Spanish children's diet: Compliance with nutrient and food intake guidelines

Abstract

To compare the diet of Spanish children against the nutrient and food intake guidelines. To calculate an index of overall diet quality and check its validity against nutrient intake.
Cross-sectional study in four cities in Spain, where information on food and nutrient intake was obtained from schoolchildren through a food frequency questionnaire.
The sample included 1112 children (overall response rate of 85%) attending public and private schools and aged 6-7 y. Children were selected through random cluster sampling in schools, and stratified by sex and socioeconomic level.
Mean nutrient intake, number of food servings, and the percentage of children who meet recommended nutrient and food-serving intake levels. The overall dietary quality was assessed using the Healthy Eating Index (HEI).
Mean micronutrient intake exceeded 100% of the recommended dietary allowances, except for vitamin B6, which registered a mean intake of 77.1%. For almost all children, intake of saturated fat was above, and that of carbohydrate below, the recommended level, in contrast to the relatively high compliance with the recommendations for poly- and monounsaturated fatty acid, salt and fiber intake (69.7, 43.7, 40.7, and 30.1%, respectively). Consumption of food servings for each of the five American pyramid food groups came close to or exceeded USDA guidelines, with the exception of cereals, with 5.4 servings per day. The mean score obtained in the HEI was 64.6. Children who complied with all the food guide pyramid recommendations registered a higher dietary variety and a healthier nutritional profile.
Children aged 6-7 y show scant compliance with the macronutrient goals for healthy eating. Micronutrient intake is adequate in general, yet there are small groups of children with risk of deficient intake of vitamins B6 and D. While Spanish children's eating habits are reasonably in line with American food guide pyramid guidelines, consumptions of cereals and fruit should be improved.

Full text

ORIGINAL COMMUNICATION
Spanish children’s diet: compliance with nutrient and
food intake guidelines
MA Royo-Bordonada
1
*, L Gorgojo
1
, JM Martı
´
n-Moreno
1,2
, C Garce
´
s
3
, F Rodrı
´
guez-Artalejo
2
,
M Benavente
3
, A Mangas
4
and M de Oya
2,3
, on behalf of the investigators of
the Four Provinces Study
1
Carlos III Institute of Public Health, Ministerio de Sanidad y Consumo, Madrid, Spain;
2
Department of Preventive Medicine and Public
Health, Universidad Auto
´
noma de Madrid, Madrid, Spain;
3
Lipids Laboratory, Fundacio
´
n Jime
´
nez Dı
´
az, Madrid, Spain; and
4
Department of Medicine, Universidad de Ca
´
diz, Cadiz, Spain
Objective: To compare the diet of Spanish children against the nutrient and food intake guidelines. To calculate an index of
overall diet quality and check its validity against nutrient intake.
Design and setting: Cross-sectional study in four cities in Spain, where information on food and nutrient intake was obtained
from schoolchildren through a food frequency questionnaire.
Participants: The sample included 1112 children (overall response rate of 85%) attending public and private schools and aged
6–7 y. Children were selected through random cluster sampling in schools, and stratified by sex and socioeconomic level.
Main Outcome Measures: Mean nutrient intake, number of food servings, and the percentage of children who meet
recommended nutrient and food-serving intake levels. The overall dietary quality was assessed using the Healthy Eating Index
(HEI).
Results: Mean micronutrient intake exceeded 100% of the recommended dietary allowances, except for vitamin B6, which
registered a mean intake of 77.1%. For almost all children, intake of saturated fat was above, and that of carbohydrate below,
the recommended level, in contrast to the relatively high compliance with the recommendations for poly- and
monounsaturated fatty acid, salt and fiber intake (69.7, 43.7, 40.7, and 30.1%, respectively). Consumption of food servings
for each of the five American pyramid food groups came close to or exceeded USDA guidelines, with the exception of cereals,
with 5.4 servings per day. The mean score obtained in the HEI was 64.6. Children who complied with all the food guide pyramid
recommendations registered a higher dietary variety and a healthier nutritional profile.
Conclusions: Children aged 6–7 y show scant compliance with the macronutrient goals for healthy eating. Micronutrient intake
is adequate in general, yet there are small groups of children with risk of deficient intake of vitamins B6 and D. While Spanish
children’s eating habits are reasonably in line with American food guide pyramid guidelines, consumptions of cereals and fruit
should be improved.
European Journal of Clinical Nutrition (2003) 57, 930–939. doi:10.1038/sj.ejcn.1601627
Keywords: food guide pyramid; children; dietary patterns; RDA; diet quality
Introduction
The role of certain nutrients and food groups in the
prevention of cardiovascular disease and some malignant
tumors has been highlighted by a considerable number of
studies (Ascherio & Willet, 1995; Cummings & Bingham, 1998).
Specifically, diets with a relatively high fruit and vegetable
intake component are associated with a lower risk of mortality
(Huijbregts et al, 1997) and of suffering cancer (Cummings &
Bingham, 1998) or cardiovascular disease (Kant et al, 2000).
Moreover, there is recent evidence to show that consumption
patterns in childhood tend to be associated with subsequent
risk of developing some types of cancer (Hansson et al, 1994),
obesity (Lichtenstein et al, 1998), arterial hypertension and
cardiovascular disease in adult life (Nicklas et al, 1988).
To promote a healthy diet, a series of recommended
dietary allowances (RDAs) (National Research Council, 1989;
Received 22 May 2002; revised 10 July 2002;
accepted 13 July 2002
*Correspondence: MA Royo-Bordonada, Area de Jefatura de Estudios,
Escuela Nacional de Sanidad, Instituto de Salud Carlos III, C/ Sinesio
Delgado 8, 20829 Madrid, Spain.
E-mail: mroyo@isciii.es
Contributors: Investigators of the Four Provinces Study: AM
(Universidad de Ca
´
diz), AG (Universidad Rey Juan Carlos), AS
(Fundacio
´
n Jime
´
nez Dı
´
az), JFP (Hospital de la Cruz Roja, Murcia), MAL
(Hospital Ramo
´
n y Cajal, Madrid).
European Journal of Clinical Nutrition (2003) 57, 930–939
&
2003 Nature Publishing Group All rights reserved 0954-3007/03 $
25.00
www.nature.com/ejcn

Moreiras-Varela et al, 1999b) and nutritional goals (Aranceta,
1995) have been set at both a national and international
level. To meet such recommendations, food guidelines have
been drawn up and, in the case of the USA, have been further
developed in recent years (USDA and USDHHS, 2000a, b). In
Spain, where official nutritional goals and food guidelines
have not been formally introduced at a national level (Serra
et al, 1999), the Spanish Society for Community Nutrition
(Sociedad Espan
˜
ola de Nutricio
´
n ComunitariaFSENC) has
nevertheless drawn up guidelines similar to those of the
USA (Aranceta, 1995). Although these recommendations are
not specific for any age group, they are also intended for
children. Further, as long as dietary habits start being formed
at ages 3–4 y and tend to become very resistant to change
from age 11 y onwards (Herna
´
ndez, 1999), it is important to
ascertain the degree to which dietary habits in the child
population conform to the pertinent recommendations. To
date, research conducted on Spanish children’s eating habits
has been characterized by a certain degree of dispersion, with
most studies being local or regional in scope. The results
yielded by these studies reflect an excess in the contribution
of lipids and proteins, and a relative deficit in the contribu-
tion of carbohydrates to total energy intake (Gorgojo et al,
1999). Although few studies have focused on analyzing
compliance with RDAs, nutrition goals and dietary recom-
mendations, at an individual level, knowing the percentage
of individuals with intakes significantly below recom-
mended levels can be extremely relevant (Truswell, 1990).
A complementary approach to assessing compliance with
nutrition and food guidelines consists of obtaining an
overall dietary index, which has the added value of taking
account of the complexity of food consumption patterns
and their multidimensional nature. In this respect, indices
based on nutrients, foods and a combination of both have
been proposed. Some of these indices have shown an
association with risk of mortality and of suffering cardiovas-
cular disease and some types of cancer, an association of a
greater magnitude than that observed for any nutrient or
food at an individual level (Kant, 1996; Osler et al, 2001).
Specifically, the Healthy Eating Index (Kennedy et al, 1995),
based on the USA dietary guidelines(USDA and USDHHS,
2000a), has been used successfully in both adults and
children to study their overall dietary quality (Bowman
et al, 1998).
This study compares the diet of children in four Spanish
cities against the following: the RDAs of the Nutrition and
Bromatology Institute, a body of the Spanish Scientific
Research Council (Consejo Superior de Investigaciones Cientı
´
fi-
casFCSIC) (Moreiras-Varela et al, 1999b), the nutritional
goals set by the SENC (Aranceta, 1995), and the US
Department of Agriculture (USDA) Food Guide Pyramid
serving recommendations (USDA and USDHHS, 2000b). The
four cities were selected from regions having different
demographic and sociocultural characteristics. Moreover,
this is one of the first studies in the Mediterranean area that
has formally tackled these questions simultaneously, includ-
ing the task of calculating an index of overall diet quality
and checking its validity against nutrient intake.
Materials and methods
Study subjects
Using a cross-sectional epidemiologic design, representative
samples of schoolgoing children aged 6–7 y were selected in
Cadiz, Madrid, Orense and Murcia (Figure 1) over the period
1998–1999. These cities were chosen both because they
registered an approximately two-fold variation in coronary
mortality, and for logistic reasons. More detailed informa-
tion on the study design is available in previous publications
(Rodrı
´
guez-Artalejo et al, 1999, 2002). The study protocol
complied with Helsinki Declaration Guidelines and Spanish
legal provisions governing clinical research on humans and
was approved by the Clinical Ethics Committee of the
Fundacio
´
n Jime
´
nez Dı
´
az in Madrid.
Children were selected by means of random cluster
sampling in schools, and stratified by sex and type of school
(ie, public vs private), the latter factor being used as an
approximate indicator of socioeconomic level. Sampling was
carried out in two stages: first, schools were selected from
lists made available by the Regional Educational Authorities;
and second, class rooms and pupils were selected. To rule out
the possibility of the values of any of the variables of interest
being altered, all children reported by parents to be suffering
from metabolic, endocrine, liver or kidney disorders were
excluded.
Data collection and study variables
The study was orally presented to the Board of Governors
(Consejo Escolar) of each of the schools. Following this, a
Figure 1 Map of Spain showing the situation of the four cities
under review
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
931
European Journal of Clinical Nutrition

letter was circulated to the parents of all the children invited
to participate in the study, outlining the study goals and
procedures, and securing their written authorization.
At each school, data were collected over a 6 week period by
a field team, comprising a physician, a nurse and a group of
persons trained in undertaking food frequency surveys, who
conducted the survey and obtained the information from
the children’s mothers or other adults in charge of super-
vising their menus. Data collection was carried out at the
schools. A total of six schools were selected in each city, and
in each school all 6 to 7-y-old children were invited to take
part (approximately 50 per school).
Food and nutritional data
Information on food and nutrition was obtained through a
food frequency questionnaire (FFQ), initially developed for
use on adults and previously validated in Spain by Martı
´
n-
Moreno and colleagues (Martı
´
n-Moreno et al, 1993). For the
purpose of this study, the questionnaire was adapted to a
primary school population by amending and downscaling
the list of foods and portions consumed on the basis of a
recent systematic review of child-population food surveys in
Spain (Gorgojo et al, 1999). The final version of the
questionnaire included a total of 77 food codes grouped
under 11 heads by affinity in nutrient content. For each
food, the usual size of the serving eaten was defined (eg, 1
cup of milk equivalent to 170 cm
3
; a dish of lentils,
equivalent to 60 g dry weight) and the mean frequency of
consumption of such servings over the previous year
ascertained. The questionnaire provided the option of, in
an open-ended way, answering in terms of the frequency per
day, week, month or year. In cases where it was difficult to
translate immediately the interviewee’s answer in terms of
mean frequency of consumption, the interviewer registered
the answer literally and, once the interview was finished, he/
she calculated the corresponding figure. Using Spanish food-
composition tables (Mataix et al, 1998; Moreiras-Varela et al,
1999a), a food frequency conversion program was designed,
which furnished a database with the annual food consump-
tion and daily nutrient intake frequencies for each indivi-
dual surveyed. This enabled nutrient and total caloric intake
to be estimated (Willet & Stampfer, 1986; Martı
´
n-Moreno,
1993). The FFQ is available from the corresponding author
upon request.
Nutritional and food guidelines
Adequacy of micronutrient and energy intake was evaluated
as against CSIC Nutrition and Bromatology Institute RDAs
(Moreiras-Varela et al, 1999b). We calculated the percentage
of children who consumed an amount equal or superior to
that recommended for each nutrient. Since the RDA is more
than most people need, it is more useful to report how many
individuals had intakes far below the recommended level
(Truswell, 1990). As this number increases, the risk of
nutritional deficiency becomes greater (Beaton, 1985), so
we also calculated the percentage of children receiving less
than 66% of the recommended intake. Adequacy of macro-
nutrient intake was evaluated by calculating the percentage
of children who complied with the nutritional goals
proposed for the Spanish population by the SENC (Aranceta,
1995). In the light of current knowledge (Williams, 1995),
the target fiber figure for the Spanish population (mean
intake 425 g/day) was regarded as relatively inadequate for
children aged 6–7 y. Accordingly, we used a range of fiber
intake between age plus 5 and age plus 10 in g/day, as
recommended by Williams et al (1995) and also endorsed by
a number of Spanish experts (Herna
´
ndez, 1999).
The SENC food pyramid does not provide sufficient
information to classify individuals as compliers or non-
compliers with the respective recommendations for any
given food or food group. Hence, and also to enable
comparison with other international studies, we assessed
the degree to which the diet conformed to the American
food pyramid (USDA and USDHHS 2000a, b). This indicates
the number of servings recommended for each of the five
main food groups (cereals, vegetables, fruit, dairy products
and meat). Such indications vary according to the individual
caloric intake prescribed for one of three pre-established
guideline levels (1600, 2200 and 2800 kcal). However, the
CSIC Nutrition and Bromatology Institute’s recommended
caloric intake for children aged 6–7 y (2000 kcal) (Moreiras-
Varela et al, 1999b) coincides with none of these above levels.
Consequently, to evaluate food intake, we took as reference
the USDA recommended number of daily servings for
children with an intake of 2000 kcal, a figure that was
obtained by interpolation of the servings corresponding to
1600 and 2200 kcal (Bowman et al, 1998).
In order to identify the number of servings in each food
group, we followed the American food pyramid criterion for
assigning foods to the respective groups, eg, nuts, such as
hazel- and walnuts, were assigned to the meat group. Mixed
foods were divided into their constituent components, so
that a single item might contribute to different food pyramid
groups according to its composition. The weight of any
serving varies in accordance with the food in question, the
way of cooking it, and the group to which it belongs. Finally,
each individual’s complier or non-complier status was
established by defining compliers as those having an intake
equal or superior to the recommended level.
Overall dietary quality was assessed using the Healthy
Eating Index (Kennedy et al, 1995) (HEI). This index consists
of: one head with five components to measure food groups; a
second with four components to measure nutrients; and
another with one component to analyze dietary variety. For
each HEI component, a value is established on the basis of
which the minimum score (0 points) is obtained, and
another on the basis of which the maximum score (10
points) is obtained. Between these two values, the score is
obtained on a proportional basis, eg, in the case of
cholesterol intake, 0 points are scored with values
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
932
European Journal of Clinical Nutrition

450 mg, and 10 points with values below 300 mg; thus, an
individual with 330 mg of cholesterol intake would obtain a
score of 8 ([450330]  10/150). The total score, which can
range anywhere from 0 to 100, is obtained by adding up the
individual scores for the 10 components.
We have followed exactly HEI guidelines (USDA, 1995),
except for two components. First, since olive oil was a staple
in the diet of the sample population, 35% was designated as
the upper limit for total fat consumption as a percentage of
total food energy intake, in line with the nutritional goals set
by the SENC (Aranceta, 1995). Secondly, the HEI was
originally designed on the basis of data drawn from food
registries and 24-h dietary recall, with the dietary variety
component being scored according to the number of
different foods consumed over a period of 3 days. However,
our dietary assessment method, ie, a SQFFQ, is designed to
measure usual intake and contains a fixed number of items.
Consequently, in line with the method proposed by
McCullough et al (2000), using an SQFFQ similar to ours’,
dietary variety was calculated according to the number of
different foods (questionnaire items) consumed with a
frequency exceeding one serving per month. Following HEI
guidelines (USDA, 1995), similar foods were grouped
together in a single item to assess the dietary variety
component. A final number of 72 items was arrived at in
this manner. To assign dietary variety scores, the sample was
divided into 11 quantiles. Children in the bottom quantile
were scored 0, those in the next quantile 1, and so on
upwards, until reaching those in the top quantile who
received a score of 10. Since the HEI dietary variety score was
based upon the distribution of the number of different foods
consumed by the children in the study, the mean value was
pre-established at 5 points. Nevertheless, the high correla-
tions observed between the original index (HEI) and that
obtained from an SQFFQ (HEI-f) by the authors previously
mentioned (McCullough et al, 2000) confirm that the HEI
can be reasonably well estimated on the basis of an SQFFQ.
Statistical data analysis
Differences between groups of children in degree of com-
pliance with recommendations were compared using the w
2
test. Subsequently, logistic regression was used to adjust for
total energy intake and to obtain odds ratios and 95% CI.
Inter-group comparisons of means (number of servings and
HEI-f) were performed using the Student’s t-test and variance
analysis. Means were adjusted for energy using covariance
analysis. All comparisons were two-sided at a 0.05 signifi-
cance level. Statistical analyses were performed using the
Statistical Analysis System computer software package (Cody
& Smith, 1991).
Results
There was an overall response rate of 85%. The valid sample
totaled 1112 individuals, comprising 557 (50.1%) boys and
555 (49.9%) girls, and had a mean energy intake of
2129 kcal/day. The mean age was 6.7 y, with no substantial
differences as between the four cities studied.
Nutrient intake compared with RDA
Examination of mean micronutrient intake showed that this
exceeded 100% of the RDA, save in the case of vitamin B6,
which registered a mean intake of 77.1%. When analyzed at
an individual level, however, less than 80% of the children
had vitamins B6, D and E intakes above the recommended
levels; moreover, there were 36.7, 12 and 3%, respectively, of
children with less than 66% of the recommended intakes
(Table 1).
The percentage of boys with vitamin A (97.3%) and
calcium (96.2%) intakes above the recommended levels
exceeded that of girls (94.2 and 92.8%, respectively). While
recognizing that IR are quoted in absolute values, we decided
to adjust for total caloric intake when comparing boys with
girls (mean energy intake of 2194 and 2063 kcal, respec-
Table 1 Percentage of children complying with the recommended dietary allowances for the Spanish population*
Total
Guideline % RDA > 100% RDA o66% RDA Boys
w
Girls
w
p
z
ORy 95% CI
Calcium 800 mg 196.9 94.5 0.5 96.2 92.8 0.01 1.39 0.8–2.5
Vitamins
A
11
400 mg 166.0 95.8 0.1 97.3 94.2 0.01 1.61 0.8–3.1
B6 1.4 mg 77.1 17.1 36.7 19.0 15.1 0.08 0.96 0.7–1.4
C 55 mg 359.8 99.2 0 99.5 98.9 0.34 1.39 0.3–5.7
D5mg 103.8 45.1 12.0 44.2 46.1 0.51 0.82 0.6–1.0
E 8 mg 136.6 77.0 3.0 76.7 77.3 0.80 0.62 0.4–0.9
Folic acid 100 mg 207.5 99.3 0 99.5 99.1 0.51 0.99 0.2–4.5
* Daily micronutrient intakes recommended by the CSIC Nutrition and Bromatology Institute (Huijbregts et al, 1997).
w
Percentage of children having an intake above 100% of the recommended level.
z
These differences decrease or disappear when >66% compliers are compared.
y
OR of being a complier (intake above 100% of the recommended level) for boys vs girls, adjusted for caloric intake.
11
Retinol equivalents.
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
933
European Journal of Clinical Nutrition

tively). In this instance, boys were observed to register a
worse dietary pattern than girls for vitamins D and E, with
ORs of having an intake above 100% of the recommended
levels of 0.82 (CI: 0.6–1.0) and 0.62 (CI: 0.4–0.9), respec-
tively. Although no differences were observed in the crude
analysis, on adjusting for energy we found that the OR of
having a vitamin B6 intake above 66% of the recommended
level was 0.76 (CI: 0.5–1.0) for boys vs girls.
Nutrient intake compared with nutritional goals
The degree of compliance with nutritional goals proved very
variable (Table 2). In terms of population means, only the
target for monounsaturated fatty acid intake (18.3%) was
complied with. In percentage terms, the level of compliance
with the recommendations for food energy supplied by fats,
saturated fatty acids and carbohydrates was practically nil, in
contrast to the high percentage of compliance with the
recommendations for poly- and monounsaturated fatty acid
(69.7 and 43.7%, respectively) and salt intake (40.7%).
Between these two extremes, the percentages of the sample
that complied with the recommendations for linoleic acid,
fiber and the saturated-to-unsaturated fatty acid ratio were
23, 30.1 and 11.6%, respectively.
While non-complier status was attributable to an excess in
the case of total fat and linoleic acid intake and a deficit in
the case of carbohydrate intake (data not shown), in the case
of monounsaturated fatty acids and fiber, deviations in both
directions were observed, albeit with a clear predominance
of non-compliance due to excess (23.1 and 61.7%, respec-
tively). From a gender standpoint, the only statistically
significant difference in the degree of compliance was
evident in the case of fiber intake (Table 2), with girls
registering a better behavior pattern than boys (33.3% vs
26.9%).
Food consumption compared with food guidelines
With the exception of cereals, mean consumption of
food servings for each of the main American pyramid
food groups came close to or exceeded USDA guidelines
(Table 3). The percentage of children with an adequate
food intake varied from 13% for the cereal group to 82.5%
for the dairy products group (data not shown). Compari-
son by sex revealed the only statistically significant differ-
ence to be in the dairy products group, with a higher
mean intake and percentage of compliers among boys.
Insofar as vegetables were concerned, the crude analysis
showed a greater mean consumption among boys, but a
similar percentage of compliers in both groups. On adjus-
ting for energy, however, the relationship was inverted,
with girls displaying a better behavior pattern for both
variables.
Table 4 shows nutrient intake according to the pattern of
compliance with food guide pyramid recommendations for
the five main food groups. Subjects who failed to comply
with any of the recommendations registered the lowest
values of energy and micronutrient intake and, in some cases
(vitamins B6 and D) fell below the intake levels recom-
mended by the SENC. At the opposite extreme, the children
who complied with all the recommendations registered a
lower percentage of energy derived from proteins and fats, a
lower cholesterol density and a higher unsaturated–saturated
fatty acid ratio. Likewise, both dietary variety and carbohy-
drate and fiber intake were higher in this group than in the
remaining patterns studied.
Overall quality of the diet
The mean score obtained in the HEI-f was 64.6. A total of
94.7% of the sample obtained an HEI-f score of 51–80 (must
improve) and only 3.7 and 1.6% obtained scores below 51
Table 2 Percentage of children complying with nutritional goals set for the Spanish population
Percentage
Guideline Mean Total Boys Girls P
Proteins* 10–13% 17.2 4.7 4.7 4.7 0.99
Fats* r 35% 45.9 0.6 0.4 0.9 0.3
Monounsaturated fatty acids* 15–20% 18.3 69.7 69.7 69.7 0.98
Polyunsaturated fatty acids* r 8% 8.3 43.7 44.9 42.5 0.43
Saturated fatty acids* r 10% 16.7 0.2 0 0.4 0.25
Ratio of unsaturated–saturated Z 2 1.6 11.6 10.2 13.0 0.15
Cholesterol density o 100 169.5 4.9 5.2 4.5 0.59
Linoleic acid* 2–6% 7.3 23.0 24.1 22.0 0.41
Carbohydrates* 55–60% 38.3 0.3 0.2 0.4 0.62
Simple carbohydrates* o 10% 21.2 1.1 1.3 0.9 0.6
Complex carbohydrates* > 50% 17.8 0 0 0 F
Salt o 6 g 6.8 40.7 35.9 45.6 o 0.01
Fiber
w
11–17 g 19.7 30.1 26.9 33.3 0.02
*Percentage of total caloric intake supplied by the nutrient in question.
w
Mean daily intake guideline established by Williams et al (1995).
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
934
European Journal of Clinical Nutrition

(poor diet) and above 80 (good diet), respectively. The HEI-f
score was slightly higher in girls (65) than in boys (64.3),
though this difference failed to reach statistical significance
(P ¼ 0.15), even after adjustment for energy (P ¼ 0.09).
Mention should be made here of the low scores registered
by the index components that analyze the proportion of
energy derived from fats and saturated fatty acids, which, on
a scale of 0–10, scored 2.97 and 0.74, respectively (Table 5).
The relationship between nutrient intakes and HEI-f
tertiles is set out in Table 6 (shown without adjustment for
energy in order to be consistent with the HEI-f). Fiber and
carbohydrate intake and the unsaturated–saturated fatty acid
ratio were positively associated with the HEI-f, while protein
intake decreased as the HEI-f increased. Vitamin A was the
only vitamin intake to be negatively associated with the HEI-
f, a phenomenon also observed for calcium intake. Further-
Table 3 Mean daily intake of servings for the five main food groups in the American food pyramid
Number of servings
Cereals (s.d.*) Vegetables (s.d.*) Fruit (s.d.*) Dairy products (s.d.*) Meat products (s.d.*)
Guideline 7.8 3.7 2.7 2 2.3
Mean intake
Overall 5.4 (2.3) 4.8 (3.1) 2.5 (1.5) 2.9 (1.1) 2.6 (0.9)
Boys 5.6 (2.4) 4.8 (3.1) 2.6 (1.6) 3.1 (1.2) 2.7 (1.0)
Adjusted
w
5.5 (2.6) 4.7 (3.9) 2.5 (2.0) 3.0 (1.3) 2.6 (1.1)
Girls 5.2 (2.1) 4.7 (3.0) 2.4 (1.4) 2.7 (1.1) 2.6 (0.8)
Adjusted
w
5.4 (2.6) 4.9 (3.9) 2.5 (2.0) 2.8 (1.3) 2.7 (1.1)
P
z
0.63 0.17 0.76 o0.01 0.62
*Standard deviation.
w
Adjusted for total caloric intake.
z
Probability of the adjusted differences.
Table 4 Nutrient intake and dietary variety in terms of compliance with USDA guidelines for the main groups in the American food pyramid
Degree of compliance
All >1 and r4 None
Guideline (n=35)(n=1037)(n=40)P
Energy* 2000 kcal 3003.6 2124.8 1480.3
Proteins
w
10–13% 16.4 17.3 16.2 o0.01
Fats
w
r 35% 43.8 45.0 46.5 o0.01
Monounsaturated fatty acids
w
15–20% 18.0 18.3 19.0 0.12
Polyunsaturated fatty acids
w
r 8% 7.6 8.3 8.9 o0.01
Saturated fatty acids
w
r 10% 14.4 16.7 16.8 o0.01
Ratio of unsaturated–saturated Z 2 1.8 1.6 1.7 o0.01
Cholesterol density o100 160.2 169.4 180.4 0.26
Linoleic acid
w
2–6% 6.8 7.3 7.9 0.02
Carbohydrates
w
55–60% 41.6 38.1 38.6 o0.01
Simple carbohydrates
w
o10% 22.0 21.2 20.3 0.45
Complex carbohydrates
w
> 50% 20.5 17.7 18.8 o0.01
Fiber* 11–17 g 29.8 19.7 12.4 o0.01
Vitamin A*
z
400 mg 827.2 667.2 435.7 o0.01
Vitamin B6* 1.4 mg 1.6 1.1 0.6 o0.01
Vitamin C* 55 mg 329.6 195.2 154.4 o0.01
Vitamin D* 5 mg 6.7 5.2 3.9 o0.01
Vitamin E* 8 mg 16.7 10.9 8.0 o0.01
Folic acid* 100 mg 326.8 206.0 142.4 o0.01
Calcium* 800 mg 2004.3 1026.3 1582.0 o0.01
Variety F 48.8 42.0 37.2 o0.01
*
Recommended daily intake.
w
Percentage of total energy supplied by the nutrient in question.
z
Retinol equivalents.
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
935
European Journal of Clinical Nutrition

more, dietary variety and energy intake increased with a rise
in the HEI-f score.
Discussion
Our findings suggest that children aged 6–7 y show scant
compliance with the nutritional goals set by the SENC for
the Spanish population, with the sole exception of recom-
mendations relating to unsaturated fatty acid, salt and fiber
intake. Micronutrient intake is adequate in general terms,
yet there are still small groups of children with a potential
risk of deficient intakes of vitamins B6 and D. While Spanish
children’s eating habits are reasonably in line with American
food guide pyramid guidelines, there is room for improve-
ment in the case of cereals and fruit. Overall, the mean score
obtained by Spanish children in the HEI-f indicates a need
for improvement in the dietary habits of this age group.
As shown by a review of earlier studies, ours has the
greatest geographic coverage of all surveys to target food and
nutrition among schoolgoers in Spain over the last 20 years
(Gorgojo et al, 1999). Nonetheless, the results should be
interpreted with caution, not only because the main source
of information relies upon mothers’ power of recall, but also
Table 5 Healthy Eating Index (HEI-f) scores for children in the study
Criterion for Criterion for Mean
Component 10 points 0 points score (s.d.*)
Food group
1.Cereals 7.8 servings 0 servings 6.62 (2.1)
2.Vegetables 3.7 servings 0 servings 8.46 (2.4)
3.Fruit 2.7 servings 0 servings 7.52 (2.7)
4.Dairy products 2 servings 0 servings 9.61 (1.2)
5.Meat products 2.3 servings 0 servings 9.48 (1.1)
Dietary guidelines
6.Total fats r 35% of energy Z 50% of energy 2.97 (2.5)
7.Saturated fats r 10% of energy Z 15% of energy 0.74 (1.6)
8.Cholesterol o 300 mg Z 450 mg 6.35 (3.9)
9.Sodium o 2400 mg Z 4800 mg 7.87 (2.9)
10.Variety FF 5
Total 64.63 (7.5)
*Standard deviation.
Table 6 Nutrient intake and dietary variety by HEI-f tertiles
HEI-f tertiles
Lower Middle Upper
Guideline (o 60.8) (60.8 – 68.6) (> 68.6) P
Energy* 2000 2047.1 2131.4 2209.1
Proteins
w
10–13% 18.1 17.3 16.2 o0.01
Monounsaturated fatty acids
w
15–20% 18.7 18.7 17.4 o0.01
Polyunsaturated fatty acids
w
r 8% 8.3 8.5 8.2 o0.09
Ratio of unsaturated–saturated Z 2 1.5 1.6 1.7 o0.01
Linoleic acid
w
2–6% 7.2 7.4 7.2 0.13
Carbohydrates
w
55–60% 35.5 37.5 41.8 o0.01
Simple carbohydrates
w
o 10% 20.3 20.6 22.8 o0.01
Complex carbohydrates
w
> 50% 16.2 17.7 19.4 o0.01
Fiber* 11–17 g 17.0 19.5 22.7 o0.01
Vitamin A
*z
400 mg 714.2 653.1 624.6 o0.01
Vitamin B6* 1.4 mg 1.0 1.1 1.1 0.02
Vitamin C* 55 mg 181.5 201.3 210.9 o0.01
Vitamin D* 5 mg 5.2 5.2 5.1 0.76
Vitamin E* 8 mg 10.7 11.1 11.0 0.48
Folic acid* 100 mg 195.8 208.9 218.0 o0.01
Calcium* 800 mg 1690.8 1578.9 1456.3 o0.01
Variety F 37.9 42.8 45.1 o0.01
*
Recommended daily intake.
w
Percentage of total energy supplied by the nutrient in question.
z
Retinol equivalents.
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
936
European Journal of Clinical Nutrition

because of the limitations inherent in the measuring
instrument. On the one hand, while some studies show that
FFQ lead to an overestimation of the caloric intake among
children (Stein et al, 1992), others indicate that it is possible
for usual intake of energy and nutrients to be properly
measured using this type of questionnaire (Treiber et al,
1990). In most cases, SQFFQs have not used portion sizes
adjusted for children’s level of intake, so the overestimation
of energy and nutrients may be due to the use of adult
portion sizes (McPherson et al, 2000). Moreover, a study
undertaken in the early 1990s on children aged 6–7 y in the
Madrid region (Va
´
zquez et al, 1996), the only Spanish study
allowing for direct comparison with this one, yielded results
similar to ours, particularly for the contribution of macro-
nutrients to total energy intake. On the other hand, recall
and information bias may be a serious concern, particularly
for socially desirable foods. To enhance validity, the inter-
viewers were given precise instructions about how to carry
out the interview, how to express the questions, and how to
take positive breaks in order to avoid deficiencies in the
information gathered that could be due to the interviewee’s
tiredness. The blood test collection included in the study
design (Rodrı
´
guez-Artalejo et al, 1999) could also have had a
positive effect on validity (Willet, 1998). Moreover, there is
evidence to show that mothers furnish reliable information
on meals made for children at home (Treiber et al, 1990).
Finally, although the observation of a high degree of
correlation between the HEI and HEI-f may be partly due
to the effect of correlated errors, a considerable degree of
overlap between the distributions of both indices has also
been observed (McCullough et al, 2000).
In most cases, intake of vitamins and minerals exceeded
the RDA, as was to be expected from the consumption of
fruit and vegetables. Nevertheless, these findings coexist
with the presence of small groups of children requiring
special attention, owing to the potential risk of their
registering deficiencies in the intake of certain micronutri-
ents, vitamins B6 and D in particular. Earlier studies
(Albertson et al, 1992; Serra et al, 1996) have already
highlighted the risk of deficiencies in the intake of both
vitamins in certain child population subgroups. Contrary to
the findings reported for children in the USA (Johnson,
2000), however, no risk of inadequate calcium intake was in
evidence.
Adherence to recommended intakes of unsaturated fatty
acids, fruit and vegetables, confirms that the diet of Spanish
children retains some of the characteristics peculiar to the
Mediterranean diet (Rodrı
´
guez-Artalejo et al, 1996). It is
nevertheless remarkable that practically all the children
studied failed to comply with nutritional goals for fat,
saturated fatty acid and carbohydrate intakes. This finding is
consistent with the reduced intake of cereals and high
consumption of dairy and meat products, which has likewise
been observed in other child population studies in Spain
(Va
´
zquez et al, 1995). These data show that Spanish
children’s dietary habits lie midway between a typically
Mediterranean pattern and one more typical of Anglo-Saxon
countries (Rodrı
´
guez-Artalejo et al, 1996), with the
ensuing risk of a potential increase in incidence of chronic
disease in adult life if the above trend in such habits is
maintained.
Mean intake for the five main groups defined in the
American food pyramid proved satisfactory. Compared with
the results of two similar studies on US children in the same
age group, the children in our study registered a higher
degree of compliance with the recommended intakes for the
five food groups in the American pyramid, except for cereals
(Mun
˜
oz et al, 1997; Brady et al, 2000). A total of 3.1% of
Spanish children complied with all the food guide pyramid
recommendations, a figure higher than that observed in one
of the above-mentioned studies (Mun
˜
oz et al, 1997). More-
over, only 3.6% of Spanish children complied with none of
the food guide pyramid recommendations, vs figures ranging
from 17 to 29% for US children (Mun
˜
oz et al, 1997; Brady
et al, 2000).
In contrast to the results reported above, when the HEI-f
value is applied, the overall quality of Spanish children’s diet
appears to be slightly lower than that of US children of the
same age (Bowman et al, 1998). To interpret this seemingly
incongruent information, two aspects must be borne in
mind. In the first place, reasons of design dictate that the
mean for the dietary variety component of the HEI-f must
inevitably have a value of 5. However, using the same
methodology, but with an appreciably smaller number of
items, the range of variety in our study (21–60) proved
comparable to that reported in two American population-
based studies (McCullough et al, 2000). Furthermore, the
mean score for this component in an American population
(including children) varied from 6.6 in 1989 to 7.6 in 1996
(Bowman et al, 1998). It can therefore be safely assumed that
a significantly higher score could have been expected for this
component in Spanish children, had the original HEI
method of dietary assessment been used. Secondly, whereas
the index assesses total fat and saturated fatty acid intakes
under two separate heads, it takes no account of unsaturated
fatty acid intake (Hu et al, 1999; Kris-Etherton, 1999). The
Mediterranean dietFrich in fats with a predominance of
monounsaturated fatty acidsFhas been associated with a
marked and significant reduction in total mortality (Tricho-
poulou & Vasilopoulou, 2000). Despite the fact that Spanish
children’s fat consumption pattern is very similar to that of
the Mediterranean profile, this circumstance is not positively
recognized in the HEI-f. In addition, although the percen-
tage of US children complying with the guidelines in respect
of fat consumption has risen in relative terms (% of total
caloric intake) in the last 8 y, fat consumption in absolute
terms (g/day) has increased over the same period of time
(Johnson, 2000).
Total caloric intake showed hardly any change with HEI-f
score, yet rose sharply according to the degree of compliance
with food guide pyramid recommendations. Caution is thus
needed when interpreting the associations between pyramid
Children’s compliance with dietary guidelines
MA Royo-Bordonada et al
937
European Journal of Clinical Nutrition

compliance patterns and macro- and micronutrient intake,
given the importance of maintaining a total caloric intake at
acceptable levels (Napoli & Horton, 1997). Children with a
dietary pattern of compliance with all the recommendations
for the pyramid’s five food groups as well as those with
highest HEI-f scores registered a more varied diet and a more
adequate nutrient intake than the remaining subjects.
Nonetheless, fat consumption and the percentage of energy
derived from saturated fatty acids were inappropriately high
across all groups; unlike the position reported for US
children (Mun
˜
oz et al, 1997), however, this intake was lower
in those children whose dietary pattern complied with all
five food group recommendations. These observations high-
light the fact that, provided due caution is exercised and its
inherent limitations are taken into account (Chung et al,
1996; McCullough et al, 2000), the HEI-f can be used to assess
the overall diet quality of Spanish children. The fact that
calcium intake decreases with a rise in the HEI-f score may be
attributable to the predominance of whole milk (79.7% of
the total) in the food profile of our child population, with
consequent increase in the intake of saturated fats, which
exert so much weight upon the HEI-f score. Given that mean
calcium intake far exceeded recommended levels (197%
RDA) and that cases of intake so low as to represent a risk of
deficiency were practically non-existent, this leaves a certain
leeway for reducing the consumption of dairy products, by
limiting saturated fatty acid intake without in any way
compromising the benefits to be derived from an adequate
intake of calcium. Lastly, it is worth pointing out that
children in the upper HEI-f tertile also registered a more
varied diet, in line with the results of other studies(McCul-
lough et al, 2000).
In conclusion, the results yielded by this study are of
public health relevance. They may help to set nutritional
goals and food guidelines based on the actual children food
and nutritional status. They also suggest the potential
usefulness of implementing measures which, while preser-
ving the still prevailing characteristics typical of a Mediter-
ranean diet, contribute to the promotion of a healthier diet,
such as reducing milk consumption or increasing cereal
intake.
Acknowledgements
This study was partly funded by grants from the
International Olive Oil Board (Consejo Oleı
´
cola
Internacional), Madrid Regional Authority (Comunidad de
Madrid), Pedro Barrie
´
de la Maza Foundation and Eugenio
Rodrı
´
guez Pascual Foundation.
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