Lourdes Ribas

Food, youth and the Mediterranean diet in Spain. Development of KIDMED, Mediterranean Diet Quality Index in children and adolescents

OBJECTIVE To evaluate dietary habits in Spanish children and adolescents based on a Mediterranean Diet Quality Index tool, which considers certain principles sustaining and challenging traditional healthy Mediterranean dietary patterns. DESIGN Observational population-based cross-sectional study. A 16-item Mediterranean Diet Quality Index was included in data gathered for the EnKid study (in which two 24-hour recalls, a quantitative 169-item food-frequency questionnaire and a general questionnaire about socio-economic, demographic and lifestyle items were administered). SETTING Spain. SUBJECTS In total, 3850 children and youths aged 2-24 years residing in Spain. RESULTS Of the sample, 4.2% showed very low KIDMED index results, 49.4% had intermediate values and 46.4% had high index results. Important geographical differences were seen, with subjects from the Northeast showing the most favourable outcomes (52% with elevated scores vs. 37.5% of those from the North). Lower percentages of high diet quality were observed in low socio-economic groups, compared with middle and upper income cohorts (42.8%, 47.6% and 54.9%, respectively). Large cities had more positive results and only slight variations were seen for gender and age. CONCLUSIONS The KIDMED index, the first to evaluate the adequacy of Mediterranean dietary patterns in children and youth, confirms that this collective is undergoing important changes, which makes them a priority target for nutrition interventions. Results challenge certain commonly perceived notions tied to income level, population size and diet quality.

Food preferences of Spanish children and young people: the enKid study.

Objective: To describe the profile of food preferences, likes and dislikes of Spanish children and young people and analyse its connection with prevailing food patterns.Design: Cross-sectional population survey.Setting: Population study. Data were collected at participants’ home address.Subjects: Random sample of the Spanish population aged 2–24 y (n=3534; 1629 boys and 1905 girls).Interventions: Food preferences, food consumption and practices as well as nutrition-related information were assessed by means of a multiple choice questionnaire. A food preference score was computed considering food items ranked as first, second or third choice within each food group. Data collection was carried out during May 1998–April 2000.Results: Bananas and apples were the fruit items preferred by Spanish children and young people across all age and gender groups. Within the vegetable group tomato sauce and salads, particularly lettuce and tomato salad scored highest, followed by carrots in all age and gender groups. However, 47% (95% confidence interval 46–48%) of the sample reported dislike for vegetables and an additional 5.7% (95% confidence interval 4.9–6.5%) a dislike for fruit. The proportion of individuals with low consumption of vegetables or fruit was significantly higher among those reporting a dislike either for vegetables (χ 2=127.69; P<0.001); fruit (χ 2=24.62; P<0.001) or for both groups (χ 2=81.53; P<0.001).Conclusion: There is a significant relationship between the likes/dislikes for fruits and vegetables and usual consumption of this food group among children and young people. Strategies addressed to improve acceptance for this food group should be considered when designing interventions aimed at promoting adequate consumption of fruits and vegetables among children and young people.Sponsorship: Kelloggs, Spain.

Determinants of Nutrient Intake among Children and Adolescents: Results from the enKid Study

Background: Although adequacy of nutrient intake has been studied considerably in children and adolescents across Europe, the factors associated with nutritional risk have rarely been addressed. This study was developed in order to explore the nutritional intakes of Spanish children and the factors influencing the risk of nutritional inadequacy. Objectives: To evaluate socio-economic and lifestyle variables associated with nutritional adequacy in Spanish children and adolescents. Methods: A cross-sectional study utilising face-to-face interviews. A random sample of 3,534 individuals aged 2–24 years were interviewed by a team of 43 dieticians in the subjects’ homes. Interviews included two 24-hour recalls (a second 24-hour recall in 25% of the sample) and other questions, including lifestyle. Weight and height were measured in all subjects. Under-reporters (18%) were excluded from the present analysis. An unconditional logistic regression analysis was used to identify variables associated with greater nutritional risk. Results: The participation rate was 68%. Twenty percent of males and 50% of females were classified as being at high nutritional risk. Variables associated with increased nutritional risk were: age between 14 and 24 years, being female, low social class, low educational level of the mother, having more than one sibling, smoking, watching TV during meals, sedentary habits at leisure time, infrequent meals and a poor quality breakfast. One dietary factor closely associated with nutritional risk was a failure to consume ready-to-eat cereals. Conclusions: Nutritional risk during infancy and adolescence is associated with socio-economic and educational variables of the family, and some lifestyle factors including physical activity and the quality of the breakfast meal.

Dietary patterns in six European populations: results from EURALIM, a collaborative European data harmonization and information campaign

Objective: To determine and describe the extent to which European dietary data collected in disparate surveys can be meaningfully compared.Design: Seven independent population-based surveys from six European countries were initially included. Differences in study designs and methodological approaches were examined. Risk factor data for 31, 289 adults aged 40–59 y were harmonized and pooled in a common, centralized database.Results: Direct comparisons of dietary measures across studies were not deemed appropriate due to methodological heterogeneity. Nonetheless, comparisons of intra-population contrasts by gender across sites were considered valid. Women consumed fruit and vegetables more often than men. Age-standardized gender differences in the prevalence of low fruit and vegetable consumption ranged from 7 to 18% and 5 to 15%, respectively. Data on energy intake showed good agreement across study populations. The proportion of total energy from macronutrients was similar for women and men. Gender differences for relative intakes of saturated fatty acids (percentage energy) were small and only in France were they significant. Dietary fibre density was significantly higher in women than in men. Overall, the participating Southern European populations from Italy and Spain exhibited more healthful food composition patterns.Conclusions: Contrasts in dietary patterns by gender across populations may provide the basis for health promotion campaigns. The most favourable patterns observed may serve as attainable goals for other populations. An international risk factor surveillance programme based upon locally run, good quality studies has the potential to provide the needed data.Sponsorship: European Community (DG V), project 96CVVF3-446-0; Swiss Federal Office for Education and Science, OFES 96.0089.European Journal of Clinical Nutrition (2000) 54, 253–262

Nutrient adequacy and Mediterranean Diet in Spanish school children and adolescents

Objective: To evaluate dietary habits and nutritional status of Spanish school children and adolescents, and their relationship with the Mediterranean Diet.Design: Cross-sectional study by face-to-face interview.Setting: Free living children and adolescents of all Spanish regions.Subjects: A random sample of 3166 people aged 6–24 y.Methods: Home interviews conducted by a team of 43 dietitians included 24-h recalls (a second 24-h recall in 25% of the sample) and a short frequency questionnaire to determine the quality of the Mediterranean Diet (KIDMED).Results: The participation rate was 68%. In general, the adequacy of the Mediterranean Diet rose with increased mean intakes of the majority of vitamins and minerals and decreased percentages of inadequate intakes (<2/3 of the RNI) for calcium, magnesium, vitamin B6 and C in both sexes, and iron and vitamin A only in females.Conclusions: This study demonstrates that the Mediterranean Diet contributes to nutritional quality, and also shows concomitant risks as the Mediterranean Diet deteriorates.Sponsorship: Kelloggs, Foundation for the Advancement of the Mediterranean Diet.

Comparative analysis of nutrition data from national, household, and individual levels: results from a WHO-CINDI collaborative project in Canada, Finland, Poland, and Spain

Study objective: This project determined to what extent data on diet and nutrition, which were collected in a non-uniform manner, could be harmonised and pooled for international and national comparison. Design: Direct comparisons of dietary data between studies were made using food balance sheets (FBS), household budget surveys (HBS), and individual dietary data (IDS); comparisons were also made within countries. Differences in study design and methodological approaches were taken into consideration. Data from research projects from the following four World Health Organisation (WHO) Countrywide Integrated Noncommunicable Disease Intervention (CINDI) countries were included—Canada, Finland, Poland, and Spain. Main results: FBS overestimated food consumption and nutrient intake compared to IDS. Results between HBS and IDS were quite similar, except for fish, meat, pulses and vegetables, which were underestimated by HBS, and sugar and honey and cereals, which were overestimated. Percentages of energy from fat, carbohydrates and proteins were higher when estimated from FBS, HBS, and IDS respectively. Conclusions: Results suggest that estimations from these three sources of dietary data are difficult to compare because they are measuring different levels of dietary information. The understanding of their relations may be important in formulating and evaluating a nutrition policy.

Obesity and other health determinants across Europe: the EURALIM project.

STUDY OBJECTIVE EURALIM (EURope ALIMentation), a European collaborative study, aimed to determine and describe the extent to which European data on risk factor distributions from different populations could be pooled and harmonised in a common database for international comparisons. SETTING Seven independent population-based surveys from six European countries (France, Italy, Northern Ireland/United Kingdom, Spain, Switzerland, the Netherlands). METHODS Data for 18 381 women and 12 908 men aged 40–59 were pooled in a common database. Central statistical analyses on major cardiovascular risk factors were conducted with careful consideration of methodological issues, including differences in study designs, data assessment tools, and analytic techniques used. MAIN RESULTS Because of the detected variability among methods used, direct comparisons of risk factor distributions and prevalences between studies were problematic. None the less, comparisons of within population contrasts by sex, age group, and other health determinants were considered to be meaningful and apt, as illustrated here for obesity. Results were targeted and disseminated to both the general public and public health professionals and framed in the context of a European information campaign. CONCLUSIONS International and national comparisons between existing locally run studies are feasible and useful, but harmonisation methods need improvement. Development of an international risk factor surveillance programme based on decentralised data collection is warranted. In the meantime, risk factor contrasts across populations can be used as a basis for targeting needed public health intervention programmes.

How could changes in diet explain changes in coronary heart disease mortality in Spain? The Spanish paradox

We review and compare trends in coronary heart disease (CHD) and stroke mortality in Spain from 1966 to 1990 and changes in food consumption at national and regional levels. Since 1976, a decrease in cardiovascular disease (CVD) mortality in males and females has been observed, and standardized CHD mortality rates have fallen. Stroke mortality decreased during the same period. Trends in food consumption show increases in intakes of meat, dairy products, fish, and fruit, but decreases in consumption of olive oil, sugar, and all foods rich in carbohydrates. Although fat and saturated fat intakes increased, these changes were not accompanied by an increase in CHD mortality rates. This paradoxical situation can be explained by expanded access to clinical care, increased consumption of fruit and fish, improved control of hypertension, and a reduction in cigarette smoking. Diet appears to have an important role in this paradox, but it may not be as critical as other factors. Nevertheless, we suggest dietary guidelines for prevention of CHD in Spain.

Influence of sociodemographic factors in the prevalence of obesity in Spain. The SEEDO'97 Study.

Objective: To analyse the influence of social and cultural factors in the prevalence of obesity in the Spanish adult population aged 25–60 y based on available population data.Design: Pooled analysis of four cross-sectional nutrition surveys.Subjects: A total of 5388 free-living subjects aged 25–60 y, respondents of the Nutritional Surveys carried out in four Spanish regions (Catalunya, Basque Country, Madrid and Valencia) from 1990 to 1994. The samples were pooled together and weighted to build a national random sample.Measurements: Weight and height were measured on each individual by trained observers. Age, gender, educational level, occupation, habitat (rural/urban) and region were considered. Obesity was defined as body mass index ≥30 kg/m2. The protocol used in each survey was in accordance with the recommendations of the Spanish Society for the Study of Obesity (SEEDO). Logisitic regression models were designed to analyse the influence of sociodemographic factors in the prevalence of obesity in men and women.Results: The prevalence of obesity was higher in older age groups in men and women, odds ratio (OR) for every 10 y OR=1.40 (95% CI 1.39–1.41) for men and OR=1.86 (95% CI 1.85–1.87) for women. Logisitic regression analysis adjusted for age showed higher obesity rates among low educated people, OR=1.80 (95% CI 1.78–1.81) in men and OR=2.36 (95% CI 2.29–2.42) in women (P<0.001). Among men the odds ratio for the prevalence of obesity in rural areas was OR=1.87 (95% CI 1.86–1.89), compared to cities. The geographical distribution showed higher obesity rates in the southeast.Conclusion: This study supports that obesity is a multifactorial problem. Older women with low educational level and low income seem to be the most susceptible group to weight gain. Therefore, Public Health Programs should consider this type of environmental factor when planning strategies aimed at preventing or reducing the problem of obesity in western societies.European Journal of Clinical Nutrition (2001) 55, 430–435

Breakfast consumption in Spanish children and young people

BACKGROUND AND OBJECTIVES Breakfast consumption is important for nutritional balance in all population groups. The objective of this paper is to describe breakfast consumption patterns in Spanish children and young people. DESIGN Random population cross-sectional nutritional survey. METHODS A random sample of 3534 people aged 2 to 24 years were interviewed by a team of 43 dietitians. The protocol included 24-hour recalls (a second 24-hour recall in 30% of the sample), a food-frequency questionnaire and other questions including lifestyles, knowledge and food preferences. RESULTS Participation rate in the survey was 68%. Of the boys, 91.2% and 92.2% of the girls in the sample usually had breakfast. Males aged 18 years and above and 14-17-year-old girls showed the lowest consumption rates. Some 4.1% of the sample did not have any food at all before lunch. Main sources of energy with breakfast were milk and dairy products (34%) and buns, cookies, croissants, etc. (24.6%). Some 44.7% of the sample was classified in the poor-quality breakfast group. Subjects from a low socio-economic background and low educated parents had lower Quality Breakfast Score. CONCLUSIONS The proportion of children having breakfast before attending school has increased in Spain in recent decades. However, intake of breakfast is not adequate in a large proportion of this population and a number of children and young people still do not eat anything before lunch. School-based nutrition education involving families, teachers and health professionals, supported by community actions, can contribute to improve this situation.