ORIGINAL COMMUNICATION

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1 (2004) 58, & 2004 Nature Publishing Group All rights reserved /04 $ ORIGINAL COMMUNICATION Germany, 8 years after the reunification The German Nutrition Survey 1998 GBM Mensink 1 * and R Beitz 1 1 Robert Koch Institute, Berlin, Germany Objective: To explore differences in food and nutrient intake as well as cardiovascular risk factors between the eastern and western parts of Germany in 1998 and to compare food consumption information between 1991 and Design and subjects: In all, 4030 people, aged y, sampled from the East and West parts of Germany participated in the German Nutrition Survey (1998) by completing dietary histories and being assessed for cardiovascular risk factors. In a separate analysis, two food frequency data sets were compared from National Health Surveys conducted in 1991 (n ¼ 7466) and in 1998 (n ¼ 4556). Results: In 1998, East Germans consumed more bread, fruit, fish, sausage, offal, and men additionally more cakes/cookies, beer and soft drinks than West Germans. They consumed less cereals, pasta, sweets, leafy vegetables, tea and drinking water, and men less vegetables and wine and women less pastry/crackers, potatoes and animal fat compared with their counterparts in West Germany. East Germans had a higher intake of total vitamin A, retinol, vitamin D, vitamin B 12 and chloride, and in addition men of alcohol, and women of monosaccharides. They had a lower intake of total water, vitamin K, calcium, magnesium and manganese, and men of linoleic acid, and women of vitamin E than their West German counterparts. In East Germany, higher mean systolic blood pressure, and total and high-density lipoprotein cholesterol concentrations were found in men, and a lower mean total serum cholesterol concentration found in women compared with West Germany. Conclusion: Differences in food intake between the eastern and western parts of Germany still existed in 1998, although these differences were smaller than those observed 1 y after the reunification. (2004) 58, doi: /sj.ejcn Keywords: food consumption; vitamins; minerals; East Germany; West Germany Introduction Germany was separated for more than 40 y into the Federal Republic of Germany (FRG, West Germany ) and the German Democratic Republic (GDR, East Germany ), situated East of the FRG. Different political constitutions and growing cultural disparities resulted in differences in market system, nutrition policies, food production, distribution and availability, and as a consequence differences in food *Correspondence: GBM Mensink, Robert Koch Institute, Seestrasse 10, D Berlin, Germany. MensinkG@rki.de Guarantor: GBM Mensink. Contributors: GBMM designed and managed the nutrition survey, aggregated and analysed the data and cowrote the article. RB updated, coded and processed data and cowrote the article. Received 24 March 2003; revised 27 October 2003; accepted 29 October 2003 consumption and dietary habits between both former German States existed. Before reunification, East Germans consumed more butter than West Germans. Around the time of reunification people living in East Germany ate more bread and sausages, and less milk, milk products, raw vegetables, citrus fruit, pasta and rice compared with their West German counterparts (Winkler et al, 1992, 1997, 1998; Thiel et al, 1993; Bellach & Hermann-Kunz, 1995; Zunft et al, 1996; Hermann-Kunz & Thamm, 1999; Hellenbrand et al, 2000). At the end of the 1990s, the food availability was almost equivalent in both parts of Germany. Nevertheless, differences in job opportunity, income, individual education history, regional and other cultural habits still existed. Also, health and nutrition consciousness may have differed and differences in dietary habits that had developed during the years of separation may have persisted even after 8 y of reunification.

2 To explore the remaining differences, the food and nutrient intake of people living in East and West Germany were compared using data from the German Nutrition Survey (GENUS) 1998, which was part of the German National Health Interview and Examination Survey (GNHIES) 1998, the first health survey representative of the reunified Germany (Thefeld et al, 1999). To compare food frequency information between 1991 and 1998 for both parts of Germany, we additionally used data from the National Health Survey (NHS) To evaluate the differences in nutrient intake and to illustrate their relevance, we compared them with the current German reference values (German Nutrition Society, 2002). In addition, some relevant classical cardiovascular risk factors, which may be modifiable by diet, were compared. Methods Sampling scheme GNHIES 1998 and GENUS 1998 From October 1997 until March 1999, a total of 7124 German adults, aged y, participated in the GNHIES The population sample was drawn from population registries, stratified by age, community size and federal state. A two-stage sampling procedure was used. In the first stage, a representative sample of German communities, with regard to their size and Federal State (Bundesland), was drawn. To ensure stable estimates for East and West Germany, mainly for objectives other than those presented here, a disproportional number of 80 sample points in West Germany and 40 sample points in East Germany was drawn. These sample points reflected the community size structure of Germany. In the second stage, samples of residents were drawn from population registries with a mathematical chance in proportion to the age (in 5 y intervals) and gender structure of Germany. The net sample included 3450 men and 3674 women. A weighting factor corrects for the disproportionality and additionally adjusts for discrepancies due to nonresponse and noncoverage between the net sample and the real age, sex, state (Bundesland) and community size population structure of For each person this weighting factor is proportional to the under- or over-representation of his 5-y-age, sex, community size and state group. The total weighted sample size is, however, the same as the unweighted one. Based on the samples of the population registries, 15% of the people could not be contacted (moved or died). Non- German speakers were ineligible to join, and a number of people refused to participate for a variety of reasons. No attempt was made to replace noncontactable, ineligible or noncooperative people. The overall response rate was 61.4%, 63.9% among East Germans and 60.2% among West Germans (Thefeld et al, 1999). The lowest response rates were observed for men aged y (56.5%) and for women aged y (50.4%). For the latter, the lack of response was more pronounced among women in the West (46.2%) than in the East (59.3%). In all, 1860 nonresponders answered some brief questions. Analysis of these data showed that responders and nonresponders were not different in some aspects of lifestyle like smoking, but that a higher proportion of nonresponders (50.1%) had not completed the Hauptschule (lowest secondary school level) compared with responders (40.5%). The distribution ratio of responders to nonresponders for these characteristics was similar for East and West Germans. A subsample (mainly drawn for financial reasons) of 1763 randomly selected men and 2267 randomly selected women participated in the GENUS. A larger proportion of women were chosen to assure that nutrition information was available for a sufficient number of women of child-bearing age who had participated in an allied folic acid study. In the nutrition sample, the proportion of women from the eastern part of Germany was similar to the proportion in the total sample (36% in the nutrition sample compared with 35% in the total sample). This small difference is corrected by the weighting factor. The clustering and the stratification design have opposite effects on the variances of estimates. However, point estimates are not influenced by design effects. With the use of Proc Surveymeans in SAS (SAS Institute, 1999), we estimated the design factors for the nutrition data. These were generally between 0.8 and 1.1 and almost always smaller than 1. Therefore, the variance estimates were in general somewhat larger in comparison to a random design, and possibly some significant differences may not have been detected. The magnitude of our design factors, however, was comparably small. Therefore, the presented results were based on traditional multivariate analyses, not correcting for the effect of clustering and stratification, which in its combination may have led to slightly larger variances. Sampling scheme NHS 1991 The NHS was conducted from April 1990 till May 1991 in the western part and from October 1991 till June 1992 in the eastern part of Germany. Similarly, as in the GNHIES 1998, a two-stage sampling procedure was used. However, some differences with the 1998 sample exist. The samples were obtained separately for West and East Germany (because of separate fundings), but according to the same principles. The West German sample was part of the German Cardiovascular Prevention Study and was conducted among persons aged y. Initially, 100 sample points (representative for state and community size structure) were drawn from which random samples of persons, stratified by 5-y-age groups and gender, were obtained. This resulted in a net sample of 5255 persons. The East German sample included 2617 persons, aged y (of which 2211 persons, aged y were used for the presented analyses), from 50 sample points. Both samples had a response rate of about 70%. 1001

3 1002 Description of questionnaires Information about sociodemographic characteristics, lifestyle, health, relevant behaviour and disease history of the participants was obtained with the use of a self-administered questionnaire. The questionnaire was checked for plausibility and completeness of information by trained interviewers in the presence of the participants. The questionnaire included a short food frequency list. In addition to this questionnaire, the participants were interviewed by a physician about their medical history including medication use during the last 12 months. The interviews were standardised and computer assisted. Smoking habits were categorised as never smoking, ex-smoking and current smoking. Sport activities were classified as no sport, less than 2 h/week and 2 or more h/week. Information on education, household income and profession was used for the construction of a socioeconomic status (SES) index (Winkler & Stolzenberg, 1999). Persons were also classified by season of the examination. The participants of GENUS were comprehensively interviewed about their dietary intake of the past 4 weeks by trained nutritionists with the use of DISHES 98, a computerised dietary history interview, especially designed for this purpose (Mensink et al, 2001). The portion sizes were estimated with models of cups, glasses, spoons, plates and bowls as well as food drawings. Consumption information on dietary supplements was also assessed during the interview. The data from the nutrition survey were transformed into nutrient and food intake data with the use of the German food composition table Bundeslebensmittelschlüssel Version II.3 (Klemm et al, 1999). Nutrient intake from supplements was also included in the calculations (Beitz et al, 2002). The food frequency questionnaire of the main survey (GNHIES 1998) was a modified version of the food frequency questionnaire conducted in the NHS For food items, which were comparable in both surveys, a comparison over time in consumption frequency was performed. For this purpose, the persons consuming specific food items daily or almost daily and several times a day were combined and considered as frequent users. Physical examination The participants were physically examined, and blood serum samples were taken after a fasting period of at least 3 h. Blood pressure was measured while people were in a sitting position, three times after at least 3 min rest. For this, a mercury sphygmomanometer (Erkameter 3000) with a maximum deviation of þ 1.8 mmhg was used. The average value of the second and the third blood pressure measurements was used for the presented analyses. The medical examination also included the measurement of height and weight. The body mass index (BMI) was calculated as the ratio of weight (kg) and squared height (m 2 ). Laboratory methods Serum lipids were analysed under internal and external control at the laboratory of the Robert Koch Institute on an automatic analyser type MEGA (Merck, Germany). Total serum cholesterol was measured with the enzymatic CHOD PAP-method (Merck, Germany) and high-density lipoprotein (HDL) cholesterol with an immunoseparation-based homogenous assay (WAKO, Japan). Statistical analyses Using data of the GENUS 1998, the average daily food and nutrient intake and differences in intake with and without adjustment for potential confounders were calculated for the eastern and western parts of Germany. The mean food and nutrient intake were adjusted for age, SES, smoking, sport activity, season and total energy intake, and the mean levels of some important cardiovascular disease risk factors were additionally adjusted for alcohol intake and BMI, using analysis of variance in the framework of general linear models (Proc GLM in SAS with the option lsmeans ). Differences in the mean levels were also calculated as a percentage of the levels in West Germany. While the nutrient intake shows almost a normal distribution, this is not the case for food intake where the median intake has also been presented. The differences based on the crude median and mean values show, however, a similar picture. Furthermore, the proportions of persons with selected intakes below current German reference values were compared for both parts of Germany. All analyses were weighted with the mentioned weighting factor to enhance the representativeness of the sample. For the comparison over time of the proportions of frequent users, another weighting factor was used to make the two independent samples comparable, because this weighting factor additionally standardises for the population age, gender, state and community size structure of The confidence intervals for these proportions were calculated using the option binomial in Proc Freq in SAS. For this analysis, only persons aged y were included, since this was the examined age range in the Western sample of the NHS Statistical analyses were performed with SAS version 8.1 (SAS Institute, 1999). Results Food and nutrient intake in 1998 of East and West Germans aged y The characteristics of participants of the GENUS 1998 are presented in Table 1. Since these data are weighted, the age distribution reflects the age structure of Germany in The prevalence of obesity (BMI Z30) was significantly higher among East compared with West German women. The prevalence of regular supplement use and of sport activity (Z2 h/week) was significantly lower among East compared with West Germans. Men living in the eastern part of

4 Table 1 Percentage of participants with specific characteristics in the German Nutrition Survey 1998, men and women aged y East (n ¼ 581) Men West (n ¼ 1182) East (n ¼ 815) Women West (n ¼ 1452) Age groups Body mass index 25 o Z * Supplement users Zonce/week *** *** Socioeconomic status Low * Middle High ** Sport activity o2 h/week Z2 h/week *** ** Smokers Current ** Past * n, unweighted number. Statistical significant differences between East and West Germans with ***Pr0.001, **Pr0.01, *Pr0.05 using w 2 -test. Germany had a significantly higher propensity to smoke. East German women significantly more often had a low SES, less often had a high SES and less often smoked in the past compared with West German women. The food consumption in grams per day and differences in food consumption between East and West Germany are presented in Table 2 for men and Table 3 for women. Most of the foods listed in Tables 2 and 3 were consumed by a similar proportion of people in both parts of Germany. Comparing East and West German consumption in 1998, offal, soft drinks, wine, spirits and coffee tended to be consumed by a higher proportion of East Germans. Water and tea tended to be drunk by a larger proportion of West Germans. East German men consumed on average 20 g/day more bread, 9 g/ day more cakes/cookies, 44 g/day more fruit, 15 g/day more sausage, 6 g/day more fish, 100 ml/day more beer and 68 ml/ day more soft drinks. West German men consumed 23 g/day more cereals, 9 g/day more pasta, 8 g/day more sweets, 13 g/ day more leafy vegetables, 20 ml/day more wine, 42 ml/day more tea and 233 ml/day more drinking water. The results for women tended to follow the same pattern (Table 3), except West German women consumed 2 g/day more pastry/crackers, 11 g/day more potatoes and 2 g/day more animal fat than their East German counterparts. The significant differences, in general, became somewhat smaller after adjustment for age, SES, smoking, sport activity and season, but were all larger than 5% (of West German intake level). The nutrient intake adjusted for age, SES, smoking, sport activity, season and energy intake, and differences in these intakes are presented in Table 4 for men, and Table 5 for women. The total energy intake and macronutrient profiles were not different between East and West Germans including percentage energy derived from protein, fat, carbohydrates and alcohol. West Germans had statistically significant higher intake, which were 5% and larger, of total water (derived from all foods), vitamin K, calcium, magnesium and manganese. West German men had a higher intake of linoleic acid than East German men. West German women had a higher intake of vitamin E than East German women. East Germans had a higher intake of total vitamin A, retinol, vitamin D, vitamin B 12 and chloride, men additionally of alcohol and women additionally of monosaccharides. We compared differences in nutrient intake excluding the supplemental intake. Differences in nutrient intake between East and West Germany were still apparent after excluding supplement use, albeit to a smaller extent. In Table 6, the percentages of persons with an average daily intake below current German reference values are presented for selected nutrients (only those nutrients for which reference values are available, for which a considerable proportion does not reach the reference and for which significant differences between East and West Germans exist). Less men and women in the eastern part of Germany had a vitamin D and vitamin B 12 intake below reference compared with those in the western part. A lower percentage of women in the East had a vitamin B 1 intake below reference compared with those from the West. However, in the eastern part more men and women had a vitamin E, calcium and magnesium intake, and more women a folate and fibre intake below reference compared with those from western Germany. Comparison of food consumption frequency reported in 1991 and 1998 by East and West Germans aged y The percentages of frequent users of specific foods in East and West Germany in 1991 and 1998 as well as East/West differences in these percentages are presented in Table 7. In both parts of Germany, a higher percentage of men consumed meat and both men and women breakfast cereals, raw vegetables, yoghurt/fresh cheese (almost) daily in 1998 as compared with In 1991, differences in the proportions of frequent users between East and West Germany were seen for almost all observed items. In 1998, all these differences generally have become smaller or almost disappeared. Important differences persisted in 1998, however, for frequent users of bread, fresh fruit and sausage among both genders. Cardiovascular risk factors in 1998 Adjusted mean levels of some nutrition associated cardiovascular risk factors for men and women from the eastern and western parts of Germany are presented in Table 8. Men 1003

5 1004 Table 2 Average food intake in grams per day for defined food groups, for participants of the German Nutrition Survey 1998, the median, mean and 95% CI of the mean, men aged y East (n ¼ 581) West (n ¼ 1182) Difference Users (%) Median Mean 95% CI of mean Users (%) Median Mean 95% CI of mean Median Mean Adjusted mean a % b Bread, rolls ( ) ( ) *** 12 Cereals (37 45) (64 71) *** 35 Pasta (27 34) (40 45) *** 22 Cakes, cookies (36 44) (28 32) *** 31 Pastry, crackers (6 10) (7 9) Sweets (41 49) (48 53) ** 15 Leafy vegetables (21 26) (40 44) *** 32 Other vegetables ( ) ( ) Cabbage (42 48) (43 46) Potatoes ( ) ( ) Fruit ( ) ( ) *** 26 Animal fat/oil (12 14) (13 15) Plant fat/oil (17 19) (17 19) Eggs (24 28) (23 26) Milk, cheese ( ) ( ) Red meat ( ) ( ) Poultry (15 18) (18 20) Sausage (74 83) (57 63) *** 26 Offal ( ) ( ) *** 58 Fish (23 27) (19 22) *** 28 Beer ( ) ( ) *** 36 Wine (27 38) (49 61) ** 36 Spirits (4 7) (3 5) Tea (63 98) ( ) ** 34 Coffee ( ) ( ) Juices ( ) ( ) Soft drinks ( ) ( ) * 21 Drinking water ( ) ( ) *** 34 Statistical significant with ***Pr0.001, **Pr0.01, *Pr0.05 using Student s t-test. a Adjusted for age, socioeconomic status, smoking, sport activity and season. b Difference in adjusted means as percentage from West German intake level. living in the eastern part of Germany had a higher mean systolic blood pressure and higher serum total and HDL cholesterol concentrations compared with men living in the western part of Germany. Women living in the eastern part of Germany had a lower mean total serum cholesterol concentration compared with women in the western part of Germany. Discussion The GNHIES provides for the first time representative and comparable data for the reunified Germany. Earlier comparisons of East and West Germany were based either on selected populations (eg of two cities), used different assessment methods or time intervals or were only conducted for men of middle age (Winkler et al, 1998). In the Nutrition Survey 1998, the same dietary assessment methods were used for all participants with documented relative validity (Mensink et al, 2001) by the same team of field workers in the same time period. The representativeness of a population sample is always somehow arbitrary. Despite a huge effort to reach a high representativeness, it remains possible that certain population groups were under-represented. For instance, the participants may have been more health conscious compared with the total population, which may especially have been the case for the nutrition survey subsample. A somewhat higher response rate was observed among East compared with West Germans. However, this is largely corrected for by the weighting factor. Our nonresponder analyses showed a somewhat higher education level among the responders. Further characteristics obtained from nonresponders were similar as observed for responders in both parts of Germany. Furthermore, the presented results on food intake showed no apparent difference in health consciousness between East and West Germans. Overall, there is no reason to assume a selection bias, which is systematically different for East and West Germans. Therefore, selection bias is very unlikely to explain the observed differences. Food and nutrient intake in 1998 of East and West Germans aged y In the Nutrition Survey of 1998, we observed significant differences in the median and mean food and nutrient

6 Table 3 Average food intake in grams per day for defined food groups, for participants of the German Nutrition Survey 1998, the median, mean and 95% CI of the mean, women aged y 1005 East (n ¼ 815) West (n ¼ 1452) Difference Users (%) Median Mean 95% CI of mean Users (%) Median Mean 95% CI of mean Median Mean Adjusted mean a % b Bread, rolls ( ) ( ) ** 7 Cereals (35 40) (53 59) *** 31 Pasta (23 27) (31 34) *** 23 Cakes, cookies (28 32) (27 31) Pastry, crackers (3 5) (5 6) * 34 Sweets (33 37) (39 44) *** 18 Leafy vegetables (25 30) (40 44) *** 23 Other vegetables ( ) ( ) Cabbage (43 47) (44 47) Potatoes (94 102) ( ) *** 11 Fruit ( ) ( ) *** 25 Animal fat/oil (9 10) (11 12) *** 19 Plant fat/oil (13 15) (14 15) Eggs (18 20) (19 21) Milk, cheese ( ) ( ) Red meat (75 81) (75 80) Poultry (14 16) (16 17) Sausage (37 41) (29 32) *** 23 Offal ( ) ( ) * 36 Fish (19 21) (16 18) *** 18 Beer (25 36) (34 45) Wine (32 41) (35 43) Spirits (1 3) (1 2) Tea (51 71) ( ) *** 41 Coffee ( ) ( ) Juices ( ) ( ) Soft drinks ( ) ( ) Drinking water ( ) ( ) *** 17 Statistical significant with ***Pr0.001, **Pr0.01, *Pr0.05 using Student s t-test. a Adjusted for age, socioeconomic status, smoking, sport activity and season. b Difference in adjusted means as percentage from West German intake level. intake in the two parts of Germany, even after adjustment for age, smoking, SES, sport activity, season and total energy intake. Without the adjustments, the differences were in general somewhat larger, although not always. The differences in food intake were substantial. All significant differences were larger than 5% and most of them between 10 and 40% of the level in West Germany. We observed differences in important food groups, being the higher bread, fruit, sausage, beer and soft drinks and the lower cereals, pasta, leafy vegetables and total water consumption in East compared with West Germany. A higher intake of bread, fish and fruit and a lower intake of pasta, drinking water and wine among East German men was also observed in a comparison of men from an East and a West German city (Winkler et al, 1998). Nevertheless, these differences may partly reflect regional habits that still existed, independent of the reunification process. In the years closely before the reunification, edible fat and especially butter consumption was observed to be considerably higher among East German compared with West German men (Winkler et al, 1992). As seen from our analyses, the difference in fats and oil from animal as well as plant origin among men at the end of the 1990s was negligible. Differences in nutrient intake seemed to be smaller than differences in food intake. Where differences in nutrient intake occurred between the eastern and western parts of Germany, most were larger than 5%. These differences were observed among average levels in a large population sample and may go together with larger differences in certain population subgroups. Therefore, these differences may have important implications for public health. Remarkably, the calcium intake was lower but vitamin D intake higher in East compared with West Germany. The main sources for calcium intake in Germany were milk and milk products that were responsible for about 50% of calcium intake (Mensink et al, 2002). The intake of milk and milk products was somewhat lower among East German men, although not significant. Among women the intake was almost equal. The second source, however, was drinking water (about 15% of calcium intake), and we observed a substantial lower intake of drinking water in the eastern part of Germany. Since about 95% of drinking water consumed in Germany is mineral water (with relatively high calcium

7 1006 Table 4 Mean daily energy and nutrient intake (including supplemental intake) and 95% CI of the mean for participants of the German Nutrition Survey 1998, men aged y a East (n ¼ 581) West (n ¼ 1182) Mean 95% CI of mean Mean 95% CI of mean Difference % b Energy (kcal) 2693 ( ) 2619 ( ) 73 3 From protein (%) 16 (16 16) 16 (16 16) 0 0 From fat (%) 33 (32 33) 33 (33 33) 0 0 From carbohydrates (%) 46 (45 46) 46 (46 46) 0 0 From alcohol (%) 5 (5 6) 5 (4 5) 0 0 Protein (g) 101 (99 102) 100 (99 101) 0 0 Animal protein (g) 65 (63 67) 64 (62 65) 1 2 Plant protein (g) 36 (35 37) 37 (36 37) 1 3 Total fat (g) 97 (95 99) 98 (97 99) 1 1 SFA (g) 41.5 ( ) 41.9 ( ) MUFA (g) 35.2 ( ) 35.0 ( ) PUFA (g) 13.8 ( ) 14.2 ( ) Linoleic acid (g) 11.4 ( ) 12.0 ( ) 0.6* 5 Carbohydrates (g) 294 ( ) 297 ( ) 3 1 Polysaccharides (g) 142 ( ) 148 ( ) 6** 4 Disaccharides (g) 84 (80 88) 86 (84 89) 3 4 Monosaccharides (g) 55 (52 59) 52 (51 54) 3 6 Fibre (g) 28 (27 29) 29 (28 29) 1* 4 Alcohol (g) 19.2 ( ) 16.8 ( ) 2.4* 14 Water (g) 2968 ( ) 3168 ( ) 200*** 6 Vitamin A c (mg) 2.1 ( ) 1.9 ( ) 0.2** 11 Carotene (mg) 4.4 ( ) 4.7 ( ) Retinol (mg) 1.2 ( ) 0.9 ( ) 0.3*** 33 Vitamin D (mg) 4.6 ( ) 3.4 ( ) 1.2*** 36 Vitamin E (mg) 15.7 ( ) 18.0 ( ) Vitamin K (mg) 404 ( ) 431 ( ) 27** 6 Vitamin B 1 (mg) 1.7 ( ) 1.8 ( ) Total folate (mg) 302 ( ) 314 ( ) 12 4 Vitamin B 12 (mg) 9.0 ( ) 7.7 ( ) 1.3*** 17 Vitamin C (mg) 179 ( ) 172 ( ) 7 4 Calcium (mg) 1187 ( ) 1320 ( ) 133*** 10 Magnesium (mg) 478 ( ) 523 ( ) 45*** 9 Iron (mg) 16.8 ( ) 17.0 ( ) Sodium (g) 3.6 ( ) 3.5 ( ) Chloride (mg) 5760 ( ) 5472 ( ) 288*** 5 Zinc (mg) 14.1 ( ) 14.6 ( ) 0.5** 3 Manganese (mg) 5891 ( ) 6556 ( ) 665*** 10 Statistical significant with ***Pr0.001, **Pr0.01, *Pr0.05 using Student s t-test. a Adjusted for age, socioeconomic status, smoking, sport activity, season and (except for energy and nutrient as per cent of energy) energy intake. b Difference as a percentage from West German intake level. c Retinol equivalents. contents), the difference in drinking water may for a substantial part explain the lower calcium intake in the East. The primary source of vitamin D intake in Germany was fish (the second one was eggs), which may partly explain the higher vitamin D intake in the East since fish consumption was significantly higher in the East. Supplement use in 1998 was in general higher in the western part of Germany (Mensink & Ströbel, 1999). This may have contributed to the observed differences in nutrient intake. For the presented analyses, we included supplemental intake, because our objective was to obtain the best estimates of total nutrient intake. Regular supplement users also had a higher nutrient intake from natural foods than nonusers (Beitz et al, 2002), which may be associated with the observed differences in food intake. However, supplement consumption is not considered to be a typical

8 Table 5 Mean daily energy and nutrient intake (including supplemental intake) and 95% CI of the mean for participants of the German Nutrition Survey 1998, women aged y a 1007 East (n ¼ 815) West (n ¼ 1452) Mean 95% CI of mean Mean 95% CI of mean Difference % b Energy (kcal) 1867 ( ) 1921 ( ) 54 3 From protein (%) 16 (16 16) 16 (16 16) 0 0 From fat (%) 33 (33 34) 34 (33 34) 1 3 From carbohydrates (%) 48 (47 48) 47 (47 48) 1 2 From alcohol (%) 2 (2 3) 2 (2 3) 0 0 Protein (g) 74 (72 75) 73 (72 74) 1 1 Animal protein (g) 47 (46 49) 46 (45 46) 2** 4 Plant protein (g) 26 (25 27) 27 (27 28) 1*** 4 Total fat (g) 73 (72 74) 74 (73 74) 1 1 SFA (g) 31.6 ( ) 32.2 ( ) MUFA (g) 25.7 ( ) 25.5 ( ) PUFA (g) 10.5 ( ) 10.9 ( ) Linoleic acid (g) 8.8 ( ) 9.2 ( ) 0.4* 4 Carbohydrates (g) 224 ( ) 224 ( ) 1 1 Polysaccharides (g) 107 ( ) 111 ( ) 4** 4 Disaccharides (g) 68 (66 71) 67 (65 68) 2 3 Monosaccharides (g) 46 (43 48) 43 (41 44) 3* 7 Fibre (g) 25 (24 25) 25 (24 25) 0 0 Alcohol (g) 6.3 ( ) 6.4 ( ) Water (g) 2593 ( ) 2752 ( ) 159*** 6 Vitamin A c (mg) 1.9 ( ) 1.8 ( ) 0.1** 6 Carotene (mg) 4.9 ( ) 5.3 ( ) Retinol (mg) 0.9 ( ) 0.7 ( ) 0.2*** 29 Vitamin D (mg) 3.4 ( ) 2.9 ( ) 0.5*** 17 Vitamin E (mg) 17.4 ( ) 24.3 ( ) 6.9* 28 Vitamin K (mg) 368 ( ) 386 ( ) 18* 5 Vitamin B 1 (mg) 1.4 ( ) 1.5 ( ) Total folate (mg) 281 ( ) 305 ( ) 24 8 Vitamin B 12 (mg) 6.0 ( ) 5.6 ( ) 0.5* 9 Vitamin C (mg) 184 ( ) 183 ( ) 1 1 Calcium (mg) 1126 ( ) 1179 ( ) 53* 5 Magnesium (mg) 408 ( ) 434 ( ) 26*** 6 Iron (mg) 14.1 ( ) 14.3 ( ) Sodium (g) 2.7 ( ) 2.6 ( ) 0.1** 4 Chloride (mg) 4264 ( ) 4075 ( ) 189*** 5 Zinc (mg) 10.9 ( ) 11.0 ( ) Manganese (mg) 5063 ( ) 5507 ( ) 444*** 8 Statistical significant with ***Pr0.001, **Pr0.01, *Pr0.05 using Student s t-test. a Adjusted for age, socioeconomic status, smoking, sport activity, season and (except for energy and nutrient as per cent of energy) energy intake. b Difference as a percentage from West German intake level. c Retinol equivalents. confounder because it is probably not independently related to other nutrition habits and East or West German residence. Therefore, a further adjustment for supplement use was not considered to be appropriate. Nutritionists should primarily be concerned about improving consumption patterns of natural foods, which is the main focus of the presented results. In summary, differences in food consumption were for the major part responsible for the observed differences in nutrient intake, irrespective of supplement use. The relevance of some differences in nutrient intake is enforced in the comparison with the German reference values, since differences may be meaningless if the intake is far more than sufficient for both parts of Germany. Generally, reference values reflect intake levels at which the requirements of almost all healthy persons (98%) are covered.

9 1008 Therefore, an intake below reference may still be sufficient. Nevertheless, this comparison indicates that differences in intake, for instance those of vitamins D and E and calcium intake, may have implications for public health and should be taken into account in nutrition campaigns. Table 6 Percentages of men and women, aged y, whose nutrient intakes are below the corresponding reference values in 1998 East (n ¼ 581) Men West (n ¼ 1182) East (n ¼ 815) Women West (n ¼ 1452) Vitamin D *** * Vitamin E *** *** Vitamin B ** Total folate ** Vitamin B * *** Fibre ** Calcium *** * Magnesium *** *** Statistical significant ***Pr0.001, **Pr0.01, *Pr0.05 using w 2 -test. Comparison of food consumption frequency reported in 1991 and 1998 by East and West Germans aged y The food frequency data show that at the end of the 1990s, people tended to eat more often breakfast cereals, raw vegetables and yoghurt/fresh cheese than in 1991 in both parts of Germany. Whereas substantial East West differences in the proportions of frequent users were seen in 1991, only the higher proportion of frequent bread, fresh fruit and sausage consumers persisted for both genders in It was suggested in an earlier publication (Winkler et al, 1998) that a strong catch-up phase towards western food consumption patterns happened shortly after the reunification. Our data show changes in food consumption behaviour from 1991 to 1998 in both parts of Germany, but more pronounced in the eastern part. This indicates that the process of adaptation was still going on. Several conditions may partly explain the differences in food consumption between East and West Germany before the reunification; among them were differences in technical innovations of food processing procedures and the availability of foods (Donat et al, 1996). The former GDR had less opportunity to import foods from other countries, and the Table 7 Percentages of frequent users a (with 95% CI) of selected food groups in 1991 and 1998, persons aged y b East (n ¼ 1051) West (n ¼ 2590) East (n ¼ 914) West (n ¼ 1757) Men % 95% CI % 95% CI Difference East West c % 95% CI % 95% CI Difference East West Bread 86.3 ( ) 69.2 ( ) 17.1*** 82.3 ( ) 68.8 ( ) 13.5*** Breakfast cereals 2.5 ( ) 7.4 ( ) 4.9*** 6.0 ( ) 9.8 ( ) 3.8** Cakes, biscuits 13.2 ( ) 6.2 ( ) 7.0*** 11.8 ( ) 8.6 ( ) 3.2* Cooked vegetables 7.4 ( ) 14.0 ( ) 6.6*** 10.7 ( ) 13.1 ( ) 2.4 Raw vegetables 11.9 ( ) 21.4 ( ) 9.5*** 29.4 ( ) 27.6 ( ) 1.8 Fresh fruit 54.2 ( ) 39.9 ( ) 14.3*** 54.8 ( ) 42.3 ( ) 12.5*** Cooked potatoes 25.8 ( ) 21.8 ( ) 4.0* 22.8 ( ) 19.9 ( ) 2.9 Yoghurt, fresh cheese 16.9 ( ) 20.9 ( ) 4.0* 25.7 ( ) 27.3 ( ) 1.6 Meat 16.7 ( ) 22.3 ( ) 5.6*** 23.6 ( ) 28.3 ( ) 4.7* Sausage, ham 68.2 ( ) 42.9 ( ) 25.3*** 62.9 ( ) 44.4 ( ) 18.5*** (n ¼ 1160) (n ¼ 2665) (n ¼ 1014) (n ¼ 1871) Women % 95% CI % 95% CI Difference East West % 95% CI % 95% CI Difference East West Bread 84.4 ( ) 75.9 ( ) 8.5*** 82.5 ( ) 72.7 ( ) 9.8*** Breakfast cereals 3.3 ( ) 9.4 ( ) 6.1*** 9.6 ( ) 12.4 ( ) 2.8 Cakes, biscuits 10.1 ( ) 6.6 ( ) 3.5*** 9.4 ( ) 11.0 ( ) 1.6 Cooked vegetables 12.3 ( ) 25.0 ( ) 12.7*** 15.5 ( ) 20.0 ( ) 4.5* Raw vegetables 22.7 ( ) 32.9 ( ) 10.2*** 44.1 ( ) 40.8 ( ) 3.3 Fresh fruit 80.1 ( ) 64.7 ( ) 15.4*** 77.3 ( ) 62.5 ( ) 14.8*** Cooked potatoes 25.9 ( ) 20.0 ( ) ( ) 27.9 ( ) 6.1 Yoghurt, fresh cheese 33.0 ( ) 39.0 ( ) 6.0** 42.2 ( ) 43.4 ( ) 1.2 Meat 8.4 ( ) 13.9 ( ) 5.5*** 10.7 ( ) 13.7 ( ) 3.0 Sausage, ham 47.7 ( ) 24.3 ( ) 23.4*** 37.2 ( ) 26.1 ( ) 11.1*** Statistical significant with ***Pr0.001, **Pr0.01, *Pr0.05 using w 2 -test. a Frequent users are persons who reported to consume these food items daily or almost daily or several times per day. b Weighted for age, federal state and community size to make the surveys comparable. c Difference as percentage of West German frequency.

10 Table 8 Adjusted mean cardiovascular risk factor levels and 95% CI in the German Nutrition Survey 1998, by gender (18 79 y) a 1009 Men Women East (n ¼ 581) West (n ¼ 1182) East (n ¼ 815) West (n ¼ 1452) Mean 95% CI of mean Mean 95% CI of mean Mean 95% CI of mean Mean 95% CI of mean Systolic blood pressure (mmhg) ( ) ( )* ( ) ( ) Diastolic blood pressure (mmhg) 85.9 ( ) 84.7 ( ) 81.2 ( ) 80.3 ( ) Body mass index (kg/m 2 ) 27.1 ( ) 26.9 ( ) 26.3 ( ) 26.0 ( ) Total serum cholesterol (mmol/l) 6.1 ( ) 6.0 ( )* 5.8 ( ) 6.0 ( )* HDL cholesterol (mmol/l) 1.3 ( ) 1.3 ( )* 1.7 ( ) 1.7 ( ) Statistical significant with *Pr0.05 using Student s t-test. a Adjusted for age, socioeconomic status, sport activity, smoking, season, energy intake, alcohol intake and (except for body mass index) body mass index. inhabitants were probably more dependent on local, conventional foods compared with West Germans. For instance, the original Swiss product muesli was not introduced until 1989 in the GDR. This may be a reason for the lower but increasing use of breakfast cereals during the 1990s, as we observed. After the reunification, many differences in life circumstances disappeared, which may have led to a gradual convergence of food consumption habits. More recent data on food consumption patterns in East and West Germany to those presented here are not yet available, but it is assumed that consumption patterns will become more similar. Cardiovascular risk factors East Germans tended to have a higher mean systolic blood pressure level than West Germans. Differences in nutrition habits may partly have been responsible for this. The differences in the other observed cardiovascular risk factors were small, although small differences observed on a population level may still have important health consequences. Most of the presented results were adjusted for age, SES, smoking, sport activity, season, energy intake and the levels of cardiovascular risk factors additionally for BMI and alcohol intake. Residual confounding of total physical activity may have appeared, since sport activity was only included as hours of sport per week. However, the inclusion of energy intake may partly reflect and, therefore, adjust for total physical activity. The presented results may help to set focus points in nutrition and health campaigns. The relatively high beer, soft drink and sausage consumption among East Germans seems worthwhile to change. We observed a higher mean systolic blood pressure in East Germany. The prevalence of hypertension was also higher in the eastern part. According to the World Health Organization (WHO) blood pressure classification, in East Germany about 40% of men and 35% of women were hypertensive in 1998 compared with 32% of men and 30% of women in West Germany (Thamm, 1999). The higher consumption of alcohol and sausages (with high salt and fat content) in East Germany may have been partly responsible for this. Hypertension is strongly associated with obesity. The high prevalence of overweight (about 50%) and obesity (about 20%) is a major nutrition-related health problem in Germany (Bergmann & Mensink, 1999). National campaigns to tackle this problem especially among children have started. In general, advice aimed at reducing the intake of energy-dense foods and encouraging physical activity is given. However, for both obesity and hypertension, dietary consultation could more strongly focus on a reduced consumption of alcohol, sweetened soft drinks and sausage in the eastern part of Germany. Although for both parts of Germany the intake of fibre, vitamins D and E and calcium should be improved, the comparison with current reference values suggests that more emphasis should be placed on improving vitamin D intake in the western part, and vitamin E, fibre and calcium intake in the eastern part of Germany. Although there was no large difference in average fibre intake level between East and West Germans, East German women in particular had a mean fibre intake below the reference value. Since a low fibre intake is associated with the occurrence of many diseases, among them constipation, colon diverticular disease, colon cancer, gallstones, obesity, hypercholesterolaemia, type II diabetes mellitus and arteriosclerosis (German Nutrition Society, 2002), it is important to increase the intake in both parts of Germany. Promoting cereal intake, particularly in the eastern part, and whole grain bread and fruit and vegetable consumption in general, are possible measures. The consumption level of fruits and vegetables was for the majority of the population less than currently recommended, and a higher consumption is now promoted in both parts of Germany. An improvement in folate intake by the introduction of folate-enriched wheat flour is currently being considered by the German Government. References Beitz R, Mensink GBM, Fischer B & Thamm M (2002): Vitamins dietary intake and intake from dietary supplements in Germany. Eur. J. Clin. Nutr. 56,

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