nutrients

Article
Determinants of Diet Quality in Adolescents: Results from the
Prospective Population-Based EVA-Tyrol and EVA4YOU Cohorts
Katharina Mueller 1,2 , Alex Messner 2 , Johannes Nairz 3 , Bernhard Winder 4 , Anna Staudt 2 , Katharina Stock 2 ,
Nina Gande 2 , Christoph Hochmayr 2 , Benoît Bernar 5 , Raimund Pechlaner 6 , Andrea Griesmacher 7 ,
Alexander E. Egger 8 , Ralf Geiger 3 , Ursula Kiechl-Kohlendorfer 2 , Michael Knoflach 1,6, *,
Sophia J. Kiechl 1,9, * and on behalf of the EVA-Tyrol and EVA4YOU Study Groups †

1 VASCage, Centre on Clinical Stroke Research, Adamgasse 23, 6020 Innsbruck, Austria;
[email protected]
2 Department of Paediatrics II, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
[email protected] (A.M.); [email protected] (A.S.); [email protected] (K.S.);
[email protected] (N.G.); [email protected] (C.H.);
[email protected] (U.K.-K.)
3 Department of Paediatrics III, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
[email protected] (J.N.); [email protected] (R.G.)
4 Department of Vascular Surgery, Feldkirch Hospital, Carinagasse 41, 6800 Feldkirch, Austria;
[email protected]
5 Department of Paediatrics I, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
[email protected]
6 Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
[email protected]
7 The Central Institute of Clinical Chemistry and Laboratory Medicine (ZIMCL), Medical University of
Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; [email protected]
8 Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Anichstrasse 35,
6020 Innsbruck, Austria; [email protected]
9 Department of Neurology Hochzirl Hospital, Hochzirl 1, 6170 Zirl, Austria
* Correspondence: [email protected] (M.K.); [email protected] (S.J.K.)
† Membership of the group is provided in Acknowledgments.
Citation: Mueller, K.; Messner, A.;
Nairz, J.; Winder, B.; Staudt, A.; Stock,
K.; Gande, N.; Hochmayr, C.; Bernar, Abstract: (1) Background: Unhealthy dietary behaviors are estimated to be one of the leading
B.; Pechlaner, R.; et al. Determinants causes of death globally and are often shaped at a young age. Here, we investigated adolescent diet
of Diet Quality in Adolescents: quality and its predictors, including nutrition knowledge, in two large Central European cohorts.
Results from the Prospective
(2) Methods: In 3056 participants of the EVA-Tyrol and EVA4YOU prospective population-based
Population-Based EVA-Tyrol and
cohort studies aged 14 to 19 years, diet quality was assessed using the AHEI-2010 and DASH scores,
EVA4YOU Cohorts. Nutrients 2023, 15,
and nutrition knowledge was assessed using the questionnaire from Turconi et al. Associations were
5140. https://doi.org/10.3390/
examined utilizing multivariable linear regression. (3) Results: The mean overall AHEI-2010 score
nu15245140
was 42%, and the DASH score was 45%. Female participants (60.6%) had a significantly higher diet
Academic Editor: Susan M Schembre quality according to the AHEI-2010 and DASH score. AHEI-2010 and DASH scores were significantly
Received: 23 November 2023 associated (p < 0.001) with sex, school type, smoking, and total daily energy intake. The DASH score
Revised: 9 December 2023 was additionally significantly associated (p < 0.001) with age, socioeconomic status, and physical
Accepted: 16 December 2023 activity. Participants with better nutrition knowledge were more likely to be older, to attend a general
Published: 18 December 2023 high school, to live in a high-income household, to be non-smokers, and to have a higher diet quality
according to the AHEI-2010 and DASH score. (4) Conclusions: Predictors of better diet quality
included female sex, physical activity, educational level, and nutrition knowledge. These results may
aid focused interventions to improve diet quality in adolescents.
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
Keywords: adolescents; diet quality; AHEI-2010; DASH score; nutrition knowledge
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

Nutrients 2023, 15, 5140. https://doi.org/10.3390/nu15245140 https://www.mdpi.com/journal/nutrients

Nutrients 2023, 15, 5140 2 of 17

1. Introduction
An unhealthy diet is estimated to be one of the leading causes of death globally [1]
and is associated with a higher risk of cardiovascular disease (CVD), cancer, and type
2 diabetes [2,3]. Food preferences and eating behaviors are often shaped at a young age
and maintained throughout adulthood [4,5]. Traditionally, nutritional studies have evaluated
individual nutrients or foods and their effect on total and cause-specific mortality [6–8]. How-
ever, evaluating dietary patterns may reflect the complexity of dietary intake and their relation
to health outcomes more holistically [9–11]. Several diet quality indices, like the Alternative
Healthy Eating Index 2010 (AHEI-2010) [11] and the Dietary Approaches to Stop Hyperten-
sion (DASH) score [10], have been developed to quantify adherence to recommended dietary
patterns. Studies have consistently shown that many adolescents follow a poor diet [12–15].
Adolescents’ poor eating habits implicate present and future diet-related diseases [16–19].
A higher proportion of energy from fat and lower intake of micronutrients like vitamins
and iron may result in nutritional inadequacies or deficits that can impair cognitive function
and physical performance and lead to obesity, arterial hypertension, hypercholesterolemia,
and dysglycemia [16,17]. Furthermore, maintaining healthy eating behaviors during ado-
lescence can help prevent future chronic diseases [18,19]. Understanding the determinants
of unhealthy dietary behaviors in adolescents is critical in addressing the rising concerns
of adolescent nutrition and health. Known determinants of unhealthy diet among ado-
lescents are male sex, higher total energy intake, low levels of physical activity, and low
socioeconomic status [20–23]. Previous studies either aimed to evaluate individual foods
and nutrients [24,25], or particular subgroups with comorbidities [26,27]. However, to our
knowledge, there are few studies investigating diet quality using more comprehensive
diet scores and using information on possible influencing factors such as school type and
nutrition knowledge. Understanding these determinants is crucial for developing effective
interventions aimed at promoting healthier eating habits among adolescents. Furthermore,
few large studies were conducted in Central Europe. Therefore, the aim of this study was to
examine the diet quality, according to a diet score that is associated with the risk of general
chronic disease (AHEI-2010) and a second one associated with the risk of CVD (DASH
score), as well as nutrition knowledge and their association with age, sex, and school type
in a large community-based cohort of Central European adolescents aged 14 to 19 years.

2. Materials and Methods

2.1. Study Population
This cohort study used data from the Early Vascular Ageing in the YOUth—EVA4YOU
(NCT04598685) and the Early Vascular Ageing (EVA)-Tyrol (NCT03929692) studies, which
both included healthy adolescents of the general population. The EVA4YOU study is a
cross-sectional study that enrolled 1517 adolescents with a targeted age between 14 and
19 years of age from North Tyrol and was conducted between January 2021 and March
2023. The EVA-Tyrol study is a community-based, non-randomized controlled study that
enrolled 2102 participants aged 14 to 22 years from high schools and companies spread
across North Tyrol, East Tyrol (Austria), and South Tyrol (Italy) and was performed between
May 2015 and July 2018. Although the EVA-Tyrol study administered a health intervention
to a subgroup of participants, only data from the baseline examination before the health
intervention were included in the current analysis. In both cohorts, components and
determinants of cardiovascular health were collected at the schools‘ or companies’ sites
and included a self-administered and assisted questionnaire, a structured interview, and a
series of examinations (blood sampling, high-resolution ultrasound of the carotid arteries,
measurement of carotid–femoral pulse-wave velocity, blood pressure measurement, and
anthropometry) conducted by specially trained medical staff. The EVA-Tyrol study protocol
and detailed information about data collection and measurement procedures are described
elsewhere [28]. Data collection and measurement procedures of the EVA4YOU study
were similar to those of the EVA-Tyrol study, except for using an electronic case report
form. The study protocols of the EVA4YOU (1053/2020) and the EVA-Tyrol (AN2015-0005
 Nutrients 2023, 15, x FOR PEER REVIEW 3 of 18

Nutrients 2023, 15, 5140 3 of 17

measurement procedures of the EVA4YOU study were similar to those of the EVA-Tyrol
study, except for using an electronic case report form. The study protocols of the
EVA4YOU (1053/2020) and the EVA-Tyrol (AN2015-0005 345/4.13) trials were approved
345/4.13) trials were approved by the ethics committee of the Medical University Innsbruck,
by the ethics committee of the Medical University Innsbruck, and the studies were
and the studies
conducted were conducted
in accordance with the inDeclaration
accordanceofwith the Declaration
Helsinki. of Helsinki.
Written informed Written
consent of
informed consent of the participants and their legal representative, in case
the participants and their legal representative, in case the participant was younger than the participant
was younger
18 years, wasthan 18 years,
obtained wasstudies.
in both obtained in both studies.
For the present analysis, we
For the present analysis, we included included participants
participants fromfrom
bothboth studies
studies aged aged 14 to
14 to 19
19years.
years.
We excluded participants with missing information regarding diet. As suggested insug-
We excluded participants with missing information regarding diet. As
gested in previous
previous publications
publications [29,30], we [29,30], we furthermore
furthermore excluded
excluded those who those
had awhodailyhad a daily
energy
energy
intakeintake
of lessof less600
than than 600orkcal
kcal more or than
more3500
thankcal
3500for
kcal for women
women andthan
and less less800
than 800orkcal
kcal
ormore
morethan
than42004200kcal
kcalforfor men
men toto limit
limit thethe bias
bias of of
anan increased
increased energy
energy intake
intake allowing
allowing for for
the
theconsumption
consumption of of more
more potentially healthyfood
potentially healthy fooditems.
items.The
The flow
flow diagram
diagram of the
of the sample
sample
selection
selectionisisshown
shown in in Figure
Figure 1.

Figure 1. Consort flow diagram of the sample selection.

Figure 1. Consort flow diagram of the sample selection.

Schooltypes
School types are
are categorized
categorizedaccording
accordingtotothe Austrian
the school
Austrian system
school where,
system after after
where, 9
years of mandatory school, students may follow three different educational pathways.
9 years of mandatory school, students may follow three different educational pathways.
They may attend secondary academic high schools with general academic education
They may attend secondary academic high schools with general academic education (gen-
(general high schools), vocation-directed secondary schools offering general and
eral high schools), vocation-directed secondary schools offering general and occupation-
occupation-specific knowledge (profession-guided high school), or become apprentices
specific knowledge (profession-guided high school), or become apprentices within specific
within specific companies and regularly visit vocational schools (vocational school).
companies and regularly visit vocational schools (vocational school).
2.2. Procedures and Assessments
2.2. Procedures and Assessments
Study personnel performed anthropometric measurements with calibrated portable
Study personnel performed anthropometric measurements with calibrated portable
electronic scales (Soehnle style sense compact 200, Backnang, Germany) that included size
electronic scales (Soehnle style sense compact 200, Backnang, Germany) that included
and weight. Body Mass Index (BMI) was calculated as weight (in kilograms) divided by
size and weight. Body Mass Index (BMI) was calculated as weight (in kilograms) divided
height (in meters) squared. To assess the weight status, BMI values were expressed as
by height (in meters) squared. To assess the weight status, BMI values were expressed
percentile values and Z-scores for the appropriate age and sex according to a German
asreference
percentile values and Z-scores for the appropriate age and sex according to a German
dataset [31]. According to the US Centers for Disease Control and Prevention,
reference dataset
we classified the BMI[31]. groups
According to theunderweight
as follows: US Centers(<5thfor Disease Control
percentile), and
normal Preven-
weight
tion, we classified the BMI groups as follows: underweight (<5th percentile),
(≥5th and <85th percentile), overweight (≥85th and <95th percentile), and obese (≥95th normal
weight ( ≥ 5th and
percentile) [32]. <85th percentile), overweight ( ≥ 85th and <95th percentile), and obese
(≥95thSmoking
percentile) [32].
status and amount of moderate to intense physical activity in minutes per
daySmoking statusby
were reported and
theamount of moderate
participants to intenseinterview.
in a face-to-face physical activity in minutes
Assessment per day
of smoking
were reported by the participants in a face-to-face interview. Assessment of smoking status
distinguished between never smoked (never smoked a whole cigarette), previous smokers
(including number who practiced abstinence), and current smokers (smoked within the last
30 days). Participants were enquired about their mean moderate- and vigorous-intensity
activity in minutes per day during school hours and leisure time in accordance with
Nutrients 2023, 15, 5140 4 of 17

Americans Heart Association’s Life’s Simple 7 [33] in a face-to-face interview. Both answers
were added up and considered their physical activity in minutes per day. Examples of
moderate- and vigorous-intensity exercises were given according to Physical Activity
Guidelines for Americans [34].
Socioeconomic status (SES) was determined with the Family Affluence Scale (FAS II)
based on four questions related to household characteristics like owning a car, traveling on
vacation with the family, having one’s own bedroom, and the family having a computer.
To calculate the FAS(II), the points were summed up, ranging from 0 to 9, and divided
into three categories: low (0–2 points), medium (3–5 points), and high (6–9 points) SES.
For international use, the FAS(II) Scale was developed and validated within the Health-
Behavior in School-aged Children (HBSC) cross-national study [35,36].
Dietary information was collected with the use of a validated food frequency ques-
tionnaire (FFQ) [37] on the basis of the gold-standard FFQ by Willett et al. [38]. Examples
of reported used serving sizes were provided on every single food item. The assessment
referred to the frequency of consumption within the last month. The frequency of consump-
tion of each food item was determined by using 9 different frequency categories ranging
from never or less than once a month to six or more times a day. Energy and nutrient
intakes for each participant were calculated by multiplying the frequency of consumption
of each food by its energy or nutrient content and summing nutrient contributors across all
of the food items. Energy and nutrient intake were calculated by converting reported food
intake into macronutrient intake values for each food using the reported serving size and
the United States Department of Agriculture’s (USDA) Food and Nutrient Database for
Dietary Studies [39].
Diet quality was estimated by using two scores, the AHEI-2010 and the DASH score.
The AHEI-2010 is a diet quality index based on foods or food components associated with
chronic disease risk [11,40]. Based on the Dietary Guidelines for Americans and as used in
numerous studies investigating healthy eating patterns [11,29,30], in this study, the AHEI-
2010 is composed of ten components: whole fruit, vegetable (excluding potatoes), whole
grains, red and processed meat, nuts and legumes, long-chain (ω-3) fats (eicosapentaenoic
acids (EPA) and docosahexaenoic acids (DHA)), polyunsaturated fatty acids, trans-fat,
sugar-sweetened beverages, and sodium. The score of each component ranges from 0
(worst) to 10 (best), with a maximum score of 100 (highest adherence). Alcohol intake
was not included as a component of the AHEI-2010 score in our study due to inconsis-
tent intake across different age groups and strong spirits not being legal until the age of
18 years in Austria and Italy. Detailed assessment of the AHEI-2010 score components and
criteria for scoring can be found in Table S1 (Supplement). Adherence to DASH diet has
been shown to have a protective effect against the incidence of CVD [10,41]. The DASH
diet emphasizes the consumption of whole grains, fruits and vegetables, low-fat dairy,
lean meat, fish, poultry, nuts, seeds, and legumes, and sparse use of fats and oils. The
DASH score created by Fung et al. [10] consists of eight components: fruit, vegetables,
nuts and legumes, whole grains, low-fat dairy products, sodium intake, red and processed
meat, and sugar-sweetened beverages. For the first five components, participants were
given one (lowest quintile) to five (highest quintile) points. Scores were reversed (five to
one for the lowest to highest quintile) for sodium intake, red and processed meat, and
the consumption of sugar-sweetened beverages. The DASH-Diet score ranged from eight
(minimal adherence) to 40 (maximal adherence). Detailed assessment of the DASH score
components and criteria for scoring can be found in Table S2 (Supplement).
Nutritional knowledge was only assessed within the EVA-Tyrol study group using a
self-administered questionnaire containing two sections (E, H) of a dietary questionnaire
originally developed and validated by Turconi et al. [42]. Section E aimed to investigate the
student’s beliefs about healthy and unhealthy diets and food. It consists of five questions,
each having four different responses, with a score ranging from one to four and a maximum
score of 20. Section H contains eleven questions focusing on nutritional knowledge. The
correct response receives one point, summing up to a maximum score of eleven points.
Nutrients 2023, 15, 5140 5 of 17

The remaining 8 sections originally included in the Turconi dietary questionnaire were
designed to assess personal data (A), food habits (B, C), eating behavior, physical activity
and lifestyle (D, F, G), and food safety (I, J) and were either not relevant to our study design
or otherwise assessed and therefore not recorded.

2.3. Statistical Analysis

For the present study, characteristics are shown as mean ± standard deviation (mean ± SD)
if normally distributed and otherwise expressed by median and interquartile range (M
(Q1, Q3)). Count data were described as n (%). Differences between groups were analyzed
using the t-test, Mann–Whitney-U, or Chi-square-Test. The diet quality scores (AHEI-
2010 and DASH score) were analyzed separately in quartiles based on the distribution of
each score. The comparison of values across different quartiles was conducted by using a
univariate ANOVA or Pearson Chi-square Test. A multivariable linear regression model
with adjustment for age, sex, school type, socioeconomic status, BMI-Z Score, and energy
intake was used to examine the association of adolescent factors with each diet quality
score. Furthermore, a linear regression analysis on nutritional knowledge was performed for
the EVA-Tyrol study, in which these data were available. p values were considered statistically
significant at p < 0.05. Diet scores were calculated using Microsoft Excel 2016 (Microsoft Inc.,
Redmond, WA, USA) and SPSS version 29.0 (SPSS Inc., Chicago, IL, USA). All statistical
analyses were conducted using SPSS version 29.0 (SPSS Inc., Chicago, IL, USA) and R version
4.3.1 for Windows (R Foundation for Statistical Computing, Vienna, Austria).

3. Results
3.1. Baseline Characteristics
As shown in Table 1, the total study sample of 3056 participants included 1329 (43.5%)
from the EVA4YOU study and 1727 (56.5%) from the EVA-Tyrol study. In the total sample,
the mean age was 16.8 years, 60.6% were female, the majority (54.5%) attended a profession-
guided high school, and the daily median energy intake according to the FFQ was 1975 kcal.
Dietary patterns were described using the AHEI-2010 and the DASH score. The median
AHEI-2010 score was 42 points (range 12–82 points), and the median DASH score was
18 points (range of 8–32 points). Participants of the EVA4YOU study tended to be older,
more often female, more often living in high-income households, were less often obese,
more physically active, and scored fewer points on the AHEI-2010 score and more on the
DASH score in comparison to participants of the EVA-Tyrol study.

Table 1. Descriptive characteristics of participants in EVA4YOU and EVA-Tyrol studies.

Total Sample EVA4YOU EVA-Tyrol

Variable p
(n = 3056) (n = 1329) (n = 1727)
Age, years, mean ± SD 16.8 ± 1.3 17.2 ± 1.3 16.5 ± 1.2 <0.001 *
Sex, n (%) <0.001 ***
male 1205 (39.4) 468 (35.2) 737 (42.7)
female 1851 (60.6) 861 (64.8) 990 (57.3)
Schooltype, n (%) <0.001 ***
Vocational school 437 (14.3) 264 (19.9) 173 (10.0)
Profession-guided high school 1667 (54.5) 678 (51.0) 989 (57.3)
General high school 952 (31.2) 387 (29.1) 565 (32.7)
FAS(II) Scale, n (%) a <0.001 ***
Low 18 (0.6) 4 (0.3) 14 (0.8)
Medium 821 (26.9) 262 (19.7) 559 (32.4)
High 2192 (71.7) 1063 (80.0) 1129 (66.3)
BMI, kg/m2 , mean ± SD 22.06 ± 3.63 22.29 ± 3.77 21.89 ± 3.51 0.003 *
BMI Z-score, mean ± SD 0.11 ± 1.04 −0.05 ± 1.04 0.22 ± 1.02 <0.001 *
Weight Group, n (%) b <0.001 ***
Underweight 133 (4.4) 84 (6.3) 49 (2.8)
Normal 2347 (76.8) 1039 (78.2) 1308 (75.7)
Overweight 347 (11.4) 148 (11.1) 199 (11.5)
Obesity 229 (7.5) 58 (4.4) 171 (9.9)
Nutrients 2023, 15, 5140 6 of 17

Table 1. Cont.

Total Sample EVA4YOU EVA-Tyrol

Variable p
(n = 3056) (n = 1329) (n = 1727)
Physical activity, min/d, M (Q1, Q3) 45 (30, 75) 55 (30, 80) 45 (25, 60) <0.001 **
Total Energy, kcal/d, M (Q1, Q3) 1975 (1483, 2542) 2014 (1548, 2586) 1941 (1439, 2517) 0.004 **
Never-smoker, n (%) 2059 (67.4) 843 (63.4) 1216 (70.4) <0.001 ***
AHEI-2010 score, M (Q1, Q3) 42 (34, 50) 39 (32, 47) 44 (36, 52) <0.001 **
DASH score, M (Q1, Q3) 18 (15, 21) 19 (17, 22) 17 (14, 20) <0.001 **
FAS(II) Scale (Family Affluence Scale II). BMI (body mass index). * t-test. ** ANOVA. *** Pearson Chi-squared Test.
a Low (0–2 points), medium (3–5 points), and high (6–9 points). b Underweight (<5th percentile), normal weight

(≥5th to <85th percentile), overweight (≥85th to <95th percentile), and obese (≥95th percentile).

3.2. Distribution of Characteristics across Quartiles of the AHEI-2010 Score

The distribution of the study characteristics across quartiles of the AHEI-2010 score
among study participants is shown in Table 2. Participants with a higher AHEI-2010 score
were more likely to be female, non-smokers, and to have a higher energy intake. A higher
AHEI-2010 score was associated with a higher intake of every single healthy food item
included in the AHEI-2010 score. Age, FAS-II Score, BMI Z-score, and amount of physical
activity did not significantly differ between the AHEI-2010 quartiles. Adolescents scored
best in having a high intake of long-chain (ω-3) fats (EPA + DHA) and nuts and legumes,
as well as a low intake of trans fat. However, only 27% did not exceed the recommended
maximum daily sodium intake, and only 8% ate five or more portions of vegetables daily
(Figure S1 in Supplementary Materials).

Table 2. Distribution of study characteristics across quartiles of the AHEI-2010 score among
EVA4YOU and EVA-Tyrol participants.

Quartiles of AHEI-2010 Score

Characteristics Q1 (n = 805) Q2 (n = 777) Q3 (n = 745) Q4 (n = 729) p
AHEI-2010 score, M (Q1, Q3)
29 (25, 32) 39 (36, 40) 46 (44, 48) 57 (53, 61) <0.001 *
Possible Range of 0–100
Age, years, mean ± SD 16.9 ± 1.3 16.8 ± 1.3 16.7 ± 1.3 16.8 ± 1.3 0.200 *
Female, n (%) 461 (57.3) 445 (57.3) 449 (60.3) 496 (68.0) <0.001 **
Schoolt ype, n (%) <0.001 **
Vocational school 171 (21.2) 102 (13.1) 96 (12.9) 68 (9.3)
Profession-guided high school 468 (58.2) 438 (56.4) 423 (56.8) 338 (46.4)
General high school 166 (20.6) 237 (30.5) 226 (30.3) 323 (44.3)
FAS(II) Score, Points,
6 (5, 7) 6 (6, 8) 6 (5, 8) 6 (5, 8) 0.357 *
M (Q1, Q3)
BMI Z-score, M (Q1, Q3) 0.03 (−0.64, 0.74) 0.14 (−0.60, 0,77) 0.11 (−0.60, 0.84) 0.12 (−0.54, 0.80) 0.192 *
Physical activity, min/d,
45 (25, 70) 45 (30, 75) 45 (30, 70) 60 (30, 80) 0.435 *
M (Q1, Q3)
Never-smoker, n (%) 491 (61.0) 532 (68.5) 513 (68.9) 523 (71.7) <0.001 **
Total energy, kcal/d, 1857 1909 2070 2141
<0.001 *
M (Q1, Q3) (1401, 2330) (1466, 2423) (1526, 2653) (1613, 2762)
Components of AHEI-2010, M (Q1, Q3)
Fruits a , servings/d 1.22 (0.70, 1.91) 1.65 (1.05, 2.56) 2.49 (1.56, 3.71) 3.52 (2.21, 5.11) <0.001 *
Vegetables b , servings/d 1.29 (0.71, 1.94) 1.91 (1.27, 2.64) 2.47 (1.76, 3.43) 3.56 (2.41, 4.99) <0.001 *
43.45 (15.12, 43.45 (23.65,
Whole grain, g/d 23.65 (3.63, 55.00) 27.5 (7.70, 55.00) <0.001 *
55.00) 55.00)
Red and processed meat intake c,
3.05 (1.81, 5.19) 2.62 (1.39, 4.84) 1.90 (0.69, 3.61) 0.89 (0.26, 2.40) <0.001 *
servings/d
Nuts and legumes d , servings/d 0.14 (0.07, 0.35) 0.35 (0.14, 0.71) 0.64 (0.29, 1.12) 1.20 (0.72, 1.97) <0.001 *
Long-chain (ω-3) fats (EPA + DHA), mg/d 0 (0, 40) 90 (0, 790) 130 (2, 830) 640 (90, 920) <0.001 *
Polyunsaturated fatty acids, % of energy 2.35 (1.70, 4.44) 3.01 (1.82, 4.85) 3.72 (2.01, 5.13) 4.27 (2.33, 5.48) <0.001 *
Trans fat, % of energy 0.67 (0.58, 0.78) 0.64 (0.54, 0.74) 0.60 (0.50, 0.69) 0.51 (0.42, 0.63) <0.001 *
SSBs and fruit juice e , servings/d 1.20 (0.62, 2.11) 0.88 (0.42, 1.82) 0.84 (0.42, 1.64) 0.42 (0.14, 0.91) <0.001 *
Nutrients 2023, 15, 5140 7 of 17

Table 2. Cont.

Quartiles of AHEI-2010 Score

Characteristics Q1 (n = 805) Q2 (n = 777) Q3 (n = 745) Q4 (n = 729) p
5920 5540 5480 4800
Sodium intake, mg/d <0.001 *
(4420, 7835) (3980, 7820) (3585, 7705) (3220, 6740)
* ANOVA. ** Pearson Chi-squared Test. EPA (eicosapentaenoic acids). DHA (docosahexaenoic acids). SSBs
(sugar-sweetened beverages). a 1 serving = medium piece of fruit, b 1 serving = 0.5 cup of typical local vegetables,
except potatoes, c 1 serving = 113.4 g of unprocessed and 42.5 g of processed meat, d 1 serving = 28.35 g, e 1
serving = 236.6 mL.

3.3. Distribution of Characteristics across Quartiles of the DASH Score

The distribution of the study characteristics across quartiles of the DASH score among
study participants is shown in Table 3. Participants in the highest DASH score quartiles
were more likely to be older, to be female, to attend a general high school, to live in a
high-income household according to their FAS(II) Score, to be more physically active, to
smoke, and to consume more kcal per day. There were no significant differences in BMI
Z-score across the quartiles of DASH score. Furthermore, a higher DASH score quartile
was associated with a more frequent intake of all healthy food items, especially fruit,
vegetables, nuts and legumes, and whole grains. Adolescents scored best in consuming
4 or more portions of fruit (20.1%), less than 2.8 portions of red and processed meat a week
(19.1%), and no sugar-sweetened beverages daily (15.8%). The DASH score item with the
lowest score was low-fat dairy products, which were consumed daily by only 25% of study
participants, and within this group, only 3% consumed the recommended 2.3 portions daily
(Figure S2, Supplement).

Table 3. Distribution of study characteristics across quartiles of the DASH score among EVA4YOU
and EVA-Tyrol participants.

Quartiles of DASH Score

Characteristics Q1 (n = 819) Q2 (n = 851) Q3 (n = 722) Q4 (n = 664) p
DASH score, M (Q1, Q3)
14 (12, 15) 17 (16, 18) 20 (19, 21) 24 (22, 26) <0.001 *
Possible Range of 8–40
Age, years, mean ± SD 16.5 ± 1.3 16.8 ± 1.3 16.9 ± 1.3 17.0 ± 1.3 <0.001 *
Female, n (%) 374 (45.3) 503 (59.1) 476 (66.2) 498 (75.3) <0.001 **
School type, n (%) <0.001 **
Vocational school 154 (18.8) 131 (15.4) 83 (11.5) 69 (10.4)
Profession-guided high school 510 (62.3) 483 (56.8) 386 (53.5) 288 (43.4)
General high school 155 (18.9) 237 (27.8) 253 (35.0) 307 (46.2)
FAS(II) Score, Points,
6 (5, 7) 6 (5, 8) 7 (5, 8) 7 (6, 8) <0.001 *
M (Q1, Q3)
BMI Z-score, 0.10 0.12 0.08 0.09
0.174 *
M (Q1, Q3) (−0.59, 0.78) (−0.58, 0.81) (−0.63, 0.82) (−0.57, 0.78)
Physical activity, min/d, M (Q1, Q3) 45 (25, 75) 45 (30, 70) 50 (30, 75) 60 (30, 80) <0.001 *
Never-smoker, n (%) 522 (63.7) 566 (66.5) 499 (69.1) 472 (71.1) 0.016
1921 1898 1986 2163
Total energy, kcal/d, M (Q1, Q3) <0.001 *
(1421, 2488) (1464, 2407) (1463, 2571) (1631, 2682)
Components of DASH score, M (Q1, Q3)
Fruit and fruit juice a , servings/d 1.35 (0.77, 2.00) 1.91 (1.19, 3.07) 2.70 (1.63, 4.09) 3.70 (2.43, 5.59) <0.001 *
Vegetables and vegetable juice b ,
1.35 (0.78, 2.00) 1.91 (1.26, 2.64) 2.51 (1.64, 3.48) 3.73 (2.56, 5.00) <0.001 *
servings/d
Nuts and legumes c , servings/d 0.25 (0.12, 0.58) 0.35 (0.14, 0.72) 0.45 (0.21, 0.95) 0.85 (0.43, 1.57) <0.001 *
Whole grain d , servings/d 0.43 (0.14, 0.79) 0.43 (0.14, 1.00) 0.79 (0.43, 1.00) 1.00 (0.43, 1.75) <0.001 *
Low-fat dairy products e , servings/d 0 (0, 0) 0 (0, 0) 0 (0, 0.07) 0 (0, 0.10) <0.001 *
Sodium intake, mg/d 6170 (4455, 8480) 5510 (4050, 7630) 5230 (3510, 7330) 4770 (3300, 6550) <0.001 *
Red and processed meat intake f ,
1.93 (1.2, 2.87) 1.18 (0.68, 2.14) 0.85 (0.42, 1.57) 0.46 (0.14, 0.97) <0.001 *
servings/d
SSBs g , servings/d 1.44 (0.56, 2.94) 0.69 (0.26, 1.72) 0.33 (0.04, 1.12) 0.14 (0, 0.56) <0.001 *
* ANOVA. ** Pearson Chi-squared Test. a 1 serving = medium piece of fruit or ½ cup of fruit juice, b 1 serving = 0.5 cup
of typical local vegetables or ½ cup of vegetable juice, c 1 serving = 1/3 cup, 42 g, d 1 serving = 1 slice of bread, ½ cup of
cooked grains, e 1 serving = 1 cup, 250 mL, f 1 serving = 30 g of red or processed meat, g 1 serving = 1 cup, 250 mL.
Nutrients 2023, 15, 5140 8 of 17

3.4. Association of Adolescent Factors and the Dietary Scores AHEI-2010 and DASH Score
The relationship between two nutrition scores, the AHEI-2010 and the DASH score,
and adolescent factors are displayed in Table 4. In a sex- and age-adjusted linear regression,
attending vocational school was significantly associated with a lower AHEI-2010 score,
and attending general high school, being physically active, being a never-smoker, and a
higher total energy intake were associated with a higher AHEI-2010 score. In a univariate
linear regression model, female sex was significantly associated with a higher AHEI-2010
score. A further multivariable analysis indicated that attendance at a general high school, a
higher socioeconomic status, more physical activity, and a higher total energy intake were
associated with a higher DASH score. In a univariate linear regression model, older age
and the female sex were significantly associated with a higher DASH score.

Table 4. Association between adolescent factors and nutrition scores.

AHEI-2010 Score DASH Score

Regression Regression
Coefficient R2 p Coefficient R2 p
(95% CI) (95% CI)
−0.250
Age, years * 0.001 0.126 0.524 (0.410–0.638) 0.026 <0.001
(−0.570–0.071)
Sex, female * 2.292 (1.44–3.139) 0.009 <0.001 1.982 (1.683–2.281) 0.052 <0.001
School type **
−2.124 −1.098
Profession-guided high school 0.018 <0.001 0.096 <0.001
(−2.954–−1.293) (−1.385–−0.810)
General high school 4.575 (3.689–5.460) 0.042 <0.001 1.896 (1.590–2.202) 0.122 <0.001
FAS(II) Score, Points 0.226 (−0.044–0.496) 0.011 0.101 0.326 (0.233–0.419) 0.094 <0.001
−0.067
BMI Z-score 0.331 (−0.069–0.731) 0.011 0.105 0.080 0.343
(−0.207–0.072)
Physical activity, min/d 0.010 (0.002–0.018) 0.012 0.012 0.008 (0.006–0.011) 0.092 <0.001
Smoking, never 2.582 (1.680–3.484) 0.020 <0.001 1.013 (0.699–1.326) 0.091 <0.001
Total energy, kcal/d 0.003 (0.002–0.003) 0.038 <0.001 0.001 (0.001–0.001) 0.107 <0.001
Linear regression with adjustment for sex and age (if not otherwise specified). * Analyzed with univariate linear
regression. ** Reference Vocational School. CI, Confidence Interval. BMI, Body Mass Index. FAS(II) Score, Family
Affluence Score II.

As shown in Figure 2, female sex, attending general high school, BMI Z-score, physical
activity, smoking, and total energy intake remained significantly associated with higher
AHEI-2010 scores after multivariable adjustment. Furthermore, after multivariable ad-
justment, a higher DASH score was significantly associated with older age, female sex,
attending general high school, FAS(II) Score, more frequent physical activity, smoking, and
a higher total energy intake. Sensitivity analysis was conducted adjusting for the study
with similar results (not shown).

3.5. Nutrition Knowledge

We also assessed the distribution of adolescent factors based on nutritional knowledge,
which was only available in the EVA-Tyrol population. The results of each section were
described separately and are summarized in Table 5. Participants with a higher score in
Section E, aiming at investigating the student’s beliefs about healthy and unhealthy diet
and food, were more likely to be female and to attend a general high school. Students with
a higher score in Section H, evaluating nutritional knowledge, were significantly more
likely to attend a general high school and to have a higher diet quality according to the
AHEI-2010 and DASH scores.
 physical activity, smoking, and total energy intake remained significantly associated with
higher AHEI-2010 scores after multivariable adjustment. Furthermore, after multivariable
adjustment, a higher DASH score was significantly associated with older age, female sex,
attending general high school, FAS(II) Score, more frequent physical activity, smoking,
Nutrients 2023, 15, 5140 9 ofthe
17
and a higher total energy intake. Sensitivity analysis was conducted adjusting for
study with similar results (not shown).

Figure 2. Independent
Figure 2. Independent influence
influence of
of adolescent
adolescent factors
factors on
on nutrition
nutritionscores.
scores. ** <0.05,
<0.05, ** <0.01, *** <0.001.
Multivariable linear regression on AHEI-2010 and DASH DASH scores.
scores. Adjustment for age, sex, sex, school
school
socioeconomic status,
type, socioeconomic status, BMI
BMI Z-score,
Z-score, physical
physical activity,
activity,smoking
smokingstatus,
status,andandenergy
energyintake.
intake.

3.5. Nutrition
Table Knowledge
5. Distribution of beliefs about healthy and unhealthy diet and food (Section E) and nutrition
We also
knowledge assessed
(Section the distribution
H) according of adolescent
to the study characteristics: factorspopulation
EVA-Tyrol based on(n =nutritional
1727).
knowledge, which was only available in the EVA-Tyrol population. The results of each
section were described separately Nutrition
andKnowledge Score
are summarized in Table 5. Participants with a
Variable higher scoreSection
in Section
E E, aiming atpinvestigating
* the student’s
Section H beliefs aboutp * healthy and
Possible Range: 5–20 Possible Range: 0–11
unhealthy diet and food, were more likely to be female and to attend a general high school.
Sex Students with a higher score in 0.034 Section H, evaluating nutritional knowledge,0.483 were
Male 12 ± 2 6±2
Female significantly12more
±1 likely to attend a general high school
6±2 and to have a higher diet quality
Schooltype according to the AHEI-2010 and DASH <0.001scores. <0.001
Vocational school 11 ± 2 5±2
Profession-guided high school 12 ± 1 6±2
General high school 12 ± 1 7±2
FAS(II) Scale a , 0.276 0.628
Low 11 ± 2 6±2
Medium 12 ± 2 6±2
High 12 ± 1 6±2
Weight Group b 0.34 0.615
Underweight 12 ± 2 6±2
Normal 12 ± 2 6±2
Overweight 12 ± 2 7±2
Obesity 12 ± 2 7±2
AHEI-2010 score Quartiles 0.225 0.003
Quartile 1 12 ± 1 6±2
Quartile 2 12 ± 2 6±2
Quartile 3 12 ± 1 6±2
Quartile 4 12 ± 2 7±2
Nutrients 2023, 15, 5140 10 of 17

Table 5. Cont.

Nutrition Knowledge Score

Section E Section H
Variable p* p*
Possible Range: 5–20 Possible Range: 0–11
DASH score Quartiles 0.412 <0.001
Quartile 1 12 ± 2 6±2
Quartile 2 12 ± 1 6±2
Quartile 3 12 ± 1 7±2
Quartile 4 12 ± 2 7±2
Values are shown as mean ± SD. * Pearson Chi-squared Test. a Low (0–2 points), medium (3–5 points), high
(6–9 points). b Underweight (<5th percentile), normal weight (≥5th to <85th percentile), overweight (≥85th to
<95th percentile), and obese (≥95th percentile).

We also assessed the association between diet quality and nutritional knowledge. The
results are displayed in Table 6. EVA-Tyrol participants attending a general high school,
having a higher BMI, and not smoking have a better understanding of a healthy diet after
adjusting for sex and age. Participants with better nutrition knowledge were more likely to
be older, to attend a general high school, to live in a high-income household, to not smoke,
and to have a higher diet quality according to the AHEI-2010 and DASH scores. There was
no significant association with female sex or physical activity.

Table 6. Association of beliefs about healthy and unhealthy diet and food (Section E) and nutrition
knowledge (Section H) and adolescent factors: EVA-Tyrol population (n = 1727).

Section E Section H
Standardized Beta Standardized Beta
R2 p R2 p
Coefficient Coefficient
Age, years * 0.041 0.002 0.107 0.255 0.065 <0.001
Sex, female * 0.021 0.000 0.423 −0.011 0.000 0.664
School type **
Profession-guided high school 0.001 0.002 0.966 −0.095 0.074 <0.001
General high school 0.071 0.007 0.006 0.187 0.099 <0.001
FAS(II) Scale 0.049 0.005 0.061 0.085 0.074 <0.001
BMI Z-score −0.064 0.006 0.014 0.016 0.064 0.540
Physical activity, min/d −0.018 0.003 0.493 −0.012 0.066 0.638
Smoking, never 0.075 0.008 0.005 0.101 0.075 <0.001
AHEI-2010 score 0.000 0.002 0.990 0.166 0.092 <0.001
DASH score 0.003 0.002 0.908 0.181 0.095 <0.001
Linear regression with adjustment for sex and age (if not otherwise specified). * Analyzed with univariate linear
regression. ** Reference Vocational School.

4. Discussion
Using data from two large community-based cohort studies of adolescents—the
EVA4YOU and the EVA-Tyrol study—this analysis examined the prevalence of diet quality
and knowledge about healthy diets depending on age, sex, and school type. The overall
diet quality of the study participants using the AHEI-2010 and DASH scores was low
in both sexes and across all ages and education types. This was the result of low scores
in all diet components, but especially of a high intake of sodium and red and processed
meat and a low intake of polyunsaturated fatty acids. The results indicate that higher
AHEI-2010 scores were associated with female sex and attending general high school, as
well as increased physical activity, non-smoking status, and a higher total energy intake.
Additionally, participants with greater knowledge about nutrition had higher AHEI-2010
scores, whereas beliefs about healthy and unhealthy diets and foods showed no such
association. Furthermore, a positive relationship between higher DASH scores and more
frequent physical activity, non-smoking status, and a higher total energy intake, as well as
greater nutrition knowledge, was observed.
Nutrients 2023, 15, 5140 11 of 17

Our results are generally consistent with previous studies that have separately in-
vestigated diet quality scores [43–49] and the prevalence of knowledge about healthy
diets [50,51] in adolescents. Within this sample of Tyrolean adolescents, the average
AHEI-2010 score was 42 points, which suggests 42% adherence to recommendations to
achieve an optimal diet quality and is therefore rather low. However, similar diet quality
index scores were determined in other youth populations. A cross-sectional study by
Zheng et al. described a US-population of 5934 adolescents aged 12 to 19 years with a mean
AHEI-2010 score of 29.17. However, in this study, the AHEI-2010 score was composed of
9 components and a maximal score of 90, missing alcohol intake and long-chain (ω-3) fats,
resulting in a 32% healthy diet adherence [43]. Ducharme-Smith et al. showed a mean
AHEI-2010 score of 47.4 in a sample size including 240 Native American adolescents with
diabetes or prediabetes with a mean age of 13.6 years [44]. In contrast to our analysis,
alcohol intake was reflected in the AHEI-2010 score, resulting in 11 components and a
possible count of 110. Therefore, a 43% adherence to dietary guidelines was found. Similar
to our results, which showed a mean calorie intake of 1975 kcal, a mean energy intake of
2016 kcal was found. However, Ducharme-Smith et al. described a BMI-Z-Score of 2.19,
reflecting an obese study population. Wang et al. applied the same AHEI-2010 score as
used in our study to assess global dietary quality, showing a mean AHEI-2010 score of 45.5
in an Austrian population aged 25 and older in 2017 [45]. Regarding the DASH diet, the
participants in our study had a mean score of 18.24 points, resulting in a 45% adherence to
the DASH diet. In comparison to other studies [46–49], this score seems rather low. One
explanation might be the consumption of dairy products. In the population described,
only 25% of participants stated that they consume low-fat dairy products. Beyond that, the
FFQ only distinguished between low- and high-fat milk and did not include other low-fat
dairy products. Furthermore, the mean sodium intake was 5955 mg, and only 10% of our
population did not exceed the recommended maximum daily sodium intake of 2676 mg.
Compared to other adolescent cohorts [44,52], this represents comparatively high amounts
of daily sodium consumption. However, a study by Hasenegger et al. found a mean dietary
salt intake in Austrian adults of 5.6 g daily [53], and similar findings among adults were
published in other European countries [54].
Furthermore, the association of higher AHEI-2010 and DASH scores with female sex,
increased physical activity, non-smoking status, and a higher energy intake are in line with
previous findings among adults [55–58]. It is not surprising that the associations with the
two diet quality scores are similar, as they are composed of several similar components
such as fruits, vegetables, whole grains, nuts, and legumes. One explanation for better diet
quality among female adolescents might be their higher intake of healthy food items like
fruits and vegetables. Similar results were found in previous studies [59,60]. Furthermore,
in our study, more female adolescents (35%) attended a general high school than male
participants (25%), possibly explaining better diet quality. However, female adolescents
were less physically active in min/day (median 40 min/day (IQR 25, 60)) than male
participants (60 (35, 90)). No significant differences between female and male adolescents
depending on age, SES, or nutrition knowledge were found in our study cohort.
Additionally, healthy behaviors like physical activity, non-smoking, and a better diet
are known to co-occur [21,61]. Meeting the recommendations on physical activity is found
to be one of the main determinants for adherence to healthy dietary patterns [62]. While
higher DASH scores were associated with older age, AHEI-2010 scores were not. Previous
studies have found mixed results [63–65]. In our study, older participants tended to have a
higher socio-economic status, which might play a role.
We described an association between higher AHEI-2010 and DASH scores in ado-
lescents attending general high school and lower scores in those attending vocational or
profession-guided schools. One possible explanation is that in profession-guided high
schools and vocational schools, nutritional education is an even lower priority than in
general high schools. To the best of our knowledge, there were no previous studies that
Nutrients 2023, 15, 5140 12 of 17

compared dietary patterns measured by the AHEI-2010 and DASH scores in different
school types among adolescents.
SES was associated with the DASH score. The association between SES and dietary
quality has been shown previously by French et al. [66]. A low SES, on the other hand, is
known to be associated with CVD risk [67], and worse dietary habits might be one of the
reasons for this link. As the connection between SES and dietary quality already applies
in adolescence, a timely consolidation of favorable dietary habits might be beneficial for
long-term disease risk.
Although lower diet quality among adolescents is known from several studies [12–15],
implicating present and future diet-related diseases like micronutrient deficiencies, obesity,
or diabetes [16–19], our results help to identify subgroups that are particularly in need of
timely interventions and to shape interventions programs focusing on different dietary
components and including education programs. Previous studies evaluated intervention
programs focusing on micronutrient supplementation and nutrition education to prevent
deficiencies or obesity among adolescents [68–70]. However, the benefits of these interven-
tions vary and are to be interpreted with caution [71]. On the other hand, some studies
suggest that a combination of interventions, including nutrition, physical activity, and
nutrition knowledge, have a greater effect than interventions focusing on them individ-
ually [71,72]. Promoting healthy nutrition behaviors among adolescents might be most
successful when including a wide range of policies that are viable and implemented both
in schools and at home [71,73,74]. Implementing nutrition interventions among subgroups
of adolescents with lower diet quality could catalyze a shift in public health outcomes.
Given the local societal context, these interventions could address specific cultural and
socioeconomic factors influencing dietary habits. Particularly, subgroups with known low
diet quality, such as adolescents with male sex, low SES, and low educational level, need to
be a special focus in intervention programs.
The association of better nutrition knowledge with older age, living in a high-income
household, non-smoking status, and the consumption of healthy foods was previously
described in several studies [50,51,75–77]. However, to the best of our knowledge, there
were no previous studies relating AHEI-2010 or DASH scores measuring healthy dietary
patterns and their association with nutrition knowledge.
The strengths of the present study include a large, well-characterized community-
based sample representative of the healthy adolescent Central European population, which
enabled us to associate diet quality with different school types and nutrition knowledge.
A large amount of data on dietary habits were assessed, applying a previously validated
FFQ to allow for an in-depth analysis. Calculating diet quality scores represents eating
behavior more holistically than looking at food items individually [9–11]. Furthermore,
foods and nutrients identified in the AHEI-2010 score have been consistently associated
with a lower risk of general chronic disease [10]. Components of the DASH score are based
on the DASH-style diet, and the DASH score was found to lower blood pressure and the
risk of chronic heart disease and stroke [11]. To our knowledge, this study is the first to
examine the association of two different dietary scores with school type and nutrition
knowledge in a large group of healthy Central European adolescents.
However, this study has certain limitations. First, measurement error may hamper
self-reported dietary behavior. However, for the FFQ employed here, validation using short-
term recall has been performed [37], and good agreement with dietary assessment using the
FFQ developed by Willet et al. in multiple cohorts has been shown [78–81]. Second, as with
most FFQs, we did not cover discretionary salt intake in cooking or seasoning. Therefore,
the sodium component in both the AHEI-2010 and the DASH score must be interpreted
cautiously, and an underestimation might have occurred. Third, we excluded information
about daily alcohol intake in calculating the AHEI-2010 score due to inconsistent intake
across different age groups and strong spirits not being legal until the age of 18. However,
the same method was used in several previously mentioned cohort studies. Fourth, we
calculated the FAS(II) Scale instead of the most recent FAS(III) Scale better reflecting SES
Nutrients 2023, 15, 5140 13 of 17

in high-income countries like Austria. However, data from the EVA-Tyrol study were
obtained before the updated Family Affluence Scale was published. Fifth, this study lacked
information on parental and family eating habits, which may be a confounding factor,
especially at the mean age of 16 years. Finally, as in all observational studies, we cannot
exclude the possibility of residual and unmeasured confounding. More prospective studies
are needed to determine the relationship between different diet quality scores and the
positive effect of extensive nutrition knowledge on healthy eating patterns in adolescents.

5. Conclusions
In this study, higher AHEI-2010 and DASH scores were associated with female sex,
higher levels of physical activity, non-smoking status, and attendance at a profession-
guided or general high school among adolescents. In addition, higher DASH scores were
associated with older age and living in a high-income household. Furthermore, greater
knowledge about nutrition resulted in a healthier diet measured by AHEI-2010 and DASH
scores. However, adolescent’s beliefs about healthy and unhealthy diets and food were
not reflected in either diet quality score. Hence, to improve dietary quality, which was, in
general, low in all sub-groups of adolescents, putting more emphasis on nutrition education
might be beneficial. Furthermore, a disadvantage faced by adolescents with low SES and
lower education levels has been found. These groups are therefore in particular need of
interventions and improving nutritional education.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/nu15245140/s1, Table S1: Alternate Healthy Eating Index (AHEI-
2010) components and criteria for scoring; Table S2: Dietary Approaches to Stop Hypertension
(DASH) score components and criteria for scoring; Figure S1: AHEI-2010 components and percentage
of participants scoring in various categories; Figure S2: DASH score components and percentage of
participants scoring in various categories.
Author Contributions: Conceptualization, K.M., M.K. and S.J.K.; methodology, K.M.; validation,
K.M., M.K. and S.J.K.; formal analysis, K.M.; investigation, K.M., M.K. and S.J.K.; data curation (EVA-
Tyrol), A.S., K.S., N.G., B.B., C.H., R.G., R.P., A.G., U.K.-K., M.K. and S.J.K.; data curation (EVA4YOU),
K.M., A.M., J.N., B.W., C.H., R.G., R.P., A.E.E., A.G., U.K-K., M.K. and S.J.K.; writing—original draft
preparation, K.M.; writing—review and editing, M.K. and S.J.K.; visualization, K.M. and S.J.K.;
supervision, M.K. and U.K.-K. All authors have read and agreed to the published version of
the manuscript.
Funding: The EVA-Tyrol study is supported by the Excellence Initiative Competence Centers for
Excellent Technologies (COMET) of the Austrian Research Promotion Agency FFG: “Research Cen-
ter of Excellence in Vascular Ageing—Tyrol, VASCage” (K-Project No. 843536) funded by Federal
Ministry for Climate Action, Environment, Energy, Mobility, Innovation and Technology; the Federal
Ministry of Labor and Economy; and the federal states of Tyrol. The EVA4YOU study is supported
by VASCage—Research Centre on Clinical Stroke Research. VASCage is a COMET Centre within
the Competence Centers for Excellent Technologies (COMET) program and funded by the Federal
Ministry for Climate Action, Environment, Energy, Mobility, Innovation and Technology; the Federal
Ministry of Labor and Economy; and the federal states of Tyrol, Salzburg and Vienna. COMET is
managed by the Austrian Research Promotion Agency (Österreichische Forschungsförderungsge-
sellschaft). FFG Project number: 898252. The funders had no role in study design, data collection,
analysis, decision to publish, or preparation of the manuscript.
Institutional Review Board Statement: The studies were conducted according to the guidelines of
the Declaration of Helsinki and approved by the Ethics Committee of Medical University Innsbruck—
EVA4YOU (1053/2020, final approval 23 September 2020) and EVA-Tyrol (AN2015-0005 345/4.13,
final approval 10 March 2015).
Informed Consent Statement: Informed consent was obtained from all subjects involved in
the studies.
Data Availability Statement: The data that support the findings of the study are available on request
from the corresponding authors after establishing an appropriate data transfer agreement.
Nutrients 2023, 15, 5140 14 of 17

Acknowledgments: Additional members of the EVA-Tyrol-Group: Gregor Broessner, Tatjana Heisinger,

Carmen Reiter, Christina Burger, Julia Klingenschmid, Julia Marxer, Mandy Asare, Manuela Bock-Bartl,
Martina Kothmayer, Maximilian Bohl, Maximilian Pircher. Additional members of the EVA4YOU-
Group: Silvia Gelmi, Alex Laner, Denise Lazarotto, Hannah Oberhammer, Theresia Beiser, Christoph
Schraffl, Jonas Huber. Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria.
Department of Paediatrics II, Medical University Innsbruck, 6020 Innsbruck, Austria. VASCage Research
Centre on Vascular Ageing and Stroke, 6020 Innsbruck, Austria.
Conflicts of Interest: The authors declare no conflict of interest.

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