Commercial complementary food in Germany: a market survey

Background: As consumption of commercial complementary food (CCF) during infancy and toddlerhood is common, the aim of the present study was to describe the current (2020) German market of CCF products targeted at infants and toddlers with a special focus on ingredients, macronutrients, and the practice of nutrient forti�cation. Methods: Information on age declarations, ingredients, energy and nutrient contents, and nutrient forti�cation was obtained in a market survey by contacting the producers and searching manufacturers' websites. Each product was assigned to one of thirteen product categories (menus, milk-cereal-meal, fruit-cereal-meal, oil, vegetables, meat, �sh, fruits, cereals, snack foods, pouches, desserts, beverages). Descriptive statistics were used in order to give an overview of the available products. Results: We identi�ed 1057 CF products on the German market (infants’ CCF (< 12 months): n=829; toddlers’ CCF (> 12 months): n=228)). Highest protein content (% of energy content, %E) was found in meat products. In pouches, beverages, cereal fruit meals, and fruits, more than 50 % of energy came from total sugar . Highest median salt content was found in toddlers’ menus and desserts. Around one third of infants’ CCF products and one quarter of toddlers’ products were forti�ed with nutrients. Vitamin B1 (thiamin) was the most frequently forti�ed nutrient, followed by vitamin C, iron, calcium, and vitamin D. Apple was the type of fruit listed most often in products with fruits, whereas carrot was the most frequent vegetable among CCF with vegetables. Conclusion: In particular the high sugar content of most CCFs currently available on the German market may promote unhealthy dietary habits. Parents need to be educated about the optimal selection of products. < 3 products; forti�ed found


Background
The introduction of complementary foods should not begin before 4 months and should not be delayed beyond 6 month (1,2). While breast milk provides all the essential nutrients after birth, complementary foods are more variable in energy and nutrient content and have to be combined to meet nutrient requirements (3,1). Furthermore, infants' taste preferences continue to develop with long-lasting effects for later life (4)(5)(6).
Parents have to decide whether they self-prepare the infants' meals from fresh foods or whether they use commercial complementary food (CCF) products. Both approaches have some advantages and disadvantages. In particular, home-made complementary food has the potential to provide a greater variety of avors and textures, whereas food variety in CCF is reported to be lower (7).
In both commercial and home-made complementary food, the composition of ingredients is decisive for energy and nutrient contents. Some characteristics of CCF are required by law in the European Union. For example, maximum contents of sucrose or other sweetening foods were set, if these ingredients were added to a product. Furthermore, upper limits for sodium content were set (8). Nevertheless, market surveys repeatedly show that additions of salt and sugars in CCF are common in Europe and other countries (9)(10)(11)(12). Another distinction of home-made and CCF is the forti cation with nutrients, which offers the possibility of supplementing possible nutrients at risk, in particular alpha-linolenic acid (ALA), docosahexaenoic acid (DHA). iron, iodine, vitamin D (13).
Consumption of CCF during infancy and toddlerhood is common in Germany and Europe (9,14,15). In the German DONALD study, only 20 % of complementary food was home made during infancy and toddlerhood, but 60 % was CCF and the remaining 20 % a combination of both (14). Hence, parents need to be con dent that the CCF they feed their children meet the speci c needs of this age group, but data on nutritional quality and composition of CCF is limited. A recent cross-sectional study described the nutritional adequacy of commercial complementary cereals on the German market (9). In this crosssectional survey, a low high sugar content and low content of zinc, iron, iodine was demonstrated (9).
However, cereals only make up a small part of the market for CCFs. The last complete market survey by CCF in Germany was conducted 20 years ago. At that time, there were more than 600 products on the market that had a high energy but low fat content. More than two thirds of the products were forti ed, mostly with vitamin C (16). Hence, the aim of the present article was to describe the current market of CCF targetad at infants and toddlers in Germany with a special focus on ingredients, macronutrients, and the practice of nutrient forti cation.

Methods
The survey started with the identi cation of relevant retailers, manufacturers and brands in April 2020 through visits to supermarkets and discounters in Bonn and websites. Then, the producers were contacted to obtain declared product information (May to July 2020). In case of no response, the necessary information was researched via the manufacturers' websites (supplementary table 1).
Each product was assigned to one product category: Complete meals: Menus: offered in jars, declared as "baby menus" (for age group 5 to 7 months) and "junior menus" (for age group 8 to 12 months), composed of vegetables, starchy food (e.g., potatoes)and protein food (e.g., meat, sh), in part with added oil and/or fruit as ingredients, including soups and stews, Milk-cereal-meal: declared as "milk porridge", "Porridge", "Good Evening Porridge", "Good Night Porridge", composed of milk and cereals, in part combined with fruit, offered as ready-to-eat meal in jars or bottles (drink meals) or instant products for the preparation with water Fruit-cereal-meal: composed of fruit and cereals, often declared as "muesli", available in jars Meal components: Oil Vegetables: Pureed vegetables in jars, in part mixed with potatoes or cereals, and oil Meat: Pureed meat, in part with starchy ingredients and/or added oil, offered in jars Fish: Pureed sh, in part with potatoes, offered in jars Fruits: Pureed fruits, in part mixed with dairy (e.g. yoghurt), cereal, or vegetables, offered in jars Cereals: instant akes or popped cereals, in part mixed with dried fruit pieces, offered as instant products Snacks and beverages: Snack foods: biscuits, wa es, rusk, or bars Pouches: pureed fruit partly mixed with vegetables, cereals or dairy, offered in compressed plastic bags with a spout and a screw cap, from which the contents can be sucked out Desserts: declared as desserts or pudding, offered in jars Beverages: juices from fruit or vegetables, in part mixed with water or tea, teas (instant, tea bags or ready-to-drink) Complete meals (i.e. menus, milk-cereal-meals, and cereal-fruit-meals) correspond to the meals within the German complementary food guidelines (17,1). The term complete meals means that they are intended as a complete, nutritionally adequate meal, without the need to add other ingredients (except water in the case of instant milk-cereal meals). Meal components (i.e., cereals, fruits, vegetables, meat, sh, and oil) can be used for the preparation of these meals. Snacks (i.e., pouches, snack foods, and desserts) do not correspond to the recommendations.
Data entry of the surveyed products were performed using Microsoft Excel (version 2016). The product characteristics included brand and product name of the manufacturer, age declaration, declared ingredients, energy and nutrient contents, and nutrient forti cation. If sodium was declared instead of salt, the amount of salt was calculated. If nutrient contents were declared as "less than" (e.g., < 20 mg sodium), the threshold value was used instead (20 mg sodium). Products with added sweetening foods (i.e., sugar, syrup, honey, fruit concentrates, as well as fruit juice) according to the WHO-de nition of free sugar (18), salt (i.e., iodized salt, sea salt, table salt), and added fat/oil were identi ed according to the ingredient list.
Descriptive statistics were performed with SAS ® procedures (version 9.2; Cary, NC, USA) and included frequencies and percentages for categorical variables and median and quartiles for continuous variables.

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The majority of infant CCF was declared for younger ages ("after 4 months"/"from the age of 5 months"), only 13 % of infant CCF was declared as "from the 10 th to 12 th months" (Table 1).

Energy and Nutrient Contents
Energy content was highest in infants' or toddlers' snack foods. Highest protein content was found in cereals. Maximum fat content was found in toddlers' snack foods and cereals. Saturated fatty acids exceeded 1.5 g/100 g only in meat products, and in toddlers' snack foods and desserts. Snack foods and cereals, both for infants and toddlers, had the highest carbohydrate contents (> 60 g/100 g). Total sugar content was around 10 g/100 g in fruit-cereal-meals, fruits, and pouches, and nearly 30 g/100 g in toddlers' snack foods. Except toddlers' menus and desserts, salt content was < 0.9 g/100 g ( Table 2).
Expressed as % of energy, highest protein content was found in meat products, followed by menus for infants and toddlers and toddlers' desserts. Carbohydrate content was lowest in meat (20.6%). In all other product groups carbohydrates provided between around 50 % and 90 % of energy content. In meat products, cereals and toddlers' menus, contribution of sugar to energy content was less than 10 %. More than 50 %E sugar was found in pouches, beverages, cereal fruit meals, and fruits ( Figure 1).

Forti cation
Around one third of infants' CCF products and one quarter of toddlers' products were forti ed with nutrients. Highest forti cation prevalence among infants' CCF was found in cereals, milk-cereal-menus, snack foods and beverages. In toddlers' CCF, cereals was the category with the highest prevalence of forti cation, followed by snack foods and pouches. Vitamin B1 (thiamin) was the most frequently forti ed nutrient, followed by vitamin C, iron, calcium, and vitamin D (Table 3). Table 3 Nutrient forti cation 1 in commercial complementary foods (CCF), results of a 2020 market survey in   2 Percentage of forti ed products in this category CCF with cereals (i.e. milk cereal meals, fruit cereal meals and cereals) were the categories most often forti ed with vitamin B1, products with fruits (i.e. fruits, beverages, pouches) and milk-cereal-meals with vitamin C. Infant menus and milk-cereal-meals were the categories most often forti ed with iron. Milkcereal-meals were also most often forti ed with calcium and vitamin D, and the only category forti ed with iodine (Table 3).

Ingredients
Apple was the type of fruit listed most often in products with fruits, whereas carrot was the most frequent vegetable among CCF with vegetables. Poultry (e.g. chicken, turkey) was the most frequent meat. Only two species were used for sh products (salmon and pollack). Four of ve infants' and toddlers' menus and vegetables were prepared with added oil, predominately rapeseed oil (Table 4). In 78 products (27.6 %), a combination of rapeseed oil and other oils was used (data not shown).
Other sweeteners, e.g. glucose, fructose, high fructose corn syrup were not found in CCF.
Among cereal-based products, whole grains were listed as ingredients in 139 products (61.0 %) (data not shown).

Salt was added in n=62 infants' menus (34.4 % of all menus), always as iodized salt. Four infants'
pouches were prepared with an oat mixture with added sea salt (3.6 %). In toddlers' menus, 80% (n=32) of products were prepared with added iodized salt, two further products with sea salt (11.7 %). Two toddlers' snack foods were prepared with iodized salt and sea salt, respectively (each 2.4 %) (data not shown).
Flavors, herbs or spices were used in 190 products (18.0 % of all CCF). Vanilla (n=35, 18.4 % of avored products) was used in milk-cereal-meals (n=16), toddlers' CCF (n=10) and desserts (n=5). Seventeen products (8.9 %) contained cacao, predominantly milk-cereal-meals and snack foods. Six products were avored with cinnamon and ve beverages (teas) were avored with aroma. Herbs (e.g. parsley, basil, oregano, marjoram, thyme, lovage, dill) were listed as ingredients in 58 infants' or toddler' menus, curry, turmeric and/or ginger in seven products (data not shown). The most frequent ingredients (types of fruits, vegetable, meat, sh, and fat/oil) in commercial complementary foods for infants and toddlers, results of a 2020 market survey in Germany European countries (19) included between n=99 and n=768 baby foods per country.
Pouches, which made up the largest group in the snack category, were not listed in the 2000 market survey in Germany (16). Pouches are criticized for their ingredients and texture (20) and are suspected to promote caries (21). As in Australia (20), pouches were mainly declared to older children aged 6 months on up. However, during this age infants should be gradually accustomed to lumpy or solid foods (22,23).
Sugar content of fruit juices is similar to soft drinks. The American Academy of Pediatrics recommended to avoid any fruit juice during the rst year of life (24). Furthermorechildren should be accustomed to water as a drink from the very beginning, to shape healthy dietary habits from the early age Menus accounted for the largest share of complete meals. The majority of menus were producted with meat. As iron requirement during the complementary feeding period is high, meat or iron forti ed cereals are recommended (25, 2, 3, 17). It is worth to mention, that in Germany only one iron forti ed infant cereal was available. However, it should be noted that common whole grains, e.g. oat, millet, or wheat, have a high natural iron content, but bioavailability is lower than of iron from meat (25).
In Germany, in contrast to other countries (26, 27), sh has hardly been included in complementary feeding (28). Beside the observed association of sh consumption during weaning and the risk reduction of allergies (27,26), sea sh is a good source of iodine, and in case of fatty sh, of long-chain polyunsaturated fatty acids (29). However, 40 % of sh products in our survey were prepared with a lowfat species (pollack).
Iodine is a potential critical nutrient during weaning (30,3,16). Except sh, non-forti ed complementary food in general is low in iodine whether self-prepared or commercial (30). In our survey, less than 4 % of all products were forti ed with iodine.

Forti cation
The overall prevalence of forti cation has decreased from 70 % in 1998 (16) to around 30 % of products in the current survey. This could be due to a shift to more organic produced CCF, which is not supposed to be forti ed. Vitamin B1, calcium and vitamin D were the nutrients most commonly used for forti cation. The extent to which this is necessary is questionable, since the reference values for calcium and vitamin B1 can be achieved without forti cation (17). However, the EU law prescribes forti cation with vitamin B1 for infant cereals. As vitamin D is supposed to be generally supplemented in the rst year of life (31, 1), the need of vitamin D forti ed CCF is also questionable. In case of iron, young children are at special risk for iron de ciency and iron-rich complementary foods are recommended. However, high iron intakes may have adverse effects (25). Furthermore, to the best of our knowledge there are no studies that prove the bene t of additional supplementation of meat-containing CCF, which is rich in heme iron with high bioavailability (17). Iodine forti cation could be a strategy to improve iodine supply in infancy, however, risk assessments would be necessary to avoid excessive uptake.

Ingredients
International authorities are unanimous in recommending that complementary foods should not be prepared with added sugar (2,3,1,17). The use of classic sweeteners as sugar and honey was low this survey. However, when fruit juice was included in the added sugars de nition (19), the proportion of sweetened CCF clearly increased. Furthermore, the intense pureeing process liberates intrinsic sugar from fruits and vegetables. Hence, sugars from these foods can be considered as free sugars, too (19). That is why a large portion of the total sugar as declared on CCF in our survey would have to be considered free sugars. It is noteworthy that total sugar content for nearly all product categories was above 10 %E, the free sugar limit recommended by the WHO for over 2-year-olds (18).
Our survey con rms the low variety of ingredients and tastes in CCF (7,10). Particularly, bitter tasting types, as spinach, broccoli, and cauli ower, were used in few products. The innate dislike of bitter tasting substances in humans (32) can be overcome by repeated exposure (33). Therefore, the complementary feeding period is regarded as a 'window of opportunity' (34), when exposure to a wider range of avors increases acceptance and reduces reluctance towards disliked and novel tastes even in the long term (35). By the observed monotony of types of fruits and vegetables in CCF, the chance to shape preferences in the sense of a healthy diet is missed. However, it should not be concealed that the variety of vegetables offered has increased in Germany in recent years. A 2012 review of fruits and vegetables in complementary foods identi ed 16 different vegetables in menus and vegetable preparations (7). In the present market survey, there were 21 varieties, which is an increase of 31 % since 2012.
Bene ts of cereals during weaning are the impact on nutrient intake, in particular iron, the promotion of an 'adult like' microbiota, and the semi-solid texture and consistency (36). Due to the higher iron and ber intake, these bene ts can be easier achieved by whole grain products instead of re ned grains. In addition, the complementary feeding period is regarded as important period for the acceptance of whole grains later in life (36).
It has not yet been systematically studied what in uence the use of spices and avors has on children's long-term food preferences. Hence, to the best of our knowledge, there is no o cial recommendation on the use of spices or herbs during infancy.

Strengths and limitations
We present data on products offered on the German food market. However, the food market is changing constantly. Furthermore, we did not have current consumption data of CCF among infants and toddlers.
In our study, all available brands and product information in Germany were collected. A furhter limitation is the use of declared energy and nutrient contents. No laboratory analyses were available, which could have provided more valid assesments of energy and nutrient contents. However, it can be assumed that the market is regulated by demand and only products are offered that are also bought by families.

Conclusion
Both the categories of the products offered (e.g. snacks, caloric beverages) as well as the high sugar content of most products may promote unhealthy dietary habits during infancy and young childhood. As CCF intake is common (9,14), parents need to be educated about the optimal selection of products. This includes in particular the avoidance of products with added salt and/or sweetened foods, including juicesweetened products, snack foods, pouches and desserts (and not using fruit products as desserts).
Furthermore, parents should be encouraged to select a variety of vegetables that should not be mixed with fruit, as well as products with sh.
Furthermore, our market survey supports the claims of Hutchinson et al. (19), i.e. the ban of added sugars and sweet snacks, the limited use of pureed fruit in some food categories, and the limitation of total sugar content of 'savory' snacks. We would further support to ban the production of sugar sweetened beverages intended to infants, even if the sugar is natural in case of juices and mixtures of juice with tea or water.

Consent for publication
Not applicable

Availability of data
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
UA and SK conceived the project. JJD carried out the data collection and data entry. JJD and UA conducted the data analysis and wrote the manuscript. All authors made substantial contributions, critically read and revised the manuscript as well as approved the nal version