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INTRODUCTION
Exposure to high food diversity in the early years modulates food preferences and improves dietary variety. Children identified with dietary neophobia have a poorly varied diet because they present an important rejection to many foods 1,2. This situation is more common at younger ages and is maintained over the years 3. Some variables associated with the consumption of vegetables (most rejected foods) in young children are: early feeding practices, parental education, and family income 4, low vegetable consumption by parents 5) and home availability 6. Likewise, breastfeeding and the early introduction of fruits and vegetables are related to their consumption 7.
Food neophobia negatively correlates with fruit acceptance and, to a greater extent, with vegetables 8. Vegetables are the least accepted food group by children, and this is probably the reason for their low consumption. It has been identified that the number and type of preparations that the child consumes depend on the type of vegetable, and the best accepted dishes are those that combine them with other foods. Likewise, consumption is greater as the variety of methods of culinary preparation increases 9. Equally, the acceptance of fish by children depends to a great extent on the method of culinary preparation 10. Recently, it has been reported that food manipulation by children through tactile contact may be related to the acceptance of a greater variety of fruits and vegetables, although not with an increase in their consumption 11. In addition, it has been proposed that the participation of children in the kitchen can reduce food neophobia and promote the consumption of foods such as vegetables 12.
Due to the above, it is important to know the impact of food neophobia on the hedonic acceptance of healthy foods, the variety of diet and eating habits in school children, as well as the lack of information about its effects on different aspects associated with the consumption of food, such as participation in the elaboration itself. The objective of the present work was to evaluate the impact of dietary neophobia on adherence to the Mediterranean diet and acceptance of healthy preparations made by students in gastronomic workshops.
METHODS
PARTICIPANTS
A cross-sectional descriptive study was carried out in schoolchildren from Murcia (Spain) aged 8-18 years. The study was carried out in the framework of sensorial gastronomy workshops, where two recipes were cooked and tasted; the main ingredients of these recipes were healthy components of the Mediterranean diet (recipe 1 = with vegetables and blue fish; recipe 2 = with fruits). The City Council of the city of Murcia carries out a program to promote the Mediterranean diet for schoolchildren that takes place in the "Raimundo González" gastronomic classroom located in a local market.
The study comprised eleven schools that voluntarily requested to participate in the project between 2013 and 2015. The total sample was stratified by gender and school level: 8-11 years (Primary level) and 12-18 years (Secondary level). All schoolchildren surveyed participated voluntarily with a written authorization from parents or guardians and with the consent of each school's management.
INSTRUMENTS AND DATA COLLECTION
The recipes were designed by the manager of the community nutrition service and adapted by a professional chef. The questionnaires were sent to the school prior to the workshop in the gastronomic classroom and were self-answered by each participant.
Each workshop consisted in a visit to the gastronomic classroom located in a local market, where the students chose the ingredients. It should be mentioned that the cost of food was covered by tenants of the local market, due to their commitment to the city council. Recipe 1 was a "healthy" pizza with various vegetables and fresh blue fish (anchovies). Recipe 2 consisted of seasonal fruits presented as a dessert and in a colorful way for students. Fruit and vegetables were chosen by children according to availability and seasonality. During the workshop, while the students were preparing and cooking the food, a nutritionist described how these foods are part of the Mediterranean pyramid and how to introduce them into your usual diet. All children participated voluntarily in the tasks related to the purchase, cutting, mixing and cooking of ingredients. Finally, after the preparation, all the children performed the tasting and hedonic evaluation of the prepared foods.
FOOD NEOPHOBIA
Participants responded to a survey assessing the presence of food neophobia 13, which is recognized and consolidated in the scientific literature as a highly reliable instrument for assessing individuals' attitudes towards novel foods 14. The survey consisted of ten questions, rated with a Likert scale of seven points (range 0-70). The presence of neophobia was defined as > 1 standard deviation of the mean, as reported in the literature 13. Before carrying out the statistical analysis, some questions of the scale were inverted in order to be able to obtain valuations in the same sense. According to another reference population, this questionnaire has shown sufficient internal validity for its application in Spanish children 15.
MEDITERRANEAN DIET
The participants answered a questionnaire on adherence to the Mediterranean diet (KIDMED) consisting of 16 items (range 0-12) and validated for the Spanish population in the ENKID study 16. In this survey, 12 aspects of the Mediterranean diet were positively rated, as the consumption of fruit and vegetables, fish, olive oil, cereal and dairy consumption at breakfast, etc., with four negative points (remaining): the consumption of fast food, sweets and candies, pastries and the omission of breakfast. Three points or less was considered as a low adhesion; 4-7 points, medium adhesion; and ≥ 8 points, good adhesion. For comparative purposes, diet quality was defined as good adherence to those with scores ≥ 8 and improved adherence with seven points or less 16.
HEDONIC EVALUATION
The acceptance of the preparations elaborated with healthy foods typical of the Mediterranean diet was carried out with the support of a hedonic scale of seven points that consisted of images of different facial expressions that represented the following: 1 = super bad, 2 = very bad, 3 = bad, 4 = not good, not bad, 5 = good, 6 = very good, and 7 = super good 15, which was previously used by our working group in school cafeteria users 17. For comparative purposes, scores of 5 to 7 were scored as good acceptance and bad ratings of 1 to 4.
STATISTICAL ANALYSIS
The normal distribution of quantitative variables was verified by the Kolmogorov-Smirnov test and internal consistency analysis of the neophobia scale (Cronbach's alpha) was performed. The associations between food neophobia, adherence to the Mediterranean diet and hedonic food assessment were determined using the non-parametric Pearson χ2 test. Since the data from the hedonic appreciation were not normal, Mann-Whitney U-analysis was used to establish differences between the groups. A stepwise multivariate logistic regression analysis was also performed to establish the independent predictors of acceptance of each preparation, previously selecting the variables with a value of p ≤ 0.2 in the univariate analysis. All analyses were performed with the statistical package SPSS version 23.0, considering the probability of 95% confidence.
RESULTS
There were 1,491 students: 478 (32%) in 2013, 592 (40%) in 2014 and 421 (28%) in 2015. The participation of public schools was 84% and of private centers, 16%. The participants were divided into two groups: 1,057 primary schoolchildren between eight and eleven years old (71.6%) and 424 secondary schoolchildren between 12 and 18 years old (28.4%). Of the total number of participants, 49.5% were girls and 50.5% were boys; 4.7% were immigrants and, of all of them, only 22% used the school cafeteria on a regular basis.
FOOD NEOPHOBIA
The mean score of the food neophobia scale was 33.5 ± 11.8 (33.1 ± 11.8 for primary and 32.93 ± 11.8 for secondary), with no significant difference between the groups. No difference was found as well between genders (34.0 ± 12.3 in females and 32.1 ± 11.3 in males). The results indicated that 13.5% of the participants presented food neophobia. The scale had an internal consistency (Cronbach's alpha) of 0.76, indicating that neophobia was reliably quantified 15. An analysis was made of age and the presence of neophobia, noting that at the primary level, the presence of neophobia did not seem to influence dietary habits, although there was a trend towards lower consumption of fruits, vegetables, fish and greater omission of breakfast. However, the secondary level, with food neophobia, did present statistical differences with a lower consumption of vegetables and breakfast cereals or derivatives, as well as greater consumption of candy and sweets (p < 0.05). There was also a trend towards lower fish consumption, although this difference was not significant (Table I). In addition, an inverse linear relationship was found between the degree of neophobia and the quality of the diet (ρ [rho] = -0.31; p = 0.001).
MEDITERRANEAN DIET
The mean score on the KIDMED scale was significantly lower in Secondary school students than in Primary school (6.9 ± 2.4 vs 8.4 ± 2.3; p < 0.01). It was also identified that the good adherence to the Mediterranean diet was lower in the Secondary group than in the Primary group (44.2% vs 68%, respectively, p < 0.01). The poor adherence category was 7.3% in the Secondary group and 4% in the Primary group, with no statistical differences.
An analysis by age and gender was carried out (Table II), showing that in the Primary level, boys consumed more dairy (milk, yogurt) and industrial bakery than girls (p < 0.05). On the other hand, in Secondary school, boys were observed to consume less vegetables once a day (p < 0.05) and for the second occasion in the day (p < 0.01). On the other hand, girls consumed fewer pastas or rice and nuts (p < 0.5), and consumed less cereals and derivatives (p < 0.01) than boys. In addition, girls skipped more breakfast and consumed more candy and sweets than boys (p < 0.05). Although no significant difference was observed, a lower consumption of fish at the Secondary level was found.
SENSORY EVALUATION
In all ages, fruit preparations (recipe 2) were better valued than those containing vegetables and fish (recipe 1) (6.1 ± vs 5.4 ±, p < 0.01) (Table III). In the Primary group, the students evaluated positively both preparations, with no statistically significant differences between them. The presence of neophobic in Primary school did not affect acceptance since both recipes had high values. However, although this difference was not statistically significant, the preparation with vegetables and fish had an average hedonic acceptance of 5.2 ± 1.9 in neophobic compared to 5.5 ± 1.7 in non-neophobic (p > 0.05). In the case of the Secondary group, the neophobics evaluated the recipe with vegetables and fish significantly (3.80 ± 1.6 vs 5.1 ± 1.2; p < 0.01), although they positively evaluated the recipe with fruits.
Table III. Impact of food neophobia (FN) on the hedonic assessment of prepared foods by educational level
Mann-Whitney U-analysis was used to establish differences between the groups (with or without FN).
Additionally, the relationship between the adherence to the Mediterranean diet and the hedonic valuations given to the elaborations prepared in the gastronomic classroom was explored. It was found that those with a good adherence gave better hedonic scores, in contrast to intermediate or lower adhesions in both age groups, especially of the preparation with vegetables and fish (Table IV).
Table IV. Impact of adherence to the Mediterranean diet (MD) on the hedonic assessment of prepared foods by educational level
Mann-Whitney U-analysis was used to establish differences between the groups (low/medium and high adherence to Mediterranean diet).
According to multivariate stepwise logistic regression analysis (Table V), it was found that in the Primary group, independent predictors of acceptance of the recipe with vegetables and fish were consumption of fresh or cooked vegetables more than once a day (OR = 1.5, 95% CI 1.1-2.1), fish consumption at least two or three times per week (OR = 1.5, 95% CI 1.1-2.1) and vegetable consumption once a week (OR = 1.7, CI 95% 1.2-2.5). In the fruit recipe, they consumed a second fruit or fruit juice every day (OR = 2.0, 95% CI 1.2-3.4), fresh vegetables or cooked once a day (OR = 2.1, 95% CI 1.2-3.6), fish at least two or three times per week (OR = 1.8, 95% CI 1.0-3.0) and legumes once a week (OR = 2.0, 95% CI 1.6-3.4). On the other hand, in the Secondary group, the only independent predictor for the recipe with vegetables and fish was to be classified as neophobic (OR = 0.2, 95% CI 0.1-0.5) and for the recipe with fruits, consumption of a fruit or fruit juice every day (OR = 7.0, 95% CI 2.2-22.1).
DISCUSSION
The present study shows that dietary neophobia affects dietary variety by adversely affecting adherence to the Mediterranean diet, and both conditions impact on the hedonic perception of healthy foods.
In our study, the prevalence of food neophobia in children and young people aged 8-11 years reached 13.5% of the participants, with an average score of 33.5 ± 11.8, in line with research in Spanish children from the same geographical area showing measurements of 37.9 ± 13.1 and 16.1% prevalence 15, and in German teenagers with a median of 31 ± 21 18. However, in a study in northern Spain 12 smaller averages are reported, of approximately 21 points in nine year-old children, probably because participation in our program does not present a participation bias, since the intervention is performed in complete classrooms, regardless of the parents' concern or motivation for a healthy diet of their children.
No differences were found in the degree of neophobia according to gender and age, although large studies in Finland and the United States between 2001 and 2010 describe greater neophobia in the upper strata of age and hold controversy over gender effects 19. Our study does not show a decrease in neophobia with age, probably due to the fact that the youngest participants were eight years old and would have exceeded the age at which the peak of neophobia occurs, maintaining stability between 8-18 years, consistent with that described in Spanish children 20. The discrepancies described in the literature on the relationship between gender and food neophobia suggest that more research is needed. Currently, one of the biggest problems in child nutrition is the low consumption of food considered as an important part of the Mediterranean diet such as fruits, vegetables and fish. It is well known that Spanish children and young adults have a very variable adherence to the pattern of Mediterranean diet, depending on the age and area of the country 1. The KIDMED test is widely used to assess adherence to the Mediterranean diet pattern in children and young adults, and is effective in evaluating the quality and variety of the diet at these ages. In a recent systematic review, there is a clear tendency to abandon this pattern, with only a mean adequate adherence of 10% 1. The average prevalence of adequate adherence to this model in our participants reaches 68% and 44.2% in younger students and 12 years or more respectively, placing us in the upper stratum of prevalence of the reviewed studies. Specifically, a study in adolescents in a geographical area near Murcia found a 30.9% adequate adherence to the Mediterranean diet 21. In the present work, it is described that the adherence to the Mediterranean diet has an inverse relation with age, since the students of the Secondary group have lower scores than those of the Primary level, as reported in a group of ten to 16 22 and in similar populations 15,21. The diet of the older students presents worse profile than that of the younger ones in 14 of the 16 items that compose the test. Boys consume less vegetables, skip breakfast, and consume more pasta and rice and nuts than girls.
According to our results, the presence of neophobia is negatively correlated with adherence to the Mediterranean diet, so that neophobia decreases the quality of the diet, in line with the results of another study in Spanish children and youngsters 20. In the Secondary group, its effect on the consumption of fruits, vegetables, fish, sweets and candies was identified, as in our study. In addition, our results also showed an effect of cereal consumption at breakfast, which indicates that the diet of older students may be inadequate from the beginning of the day, in congruence with findings in the Spanish population, where only 18% of young people make an adequate breakfast 22. At the Primary level, our results show a tendency to decrease the consumption of fruits, vegetables, fish and greater omission of breakfast, but without significant differences, unlike the study by Maiz E et al. 20.
The hedonic evaluation of the foods prepared by the students in the gastronomic workshops indicated an effect of the age, since those of the Primary level group positively evaluated both preparations; however, those of the Secondary level group negatively evaluated the preparation, which included vegetables and blue fish, although the valuation of the fruits was positive. Negative assessment of vegetables may be associated with poor participation of adolescents in the preparation of family meals and low self-efficacy for the preparation of these healthy foods, a relationship that has been previously reported 23. In addition, regression analysis indicated that food neophobia was a negative predictor of the hedonic assessment of the recipe with vegetables and fish in the older group.
Little has been explored the influence of the presence of neophobia in the acceptance of foods prepared by the students themselves in an environment outside the home, but according to a recent experimental research, when children participate in the elaboration of healthy foods with fruits and vegetables, they show a higher preference for these processed foods themselves, increase their willingness to try new foods and choose foods that contain vegetables 12. It has also been pointed out that children's participation in household food preparation may favor increased vegetable intake 24 and a better quality of diet for young adults identified as a valuable educational tool in these age groups 25. Likewise, it has been recommended that simple food preparation activities can lead to improved eating habits 26.
Another important finding was that those who had a better adherence to the Mediterranean diet gave higher hedonic assessments, especially to the preparation with vegetables and blue fish in both age groups, so it is clear that familiarity (intake in his habitual diet) with these foods, increased their acceptance 7.
Most recent studies analyze hedonic acceptance by subjecting different recipes to visual or tasting tests primarily in school canteens. There are few studies that have analyzed complex interactions between neophobia, diet quality and hedonic acceptance of key foods in the Mediterranean diet in a participatory context of gastronomic and sensorial workshops developed in the framework of seasonal sales and closeness.
In spite of this, one of the major strengths of the study is the participation mediated by the educational centers, which causes all the students of the courses selected by the center carry out the gastronomic workshop and all the questionnaires of the program, thus saving possible participation biases.
Given the efficacy of the dietary pattern of the Mediterranean diet in its well-known health benefits, it is necessary to promote its consumption not only in non-Mediterranean countries, but also in Mediterranean countries, where adherence has been declining in recent decades. Special attention to children and young people with a clear tendency to rapid abandonment should be paid.
The results of this study demonstrate implications for public health policies that should foster familiarity with a wide variety of foods from the earliest ages in both, families and school canteens. In addition, the introduction of practical workshops on gastronomy and sensory education as part of school programs can contribute to the creation of positive experiences with new flavors to encourage children to try new foods and therefore, increase the variety in their diets. In addition to the implications for health, the influence of these factors on the current trend of control and reduction of food waste in the domestic and community domains should be taken into account.
Among the limitations of the study are the lack of collection of demographic variables related to increased exposure to a variety of foods, such as the level of income and family income and the urban environment, and showing positive effects on neophobia. In addition, as a cross-sectional study, causal relationships cannot be established.
The results of this study indicated that food neophobia affects the adherence to the Mediterranean diet and the acceptance of healthy foods elaborated in gastronomic workshops by Spanish schoolchildren.
