija Eloranta
Department of Physiology
Institute of Biomedicine
University of Eastern Finland
PO Box 1627
FI-70211 Kuopio, Finland
Email: [email protected]
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Citation: Food & Nutrition Research 2016, 60: 32444 - http://dx.doi.org/10.3402/fnr.v60.32444
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