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INTRODUCTION
The traditional food of Andalusia is a specific expression of the Mediterranean diet and includes stews with vegetables, pulses and/or meats or fish, with variations that reflect local differences in climate and soil. The use of olive oil was inherited from the Romans; seasonings, herbs, and species, from the Arabs; and desserts, from the Jews, alongside a tradition among shepherds of simple stews cooked in the open 1.
The health benefits of the Mediterranean diet have been attributed to its low saturated fatty acid contents, high complex carbohydrates and dietary fiber contents and antioxidant properties. The diet is rich in vitamins and minerals derived from vegetables and fruits, wholemeal cereals, virgin olive oil, fish and wine, minimizing the risk of a deficient micronutrient intake 2,3. Thus, consumption of the vitamin B group (B1, B2, niacin, B6, folate, and B12) and antioxidant vitamins E and C was found to be more than adequate in the Mediterranean basin 4. However, epidemiological studies have signaled a rapid change in dietary patterns in Mediterranean countries towards a higher consumption of animal products and saturated fat to the detriment of plant-based foodstuffs 5. This trend increases the risk of the deficient intake of some vitamins (e.g., folate and vitamins A, E and D) and minerals, especially in certain population groups 6,7,8.
The dietary intake of children should be monitored because of its influence on their health in later life 9. It is now widely accepted that childhood nutrition is linked to diseases such as obesity 10,11 and to a higher risk of cardiovascular disease when adults 12,13. Analysis of dietary intake during childhood may therefore be useful to identify possible risk factors for disease in adulthood 12,18.
Several indices have been developed for assessing the diet quality of previously defined population groups. Since Kant et al. 19 published the dietary diversity score, based on the daily consumption of foods classified in five groups, several indices and modifications have been proposed. The Healthy Eating Index (HEI) 20 rated the diet of participants aged ≥ 2 years in the Continuing Survey of Food Intakes by Individuals (CSFII) 21. An adaptation of the HEI for children led to the Youth Healthy Eating Index (YHEI) 22. Kim et al. 23 developed the Diet Quality Index-International (DQI-I), based on food frequency questionnaires (FFQs) and the quantitative assessment of reference nutrients, and it has been modified to evaluate adherence to the Mediterranean diet 7,24.
The objectives of this study were to compare the nutritional status of Andalusian children and adolescents in a sample divided between sportspeople and non-sportspeople and to examine the relationship between their diet quality and socio-demographic or lifestyle factors.
SUBJECTS AND METHODS
SUBJECTS
The study population included 288 young people (168 males and 120 females) aged 6-17 years living in the Granada province, in Southern Spain; 20.6% were < 10 years old and 79.6% were ≥ 10 years old. They were recruited from among young federated skiers at the High-Performance Centre (CAR) of Sierra Nevada (n = 88, 53 males and 35 females) and from among students at two schools in the city of Granada (n = 200, 88 males and 112 females). Informed written consent to participation was obtained from the parents/guardians. The study was approved by the Ethics Committee of the University of Granada. This sample of children and adolescents was previously investigated by our group 7,25,26).
ANTHROPOMETRIC MEASUREMENTS
Height was measured to the nearest 1 mm using a mobile anthropometer (Kawe, France), with the head in Frankfurt plane. Body weight was determined to the nearest 100 g using a Tefal 9210 digital scale (Tefal(r), Rumilly, France). Subjects were weighed in bare feet and underwear. All anthropometric measurements were performed by a single observer to avoid between-observer variations. Body mass index (BMI) was calculated as kg/m2.
QUESTIONNAIRES
The study was based on the 24-h recall and food frequency questionnaires (FFQ) previously utilized in this population to calculate their DQI 7. This FFQ contains 92 food items classified by food group, gathering data on the consumption or not of an item, the number of times it was consumed per week, and the amount consumed each time (in household measures) 7,23,24. An additional questionnaire was administered on lifestyle characteristics and daily activities, which included items on the educational level of the parents and the setting of lunch. Daily activity data were derived from reports by participants on activities performed during the 24-h period before the interview. Lifestyle findings were correlated with diet quality estimations, and 24-h activity recall data were used to estimate MET values 27. Three 24-h dietary recalls were performed between February and May. These data were processed using the DIAL v.2 diet program 28. Questionnaires were administered at the center/school by well-trained dieticians between Tuesday and Friday. Exclusion of questionnaires as unreliable was based on the criteria of Goldberg et al. 29, taking account of energy intake (EI) results, based on the three 24-h dietary recalls, and the daily total energy expenditure (TEE), estimated from the 24-h activity recall data.
Outcome variables were the daily EI; the intake of carbohydrates, lipids, proteins, vitamins and minerals; and the MET, i.e., the ratio of energy expended (kcal/kg-1/h-1) in a specific activity to the basal metabolic rate 27.
The nutritional adequacy of the diet was assessed by comparison with the recommended daily intake (RDI) 30 for Spaniards 31 of 14 items (protein, energy, Fe, Ca, Mg, Zn, Se, I, vitamins B1 and B2, niacin and vitamins A, C and E). A score of 1 was assigned for an intake < 2/3 of the RDI 2,7 and a score of 0, for an intake below this level, giving a score range for dietary adequacy of 0 (worst) to 14 (best).
Energy intake values did not differences in food intake and nutritional habits between Spanish adolescents who engage in ski activity and those who do not differ between ski and non-ski groups, either between SP and N-SP females or between SP and N-SP males. For all study groups, the energy intake was highly significantly below Spanish recommendations for these age groups 32.
SOCIO-DEMOGRAPHIC, LIFESTYLE AND DIETARY FACTORS
Analyses of socio-demographic, lifestyle and dietary factors potentially associated with the food intake of this population were conducted, including: participants sex and age; parental education level (low = no/only primary, medium = secondary, high = university); their physical activity level, classified as sedentary or active 33 according to MET values 27; and their BMI, classifying participants as underweight, normal weight or overweight/obese according to cut-off points established for each sex at different ages 34.
STATISTICAL ANALYSIS
SPSS version 20 (IBM SPSS, Chicago, IL, USA) was used for the statistical analyses. The Chi-square test was used to compare characteristics of participants between age groups (6-9 years vs 10-17 years) and the Student's t-test was applied to compare their intake of energy and nutrients. Multivariate logistic regression analysis was performed with diet quality score (high vs low) as dependent variable, entering socio-demographic, lifestyle and dietary results as independent variables and calculating crude and adjusted odds ratios (ORs) with 95% confidence intervals. p < 0.05 was considered as significant.
RESULTS
Out of a total of 288 completed questionnaires, eleven were excluded from the study after applying the criteria of Goldberg et al. 27,32. Table 1 displays the socio-demographic and lifestyle characteristics of the 277 children and adolescents in the final study sample. A similar percentage of the 6 to 9-year-old group (23.8%) and 10 to 17-year-old group (22.6%) was classified as overweight. The only significant difference between sexes was in the physical activity of the 10 to 17-year-old (p < 0.001; 2 = 11.94). Participants mainly had meals at home. Most 6 to 9-year-old individuals spent 10-20 minutes on breakfast and 15-60 minutes each on lunch and dinner, whereas most 10 to 17-year-old individuals spent < 10 minutes on breakfast and 15-30 minutes each on lunch and dinner. Most subjects talked or experienced distractions during lunch, especially among the 6 to 9-year-old participants. The vast majority of subjects did not consider breakfast to be an important meal.
Table 2 exhibits the mean (SD) daily energy and nutrient intakes of participants. Intakes of energy per kg body weight, MET per kg body weight, minerals and vitamins (Fe, Ca, Mg, Zn, Se, iodine, vitamin B2, niacin, vitamin E) were significantly higher in 6 to 9-year-old participants than in the 10 to 17-year-old group. A good correlation was found (data not shown) between energy intake (MJ/kg body weight) and estimated energy (MET MJ/kg body weight) (r = 0.739; p < 0.001). The mean (SD) diet quality score was 12.1 (1,9) for the younger children (6-9 years) and 9.4 (3.2) for the older group (10-17 years), showing a significant (p < 0.001) difference.
Univariate analyses of socio-demographic and lifestyle variables (Table 3) revealed that a higher diet quality score was associated with higher age, weight-for-height status and physical activity values. These factors were entered in the multivariate analysis, which showed that the diet quality score was positively associated with higher age and physical activity and inversely associated with weight-for-height status.
Table II Daily intakes of energy and nutrients (mean ± SD) in young peopleof Southern Spain
%E: percentage of energy; b.wt.: body weight; %RDI: percentage of recommended dietary intake. *Significant differences between 6 to 9-year-old and 10 to 17-year-old subjects by ANOVA. †A diet quality score was computed considering the risk of inadequate intake of the nutrients considered. A value of 0 or 1 was assigned to each of the 14 nutrients. Individuals whose consumption was < 2/3 of the RDI for each nutrient were assigned a value of 0, and those whose consumption was ≥ 2/3 of RDI were assigned a value of 1. Hence, the total score ranged from 0 (very poor quality) to 14 (high quality).
Table III Socio-demographic and lifestyle characteristics of individuals with low and high diet quality scores (n = 277)
*Individuals with low diet quality score (≤ 9 points). †Individuals with high diet quality score (≥ 13 points). ‡Univariate analysis (logistic regression analysis considering the effect of only one explanatory variable). §Multivariate analysis (multiple logistic regression analysis considering the simultaneous effect of all explanatory variables). ǁp < 0.05; ¶p < 0.01; **p < 0.001.
DISCUSSION
The sex and age distribution of the sample did not significantly differ from that recorded in Southern Spain 35. Under-reporters were excluded from the analysis of dietary patterns and nutrient intake to avoid the typical respondent bias in dietary recall methods.
The habits of this population at the table show interesting trends. The younger children spent more time eating and reported more distraction during meals, as previously observed 36,37,38. Most participants talked at the table, which has been described as a positive factor, implying family participation and favoring diet quality and the habit of taking breakfast 26,29,40).
These young people showed an elevated consumption of total fat (40.9% of total energy intake in 6 to 9-year-old participants and 41.8% in the 10 to 17-year-old group) and protein (14.8% of total energy intake in 6 to 9-year-olds and 14.9% in 10 to 17-year-olds), and a reduced consumption of carbohydrates (44.2% of total energy intake in 6 to 9-year-olds and 43.4% in 10 to 17-year-olds). In both groups, the contribution of SFA to the total energy intake was above the recommendations, while the contribution of PUFA was below recommendations. These findings are similar to those obtained in young people by other epidemiological studies in Spain and the United States 6,41,42,43. In comparison to recommendations, the intake of iodine was lower than recommended in the younger group and the intakes of iron, calcium, magnesium, zinc, iodine, vitamin B2, and vitamin E were lower in the adolescents 44. These deficiencies represent a risk factor for metabolic disease in adulthood 45 and may reflect a shift from the traditional Mediterranean diet, which provides an adequate supply of these micronutrients. The lesser change observed in the younger children may reflect a greater control by parents on their dietary habits in comparison to adolescents.
Disruptions in the balance between nutrient requirements and intake during adolescence have an effect on subsequent health. Early adoption of healthy eating habits may contribute to a lower incidence of disease in adulthood and improved quality of life in later life. Dietary habits are complex in nature and many factors influence food practices 46. Adolescence is a transitional stage and many changes take place at physiologic and behavioral levels. Socio-cultural factors, i.e., parental occupational status, maternal level of education, cultural and/or religious habits, the role of family, patterns of beauty, etc., are factors that have a strong influence on eating habits and nutrient intake in this age group 47,48. It has previously been reported that parental educational level should be considered when developing childhood obesity prevention programs 49 and that further information is required on parent and child perceptions of diet and physical activity 50. The best diet quality scores were observed in active young people of normal weight, as previously reported in Spanish university students 51. A good correlation was found between the energy intake (MJ/kg body weight) and estimated energy (MET MJ/kg body weight), validating this estimation method.
In conclusion, the food intake of the younger children in this study was closer to recommendations in comparison to the adolescents, who generally reported a lower energy supply in their diet than recommended. The adolescents obtained a significantly lower diet quality score in comparison to the younger group.
