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Diet Quality of Preschoolers in Greece Based on the Healthy Eating Index: The GENESIS Study
RESEARCH Current Research
Diet Quality of Preschoolers in Greece Based on the Healthy Eating Index: The GENESIS Study YANNIS MANIOS, PhD; GEORGIA KOURLABA, MSc; KATERINA KONDAKI, MSc; EVANGELIA GRAMMATIKAKI, MSc; MANOLIS BIRBILIS, MSc; EVDOKIA OIKONOMOU, MSc; ELEYTHERIA ROMA-GIANNIKOU, MD, PhD
ABSTRACT Background The current study aimed to assess the diet quality of Greek preschoolers and the potential role of several sociodemographic factors related to it. Methods A representative sample of 2,287 Greek children aged 2 to 5 years (from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers) was used in this work. Dietary intake data was obtained using a combination of techniques comprising weighed food records, 24-hour recalls, and food diaries. A Healthy Eating Index (HEI) score was calculated summing the individual scores (0 to 10) assigned to each one of 10 index components. Results Eighty percent of participants had an HEI score ⬍50 (ie, “poor” diet), 0.4% had an HEI score ⬎80 (ie, “good” diet), and the overall mean HEI score was 59. HEI scores were significantly higher among boys, children aged 4 to 5 years, children participating in moderate to vigorous physical activities for more than 3 hours per week, children living in rural or small towns, and those whose mothers were employed and had higher educational status (⬎12 years). HEI score was also found to be strongly associated with several macronutrient and micronutrient intakes. Conclusions Based on HEI scores, the vast majority of Greek preschoolers was found to have a poor diet. Moreover, low HEI scores were associated with low levels of physical activity, low vegetable intake, high saturated fat
Y. Manios is an assistant professor, G. Kourlaba is a biostatistician, K. Kondaki is a public health nutritionist, E. Grammatikaki is a dietitian-public health nutritionist, M. Birbilis is a public health nutritionist, and E. Oikonomou is a dietitian-public health nutritionist, Department of Nutrition and Dietetics, Harokopio University of Athens, Kallithea, Greece. E. Roma-Giannikou is a pediatrician, First Department of Pediatrics, Athens University, Athens, Greece. Address correspondence to: Yannis Manios, PhD, Department of Nutrition and Dietetics, Harokopio University, 70 El.Venizelou Ave, 176 71 Kallithea, Athens, Greece. E-mail: [email protected] Manuscript accepted: October 28, 2008. Copyright © 2009 by the American Dietetic Association. 0002-8223/09/10904-0002$36.00/0 doi: 10.1016/j.jada.2008.12.011
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intake, lower maternal educational level, and unemployment status. J Am Diet Assoc. 2009;109:616-623.
I
t is a well-known fact that nutrition during infancy and childhood is strongly associated with a child’s physical growth and cognitive and emotional development (1,2). Moreover, increased total energy and fat intakes observed among children in developed countries during past decades (3-6) have resulted in an increasing prevalence of risk factors for chronic diseases such as obesity, high blood pressure, and high cholesterol levels in children (7-9). However, it has been proposed that children with obesity may become adults with obesity, putting them at greater risk for developing several chronic diseases (eg, cardiovascular disease, hypertension, cancer, and diabetes) (10,11). Therefore, it is extremely important to monitor diet quality of young children. Assessment of diet quality is complicated because the evaluation of a single nutrient or single day’s food intake cannot be a token of overall diet quality. Several national epidemiologic studies have examined dietary intakes of toddlers and preschoolers and revealed increased consumption of energy, inadequate intakes for certain nutrients (eg, fiber), excessive intakes of other nutrients (eg, total fat, saturated fat, and sugar) (3-5,12,13), and low fruit and vegetable intake (14,15). Despite the fact that these findings indicate inadequacies in some nutrients or foods, they do not reflect overall diet quality. However, during the past decades composite index development has emerged as an alternative way to evaluate not only overall diet quality but also the association between diet and several chronic diseases (16). These indexes are called composite diet quality indexes and they are attractive because they capture the multidimensional nature of people’s diets. To date, several dietary indexes have been proposed in the literature (17-20). The vast majority are inappropriate for preschool children because they were developed based on dietary recommendations proposed for adults (17,18,20). However, the Healthy Eating Index (HEI) was designed to assess diet quality in people aged 2 years and older (19). Although several studies have investigated whether this index is related to nutrient adequacy or particular health outcomes among adults (21-23), similar data are limited among preschoolers (24). Moreover, to the best of our knowledge, no previous work has been conducted to evaluate the overall diet quality of preschoolers in Greece. This work aimed to evaluate the overall diet quality of Greek preschoolers using HEI score and to examine so-
© 2009 by the American Dietetic Association
ciodemographic factors that may be associated with this score. In addition, it was investigated whether HEI score is strongly associated with particular nutrients/foods intake (ie, whether it is valid against nutrients/foods intake) among Greek preschoolers. METHODS Sampling The design and rationale of the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) have been described meticulously in a previous work (25). In brief, 2,518 children aged 1 to 5 years were enrolled in the study between April 2003 and July 2004. This cohort was recruited from a representative sample of randomly selected public and private nurseries as well as daycare centers within municipalities in five counties of Greece. All nurseries invited to participate responded positively. Among the total number of nursery schools studied (n⫽115), 63 were in Attica, 10 were in Thessalonica, 12 were in Halkidiki, 22 were in Aitoloakarnania, and eight were in Helia. The selected counties are widely scattered across the Greek dominion and their overall local population comprises about 70% of the total Greek population (Census 1999). After adjusting for parental age and education level of the population agreeing to participate in the study we observed no significant differences between the overall population characteristics and the study sample within counties, according to data provided by the National Statistical Service of Greece (Census 1999). Thus, the final sample is representative of 70% of the Greek population with proportions of children 12 to 23, 25 to 35, 36 to 47 and 48 to 60 months old being 8.7%, 21.7%, 38.8%, and 31.4%, respectively. Both a letter explaining the aims of the study and a consent form were distributed to each parent with a child in these nurseries. Parents agreeing to participate in the study had to sign the consent form and provide contact details. Approval to conduct the study was granted by the Ethical Committee of Harokopio University of Athens and by all municipalities invited to participate in the study. For this research only children aged 2 years or older were included because the HEI has been proposed for people aged ⱖ2 years (2,287 out of 2,518 children participated in the study). Anthropometric Measurements Anthropometric data (ie, body weight and height) of children were obtained by the use of standard procedures in all study sites (25). Body mass index (BMI) was calculated as kg/m2. Height of all children older than 2 years was measured standing. The Nutstat module of Epi Info (version 3.3.2, 2004, Centers for Disease Control and Prevention Division of Integrated Surveillance Systems and Services, Atlanta, GA) was used to determine children’s age- and sex-specific percentiles for weight, height and BMI. The US Centers for Disease Control and Prevention age- and sex-specific growth charts and relative cutoff points were used for the definition of overweight (26). Specifically, for children older than age 24 months, the BMI-for-age chart was used to classify children ⱖ85th and ⬍95th percentile as at risk of overweight and those ⱖ95th percentile as overweight.
Dietary Assessment Dietary intake data was obtained for 2 consecutive weekdays and 1 weekend day using a combination of techniques comprising the weighed food records (during nursery hours) and 24-hour recall or food diaries (outside nurseries). During the 2 weekdays, and while the child was at the nursery, a team member (ie, a registered dietitian) weighed and recorded all foods consumed by each child. Information on the food consumed outside the nursery for these specific weekdays was obtained during a prearranged meeting with the parent/guardian the following morning, using the procedure of the 24-hour recall. During these two morning interviews parents/guardians were familiarized with portion sizes and the relevant procedures required to successfully complete a food record at home on the forthcoming weekend day, most preferably Sunday. Parents/guardians were advised to return the food diaries at the nursery on Monday mornings, where a team member received and checked the records for potential errors. Food intake data were analyzed using the Nutritionist V diet analysis software (version 2.1, 1999, First Databank, San Bruno, CA), which was extensively amended to include traditional Greek foods and recipes, as described in Food Composition Tables and Composition of Greek Cooked Food and Dishes (18,27). Furthermore, the database was updated with nutrition information of chemically analyzed commercial food items widely consumed by infants and preschoolers in Greece. The ratio of reported energy intake and predicted basal metabolic rate was used to check for underreporting. More details are reported elsewhere (5). Diet Quality Assessment HEI score was used to assess overall diet quality of preschoolers (19). The HEI score is the sum of individual scores for 10 components. The first five components measure the degree of compliance of people’s diet with the US Department of Agriculture Food Guide Pyramid recommendations for grains, vegetables, fruit, dairy, and meat as expressed in servings per day. The next four components of the HEI assess the degree of adherence to Dietary Guidelines for Americans recommendations regarding several nutrients (eg, total fat, saturated fat, cholesterol, and sodium intakes). The final component examines the variety of foods in a person’s diet. Foods that were similar, such as two different forms of white bread, were considered one item as concerns variety. Scores between 0 and 10 were assigned to all components. For example, a score of 10 was assigned to each one of the first five components (ie, food groups) when someone consumed equal to or more than the recommended number of servings, as indicated in Table 1, whereas a score of 0 was assigned when no consumption was reported. Intermediate scores were computed proportionately to the number of servings consumed. As in the past (19), the score for each component was divided into three categories as follows: score⬍5 (poor diet), score between 5 and 8 (diet needs improvement), and score ⬎8 (good diet). In terms of HEI score, the categorization proposed by Kennedy and colleagues (19) was initially used (ie, an HEI score ⬎80 implies a “good” diet, a score between 50 and 80 indicates a diet needs improvement, and a score lower than 50
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Table 1. Components of the Healthy Eating Index and scoring systema as used to assess diet quality in the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287 children)b Component Grain consumption Children, 2-3 y Children, 4-5 y Vegetable consumption Children, 2-3 y Children, 4-5 y Fruit consumption Children, 2-3 y Children, 4-5 y Milk consumption Children, 2-3 y Children, 4-5 y Meat consumption Children, 2-3 y Children, 4-5 y Total fat intake Saturated fat intake Cholesterol intake Sodium intake Variety a
Scoring range
Criteria for minimum score of 0
Criteria for maximum score of 10
0-10
0 servings/d
6.0 servings/d 7.0 servings/d
0-10
0 servings/d
3.0 servings/d 3.3 servings/d
0-10
0 servings/d
2.0 servings/d 2.3 servings/d
0-10
0 servings/d
2.0 servings/d 2.0 servings/d
0-10
0 servings/d
0-10 0-10 0-10 0-10 0-10
ⱖ45% of energy from fat ⱖ15% of energy from saturated fat ⬎450 mg ⬎4,800 mg ⱕ9 different items over 3 d
2.0 servings/d 2.1 servings/d ⱕ30% of energy from fat ⬍10% of energy from saturated fat ⬍300 mg ⬍2,400 mg ⱖ24 different items over 3 d
The scores for intakes between the maximum and the minimum cutoffs were assigned proportionately. Adapted from Kennedy and colleagues (19).
b
indicates a “poor” diet). However, because only 0.4% of participating children had a score ⬎80, further analyses were performed using the quartile of the HEI score. In addition to the HEI, the HEI components as well as total energy intake, carbohydrate and protein intake, and some other selected nutrients such as folate, fiber, iron, vitamin C, magnesium, phosphorous, zinc, and calcium, were used to further assess preschoolers’ diet quality. These nutrients were selected because they are very important for children’s growth and because the risk for deficiencies is increased. Physical Activity Assessment Using a valid, structured questionnaire, information regarding children’s physical activity was obtained by parents during scheduled interviews at the nurseries (25,28). Emphasis was placed on light to vigorous physical activities with intensity higher than 4 metabolic equivalents (METs). More information on the type of activities comprising light to vigorous physical activity is presented elsewhere (25). Based on light to vigorous physical activities, children were divided into those with more than 3 hours of physical activity per week and those with ⬍3 hours/week. Statistical Analysis The Shapiro-Wilk test was used to evaluate the normality of continuous variables (ie, HEI score, HEI components score, energy intake , and several nutrients intake) (29). Continuous variables are presented as mean⫾standard deviation and categorical variables are summarized as
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relative frequencies (%). Correlations between food, macronutrient, or micronutrient intakes and HEI score were evaluated by the Pearson or Spearman correlation coefficient, as appropriate. Moreover, the associations between the HEI components, the overall HEI scores, and binary variables (ie, sex, child’s physical inactivity, maternal employment status, place of residence, and child’s age) were evaluated using Student t test or Mann-Whitney U test when scores had normal or skewed distribution, respectively. The associations between food/nutrient intakes and the groups of the HEI score as well as the associations of the HEI components/overall HEI scores with maternal educational status and children BMI status were examined using one-way analysis of variance after testing for equality of variances (homoscedacity) or Kruskal-Wallis test. However, due to multiple significance comparisons, the Bonferroni correction was used to account for the increase in Type I error. Finally, stepwise linear regression analysis was performed to determine the independently associated factors with the HEI score. Several sociodemographic characteristics (eg, maternal educational status and employment; child’s sex, age, and BMI; and the place of residence) were used as independent variables. A probability value of 0.05 was considered statistically significant. All statistical calculations were performed using the SPSS version 14.0 software (2005, SPSS Inc, Chicago, IL). RESULTS Among 2,287 participants, 22% were 2 years old, 41% were 3 years old, 32% were 4 years old, and the remaining
Table 2. Healthy Eating Index (HEI) component scores among preschoolers in Greece using results from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287 children) % in HEI Component Scores Group Food variable
Components score MeanⴞSDa
“Poor” diet (score<5)
“Needs improvement” diet (score 5.1-8)
“Good” diet (score >8)
Grains Vegetables Fruits Milk Meat Total fat Saturated fat Cholesterol Sodium Variety
4.5⫾1.9 1.2⫾1.5 5.5⫾3.5 9.4⫾1.7 5.5⫾2.9 3.3⫾0.6 1.2⫾2.4 9.8⫾0.9 9.9⫾0.3 8.3⫾2.3
68.9 97.3 51.7 8.2 48.8 99.7 90.3 1.3 0.1 11.0
25.7 2.4 14.2 6.0 28.2 0.3 6.1 2.2 0.1 34.7
5.5 0.3 34.1 85.8 23.0 0.0 3.6 96.5 99.8 54.4
a
SD⫽standard deviation.
5% were 5 years old. The majority of preschoolers had a poor diet as indicated by the fact that 80.5% had an HEI score ⬍50. Only 0.4% of preschoolers had HEI score ⬎80. The overall mean HEI score was 58.7⫾8.2. This implies that the participating preschoolers showed almost 59% (ie, 58.7 out of 100) adherence to the healthful diet that the HEI evaluates. Table 2 presents the mean values of all HEI components. They ranged between 1.2 and 10. The lowest mean values were found in components measuring vegetable and saturated fat intake (1.2⫾1.5 and 1.2⫾2.4, respectively) reflecting extremely low vegetable intake and excessive consumption of saturated fat. On the contrary, the highest mean values were observed in components measuring milk, cholesterol, and sodium intake as well as in the component that reflects the variety of foods consumed daily (9.4, 9.8, 10, and 8.3, respectively). In addition, Table 2 presents the percentage of participants having “poor” diet, diet that “needs improvement,” and “good” diet based on HEI components score. It is observed that almost all preschoolers (⬎90% of participants) had “poor” diet as concerns vegetable and total and saturated fat consumption and “good” diet regarding milk, cholesterol, and sodium consumption. Table 3 presents the mean values of the 10 HEI component scores and selected nutrients by the quartiles of the HEI score. As expected, the consumption of foods (in servings/day) and cholesterol (in milligrams/day) used as HEI components increases with increasing HEI score (ie, higher quartiles of HEI score), whereas total and saturated fat intakes decrease across higher quartiles of the HEI score. Moreover, it was observed that the selected nutrients were strongly correlated with HEI score, indicating that increased HEI score values reflect better diet quality (Table 3). In particular, folate, fiber, iron, vitamin C, magnesium, phosphorous, and zinc intakes were higher in the highest quartile of the total HEI score compared to the lowest quartile. Table 4 summarizes the mean values of HEI component scores and HEI score based on several sociodemographic characteristics. It was observed that HEI score was significantly higher among boys, children aged 4 to 5
years, children with more than 3 hours/week of physical activity, children living in rural or small towns, and those whose mothers had high educational status (⬎12 years) and were employed compared to their counterparts. No significant association was detected between child’s BMI status and HEI score. Although several subgroups were found to have higher average HEI scores compared to others, no subgroup had average score ⬎80 (which implies a “good” diet). Performing multiple linear regression, it was found that sex, age, and place of living as well as maternal educational and employment status were factors significantly associated with the total score (Table 5). DISCUSSION The HEI has been proposed by the US Department of Agriculture’s Center for Nutrition Policy and Promotion as a useful tool to assess the dietary status of Americans. The total score can be used to rank individuals by their diet quality, whereas individual components scores of HEI can be used to determine adequacy or inadequacy for dietary intake of specific food groups and nutrients. Although this index has been developed to assess dietary habits for people aged 2 years and older, there are limited data regarding the success of this index in assessing diet quality among preschoolers. In addition, this index has never been implemented in a Greek population and our work aimed to evaluate the dietary habits of Greek preschoolers through the HEI score and to investigate factors that may influence this score. Our results indicate that the HEI is a good tool to detect diet quality among preschoolers because it was observed that the HEI score was moderate to strongly associated not only with foods and nutrients that are index components but also with other selected nutrients such as folate, vitamin C, iron, potassium, magnesium, and fiber. These findings are in accordance with those reported in a previous work where the HEI score was applied in children aged between 9 and 14 years (30). Regarding Greek preschoolers’ diet quality, our results revealed that there is an increased necessity to improve children’s diet, because the vast majority of participants
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Table 3. Differences in food and nutrient intakes by Healthy Eating Index (HEI) score categories among preschoolers in Greece, based on results from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287 children) HEI Total Score Quartile Variable
1st (HEI <53)
2nd (HEI 53-59)
3rd (HEI 59-65)
4th (HEI >65)
P value
Correlation with HEI
4™™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™™™™3 HEI components Grains (servings/d) Vegetables (servings/d) Fruit (servings/d) Milk (servings/d) Meat (servings/d) Fat (% energy) Saturated fat (% energy) Cholesterol (mg/d) Intake of energy and other nutrients Energy (kcal/d) Carbohydrate (% energy) Protein (% energy) Folate (g/d) Fiber (g/d) Iron (mg/d) Vitamin C (mg/d) Magnesium (mg/d) Phosphorus (mg/d) Zinc (mg/d) Calcium (mg/d)
2.3⫾0.9 0.1⫾0.2 0.5⫾0.5 2.9⫾1.5 0.8⫾0.5 40.4⫾0.8 18.0⫾2.9 188⫾81
2.7⫾1.2 0.3⫾0.4 1.0⫾0.9 3.1⫾1.4 1.1⫾0.7 40.0⫾0.8 16.9⫾2.9 202⫾81
3.0⫾1.2 0.4⫾0.5 1.6⫾0.9 3.1⫾1.3 1.3⫾0.8 39.9⫾0.7 16.4⫾2.9 213⫾82
3.6⫾1.6 0.6⫾0.6 2.3⫾1.2 3.0⫾1.3 1.6⫾0.8 39.6⫾0.8 14.6⫾3.0 219⫾76
⬍0.001 ⬍0.001 ⬍0.001 0.026 ⬍0.001 0.001 ⬍0.001 ⬍0.001
0.37 0.41 0.69 0.04 0.42 ⫺0.34 ⫺0.39 0.18
1,192⫾225 45.3⫾0.8 17.2⫾1.4 115⫾45 8⫾3 9.3⫾6.3 46⫾28 153⫾38 1,032⫾312 7.4⫾2.7 970⫾328
1,366⫾243 45.6⫾0.8 17.1⫾1.7 143⫾50 10⫾3 9.8⫾4.9 65⫾38 181⫾41 1,130⫾349 8.4⫾2.8 1,020⫾311
1,490⫾271 45.7⫾0.7 16.9⫾1.7 171⫾60 12⫾4 10.7⫾4.5 86⫾48 201⫾46 1,235⫾342 8.8⫾2.9 1,065⫾299
1,597⫾286 45.9⫾0.8 16.9⫾1.8 198⫾64 14⫾5 11.4⫾4.7 106⫾53 219⫾50 1,247⫾359 9.2⫾2.9 1,028⫾324
⬍0.001 ⬍0.001 0.04 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
0.56 0.30 ⫺0.05 0.56 0.60 0.25 0.52 0.55 0.27 0.28 0.09
(80.5%) have “poor diet” and almost the rest of participants (19%) have a diet that “needs improvements.” Furthermore, the mean value of the HEI score was almost 59. This value indicates that diet quality of Greek preschoolers is lower compared to that of US preschoolers and children (24,31,32). For instance, in a survey conducted during 1999-2000, Basiotis and colleagues (32) reported that the mean value of the total HEI score was 75.5 and 66.9 for children aged 2 to 3 years and 4 to 6 years, respectively. In addition, a study carried out among US children aged 2 to 5 years to evaluate their diet quality by beverage pattern revealed that the HEI mean score ranged between 70.9 and 79.0 (24). Similar results were found among low-income US children aged 2 to 3 and 4 to 8 years because the HEI mean score was 68.8 and 65.8, respectively, for light eaters and 78.1 and 69.6, respectively, for substituters (31). On the other hand, the mean HEI score in our work was close to that proposed from a similar study conducted in another Mediterranean country (Spain) among children aged 6 to 7 years (mean HEI score 64.6) (33). These results indicate that the diet quality of children from Mediterranean countries is lower compared to that observed in children from the United States. Low diet quality observed both in our work and in the study conducted in Spain could be partially attributed to the increased consumption of total and saturated fat. It is remarkable that the scores of HEI components measuring total and saturated fat intakes were too low in both studies. In particular, the score was 3.3 and 2.9 for total fat and 1.2 and 0.7 for saturated fat intake in our study and the Spanish study (33), respectively, indicating that
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the vast majority of children consumed extremely high quantities of total and saturated fat. In our study, the consumption of total and saturated fat was higher than the recommended even among children in the highest HEI quartiles. The low consumption of vegetables and grains observed in our study may contribute to the low overall diet quality of Greek preschoolers. In particular, it was found that the daily consumption of these foods was lower than recommendations even in children in the highest HEI quartile. These findings are not in accordance with those reported in the study conducted in Spain (33). However, these findings are in agreement with studies reporting that fruits, vegetables, and whole grains consumption could be increased in children from the United States (34,35). Therefore, it was realized that Greek preschoolers’ dietary habits adhere more to a Western diet pattern rather than to a Mediterranean diet as was expected. These findings are consistent with the results of other studies conducted in Greek populations, indicating that dietary habits in Greece have changed dramatically during past decades toward a more Westernized pattern (36). In particular, it has been revealed that fat intake among children and adolescents are much higher than recommended (37,38). Moreover, a recently published study showed that a majority of Greek children consume sugaradded beverages on a daily basis and this is strongly related to low intake of fruit and vegetables (39). Finally, it was detected that children whose mothers had low educational status (ie, ⬎9 years) or were unemployed had lower HEI score compared to those whose mothers’ education lasted more than 9 years or were
Table 4. Healthy Eating Index (HEI) component scores and total HEI score by several characteristics of preschoolers and their mothers in Greece, based on results from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287) HEI Component Characteristic
Grains
Vegetables Fruits
Milk
Meat
Total fat
Saturated fat Cholesterol Sodium
Variety
Overall
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3 Sex Male Female Age (y) 2-3 4-5 Child body mass index status Normal weight At risk of being overweight Overweight Physical activity status ⬍3 h/wk ⬎3 h/wk Place of residence Large urban/urban Rural/small towns Maternal employment Unemployed Employed Maternal educational status (y) ⬍9 9-12 ⬎12
4.7⫾1.9* 1.2⫾1.5 4.4⫾1.8 1.2⫾1.6
5.5⫾3.5 5.5⫾3.5
9.5⫾1.5* 5.6⫾2.9 9.3⫾1.9 5.4⫾2.9
4.0⫾1.6* 1.0⫾1.4* 5.6⫾1.9 1.4⫾1.8
5.1⫾3.5* 9.4⫾1.6 6.2⫾3.6 9.3⫾1.8
4.5⫾1.8* 1.2⫾1.6
5.6⫾3.5
4.6⫾1.9 4.9⫾1.9
1.2⫾1.5 1.1⫾1.6
5.4⫾3.4 5.1⫾3.5
4.5⫾1.8 4.7⫾1.8
3.3⫾0.6 3.3⫾0.6
1.2⫾2.4 1.2⫾2.4
9.8⫾1.0 9.8⫾0.9
9.9⫾0.3 8.4⫾2.2* 59.2⫾8.3* 9.9⫾0.1 8.2⫾2.3 58.2⫾8.1
5.9⫾3.0* 3.4⫾0.6* 1.1⫾2.3* 4.6⫾2.5 3.1⫾0.5 1.4⫾2.6
9.9⫾0.6* 9.6⫾1.4
9.9⫾0.3 8.1⫾2.3* 58.2⫾0.2* 9.9⫾0.2 8.7⫾2.0 59.9⫾8.4
9.3⫾1.7
5.5⫾2.9
3.3⫾0.6
1.2⫾2.4
9.8⫾0.9
10.0⫾0.3 8.3⫾2.3
58.8⫾8.2
9.6⫾1.5 9.5⫾1.6
5.5⫾2.9 5.7⫾2.8
3.3⫾0.5 3.3⫾0.6
1.2⫾2.3 1.1⫾2.2
9.9⫾0.7 9.7⫾1.2
10.0⫾0.1 8.3⫾2.2 10.0⫾0.1 8.4⫾2.1
58.9⫾8.0 58.8⫾7.9
1.1⫾1.5* 1.6⫾1.7
5.4⫾3.5* 9.4⫾1.7* 5.5⫾2.9 6.1⫾3.4 9.7⫾1.4 5.5⫾2.8
3.3⫾0.5 3.3⫾0.5
0.8⫾2.1* 1.3⫾2.4
9.8⫾0.9 9.9⫾0.6
10.0⫾0.3 8.2⫾2.3* 58.5⫾8.2* 10.0⫾0.1 8.8⫾2.0 60.4⫾7.3
4.5⫾1.9* 1.1⫾1.5* 4.7⫾1.7 1.4⫾1.6
5.4⫾3.6* 9.3⫾1.8* 5.5⫾2.9 5.8⫾3.4 9.7⫾1.3 5.6⫾2.8
3.2⫾0.5* 0.5⫾1.7* 3.4⫾0.6 1.4⫾2.6
9.8⫾1.0 9.9⫾0.6
10.0⫾0.3 8.2⫾2.3* 58.5⫾8.3* 10.0⫾0.1 8.6⫾2.0 59.4⫾7.7
4.5⫾1.8 4.5⫾1.9
1.0⫾1.5* 1.3⫾1.5
4.7⫾3.6* 9.3⫾1.7 5.8⫾3.5 9.4⫾1.7
5.5⫾2.9 5.5⫾2.9
3.3⫾0.6 3.3⫾0.5
1.2⫾2.4 1.3⫾2.4
9.8⫾0.9 9.8⫾0.9
10.0⫾0.1 7.9⫾2.5* 57.2⫾8.9* 10.0⫾0.3 8.4⫾2.2 59.3⫾7.9
4.6⫾1.9 4.7⫾1.7 4.5⫾1.9
0.8⫾1.4* 1.2⫾1.6 1.3⫾1.6
4.9⫾3.6* 9.4⫾1.7 5.1⫾3.6 9.3⫾1.8 5.8⫾3.4 9.5⫾1.5
5.8⫾2.9 5.4⫾2.9 5.5⫾2.9
3.2⫾0.5 3.3⫾0.5 3.4⫾0.6
0.9⫾2.0 1.1⫾2.3 1.3⫾2.5
9.6⫾1.5* 9.8⫾0.9 9.8⫾0.9
10.0⫾0.1 8.1⫾2.4 10.0⫾0.1 8.2⫾2.3 10.0⫾0.3 8.4⫾2.2
57.7⫾8.0* 58.3⫾8.3 59.4⫾8.1
*P⬍0.05 for comparisons of HEI component values and total HEI score among the several groups of each characteristic (eg, between boys and girls).
employed. This finding implies that children who live in a household with low socioeconomic status have lower diet quality compared to children from households with high socioeconomic status. This result is in agreement with previous studies reporting that socioeconomically disadvantaged groups adopt a dietary profile less consistent with dietary recommendations (40,41). As concerns the relationship between education status and diet quality, the level of knowledge regarding nutrition and its links with health has been proposed as a possible pathway. Several epidemiologic studies conducted among adults have reported that people with low education status have low level of knowledge about healthful dietary practices and their benefits on health (42). It is possible that uneducated or low educated mothers are not familiar with the importance of a healthful diet for their child’s normal development and prevention of several chronic diseases and with the existence of specific dietary recommendations for this age group. Moreover, education level is an important determinant of occupation and consequently this is a determinant of income level. That is, people with low education status are more likely to be unemployed and to have a low income level. Previous work has shown that people with low economic status exhibit food purchasing behavior that is as least as consistent with a
healthful dietary pattern as their higher economic status counterparts. More specifically, it has been detected that the former are more likely to purchase high-fat and highsugar foods and less likely to buy foods rich in fiber compared to the latter (42-45). These choices have partly been attributed to the increased cost of healthful foods (42). Still, there are some potential limitations in this study. The weekday intakes were collected with greater precision than the weekend intakes because 24-hour recall or food diaries were used for preschoolers’ dietary assessment outside nurseries. Therefore, it is possible that there is a bias in the estimation of children’s diet quality through the HEI score (ie, skewed diet scores), because score of 0 was assigned when no consumption was reported. However, the addition of a third weekday, the use of weighted records for 2 of 3 days, cultural tailoring of the dietary data base, parental training by a trained registered dietitian, and the availability of a registered dietitian during the weekday/weekends were used to address these limitations, strengthen the study. Another limitation of this work is that the HEI score was calculated according to the version based on the 2000 Dietary Guidelines for Americans HEI-2000) instead of the updated HEI based on 2005 recommendations (HEI-2005), which have recently been published (46). This limitation
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Table 5. Sociodemographic factors associated with Healthy Eating Index (HEI) total score among preschoolers in Greece, based on results from multiple logistic regression of data from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287) Independent variable Sex Male Female Child’s age (y) 2-3 3-4 Place of residence Large urban/urban Rural/small towns Maternal employment Unemployed Employed Maternal educational status (y) ⬍9 9-12 ⬎12 a
 (95% CIa)
P value
Reference category ⫺1.00 (⫺1.75 to ⫺0.25)
— 0.009
Reference category 2.05 (1.23 to 2.87)
— ⬍0.001
Reference category 1.79 (0.89 to 2.69)
— ⬍0.001
Reference category 2.12 (1.14 to 3.10)
— ⬍0.001
Reference category .69 (⫺0.62 to 2.01) 1.45 (0.15 to 2.76)
— 0.303 0.029
CI⫽confidence interval.
is attributed to the lack of records for some dietary data (eg, whole fruits, dark green and orange vegetables, and legumes) that are components of the HEI-2005. However, the use of the total HEI-2000 and HEI-2005 scores in the same population showed that the latter was lower compared to the former (46). That is, the HEI-2005 is stricter in evaluating the diet quality compared to the HEI-2000. Therefore, it is ensured that the main conclusion of our study (ie, a majority of Greek preschoolers follow a poor diet) is not biased by the use of HEI-2000. Moreover, a valid questionnaire to assess the children’s physical activity was used, although it is widely accepted that the use of accelerometry would provide more valid data. HEI was found to be strongly associated with the intake of several essential nutrients that are important for children’s development and health. Therefore, the HEI could be considered a good index to assess diet quality of preschoolers. Moreover, our study provides a snapshot of the diets of Greek preschoolers that indicates that they follow a poor diet that is high in total and saturated fat and inadequate in fruits, vegetables, and grains. These findings highlight the need to draw up and implement policies and programs that raise the awareness of parents regarding their children’s poor diet quality and the potential adverse effects of this on their children’s health and development. These programs should focus especially on parents with low education status or those who are unemployed, as well as those living in large urban areas and underscore the need to enrich their children’s diet with more fruits, vegetables, and grains and reduce total and saturated fat intakes to meet recommendations. The GENESIS study was supported by a Research Grant from Friesland Foods Hellas. Yannis Manios works as a
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part-time scientific consultant for Friesland Foods Hellas. The study sponsor had no interference in the study design, data collection, or writing of the manuscript. The authors thank Vivian Detopoulou, Anastasia Anastasiadou, Christine Kortsalioudaki, Elina Ioannou, Margarita Bartsota, Thodoris Liarigkovinos, Elina Dimitropoulou, Nikoleta Vidra, Theodoros Athanasoulis, Pari Christofidou, Lilia Charila, Sofia Tzitzirika and Christos Vassilopoulos for their contribution to the completion of the study. References 1. Stevenson J. Dietary influences on cognitive development and behaviour in children. Proc Nutr Soc. 2006;65:361-365. 2. Martin HP. Nutrition: Its relationship to children’s physical, mental, and emotional development. Am J Clin Nutr. 1973;26:766-775. 3. Devaney B, Ziegler P, Pac S, Karwe V, Barr SI. Nutrient intakes of infants and toddlers. J Am Diet Assoc. 2004;104(suppl 1):S14-S21. 4. Kranz S, Siega-Riz AM, Herring AH. Changes in diet quality of American preschoolers between 1977 and 1998. Am J Public Health. 2004;94:1525-1530. 5. Manios Y, Grammatikaki E, Papoutsou S, Liarigkovinos T, Kondaki K, Moschonis G. Nutrient intakes of toddlers and preschoolers in Greece: The GENESIS study. J Am Diet Assoc. 2008;108:357-361. 6. Munoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and adolescents compared with recommendations. Pediatrics. 1997;100:323-329. 7. Magkos F, Manios Y, Christakis G, Kafatos AG. Age-dependent changes in body size of Greek boys from 1982 to 2002. Obesity (Silver Spring). 2006;14:289-294. 8. Angelopoulos PD, Milionis HJ, Moschonis G, Manios Y. Relations between obesity and hypertension: Preliminary data from a crosssectional study in primary schoolchildren. Eur J Clin Nutr. 2006;60: 1226-1234. 9. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA. 2004;291: 2107-2113. 10. Hesketh K, Wake M, Waters E, Carlin J, Crawford D. Stability of body mass index in Australian children: A prospective cohort study across the middle childhood years. Public Health Nutr. 2004;7:303-309. 11. Boulton TJ, Magarey AM, Cockington RA. Tracking of serum lipids and dietary energy, fat, and calcium intake from 1 to 15 years. Acta Paediatr. 1995;84:1050-1055. 12. Kranz S, Mitchell DC, Siega-Riz AM, Smiciklas-Wright H. Dietary fiber intake by American preschoolers is associated with more nutrient-dense diets. J Am Diet Assoc. 2005;105:221-225. 13. Kranz S, Smiciklas-Wright H, Siega-Riz AM, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr. 2005;146:105-111. 14. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med. 2000;154: 1148-1152. 15. Hampl JS, Taylor CA, Johnston CS. Intakes of vitamin C, vegetables and fruits: Which schoolchildren are at risk? J Am Coll Nutr. 1999; 18:582-590. 16. Hu FB. Dietary pattern analysis: A new direction in nutritional epidemiology. Curr Opin Lipidol. 2002;13:3-9. 17. Huijbregts P, Feskens E, Rasanen L, Fidanza F, Nissinen A, Menotti A, Kromhout D. Dietary pattern and 20-year mortality in elderly men in Finland, Italy, and The Netherlands: Longitudinal cohort study. BMJ. 1997;315:13-17. 18. Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, Gnardellis C, Lagiou P, Polychronopoulos E, Vassilakou T, Lipworth L, Trichopoulos D. Diet and overall survival in elderly people. BMJ. 1995;311:14571460. 19. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: Design and applications. J Am Diet Assoc. 1995;95:1103-1108. 20. Patterson RE, Haines PS, Popkin BM. Diet quality index: Capturing a multidimensional behavior. J Am Diet Assoc. 1994;94:57-64. 21. Fung TT, Hu FB, Barbieri RL, Willett WC, Hankinson SE. Dietary patterns, the Alternate Healthy Eating Index, and plasma sex hormone concentrations in postmenopausal women. Int J Cancer. 2007; 121:803-809. 22. Pick ME, Edwards M, Moreau D, Ryan EA. Assessment of diet quality
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in pregnant women using the Healthy Eating Index. J Am Diet Assoc. 2005;105:240-246. Gao SK, Beresford SA, Frank LL, Schreiner PJ, Burke GL, Fitzpatrick AL. Modifications to the Healthy Eating Index and its ability to predict obesity: The Multi-Ethnic Study of Atherosclerosis. Am J Clin Nutr. 2008;88:64-69. LaRowe TL, Moeller SM, Adams AK. Beverage patterns, diet quality, and body mass index of US preschool and school-aged children. J Am Diet Assoc. 2007;107:1124-1133. Manios Y. Design and descriptive results of Growth, Exercise and Nutrition Epidemiological Study In preSchoolers: The GENESIS study. BMC Public Health. 2006;6:32. CDC Growth Charts 2000. National Center for Health Statistics and the National Center for Chronic Disease Prevention and Health Promotion Web site. http://www.cdc.gov/GrowthCharts/. Accessed January 8, 2009. Food composition tables. University of Crete Web site. http://nutrition. med.uoc.gr/GreekTables/. Accessed January 8, 2009. Manios Y, Kafatos A, Markakis G. Physical activity of 6-year-old children: Validation of two proxy methods. Pediatr Exerc Sci. 1998; 10:176-188. Shapiro S, Wilk M. An analysis of variance test for normality (complete samples). Biometrika. 1965;52:591-611. Feskanich D, Rockett HR, Colditz GA. Modifying the Healthy Eating Index to assess diet quality in children and adolescents. J Am Diet Assoc. 2004;104:1375-1383. Knol LL, Haughton B, Fitzhugh EC. Dietary patterns of young, lowincome US children. J Am Diet Assoc. 2005;105:1765-1773. Batsiotis PP, Carlson A, Gerrior SA, Juan WY, Lino M. The Healthy Eating Index: 1999-2000. Washington, DC: US Department of Agriculture, Center for Nutrition Policy and Promotion; 2002. Royo-Bordonada MA, Gorgojo L, Martin-Moreno JM, Garces C, Rodriguez-Artalejo F, Benavente M, Mangas A, de Oya M. Spanish children’s diet: Compliance with nutrient and food intake guidelines. Eur J Clin Nutr. 2003;57:930-939. Langevin DD, Kwiatkowski C, McKay MG, Maillet JO, TougerDecker R, Smith JK, Perlman A. Evaluation of diet quality and weight status of children from a low socioeconomic urban environment supports “at risk” classification. J Am Diet Assoc. 2007;107:1973-1977.
35. Dennison BA, Rockwell HL, Baker SL. Fruit and vegetable intake in young children. J Am Coll Nutr. 1998;17:371-378. 36. Kafatos A, Diacatou A, Voukiklaris G, Nikolakakis N, Vlachonikolis J, Kounali D, Mamalakis G, Dontas AS. Heart disease risk-factor status and dietary changes in the Cretan population over the past 30 y: The Seven Countries Study. Am J Clin Nutr. 1997;65:1882-1886. 37. Hassapidou MN, Fotiadou E. Dietary intakes and food habits of adolescents in northern Greece. Int J Food Sci Nutr. 2001;52:109-116. 38. Roma-Giannikou E, Adamidis D, Gianniou M, Nikolara R, Matsaniotis N. Nutritional survey in Greek children: Nutrient intake. Eur J Clin Nutr. 1997;51:273-285. 39. Linardakis M, Sarri K, Pateraki MS, Sbokos M, Kafatos A. Sugaradded beverages consumption among kindergarten children of Crete: Effects on nutritional status and risk of obesity. BMC Public Health. 2008;8:279. 40. Irala-Estevez JD, Groth M, Johansson L, Oltersdorf U, Prattala R, Martinez-Gonzalez MA. A systematic review of socio-economic differences in food habits in Europe: Consumption of fruit and vegetables. Eur J Clin Nutr. 2000;54:706-714. 41. Giskes K, Turrell G, Patterson C, Newman B. Socioeconomic differences among Australian adults in consumption of fruit and vegetables and intakes of vitamins A, C and folate. J Hum Nutr Diet. 2002;15: 375-385. 42. Turrell G, Kavanagh AM. Socio-economic pathways to diet: Modelling the association between socio-economic position and food purchasing behaviour. Public Health Nutr. 2006;9:375-383. 43. Ricciuto L, Tarasuk V, Yatchew A. Socio-demographic influences on food purchasing among Canadian households. Eur J Clin Nutr. 2006; 60:778-790. 44. Galobardes B, Morabia A, Bernstein MS. Diet and socioeconomic position: Does the use of different indicators matter? Int J Epidemiol. 2001;30:334-340. 45. Manios Y, Harizani K, Markakis G, Galani P, Manios T. Relating fruit and vegetable consumption in households with residue generation and utilization in the city of Heraklion, Crete, Greece. Int J Sustain Devel World Ecol. 2005;12:1-9. 46. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and Evaluation of the Healthy Eating Index-2005: Technical Report. Alexandria, VA: US Department of Agriculture Center for Nutrition Policy and Promotion; 2007.
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Diet Quality of Preschoolers in Greece Based on the Healthy Eating Index: The GENESIS Study YANNIS MANIOS, PhD; GEORGIA KOURLABA, MSc; KATERINA KONDAKI, MSc; EVANGELIA GRAMMATIKAKI, MSc; MANOLIS BIRBILIS, MSc; EVDOKIA OIKONOMOU, MSc; ELEYTHERIA ROMA-GIANNIKOU, MD, PhD
ABSTRACT Background The current study aimed to assess the diet quality of Greek preschoolers and the potential role of several sociodemographic factors related to it. Methods A representative sample of 2,287 Greek children aged 2 to 5 years (from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers) was used in this work. Dietary intake data was obtained using a combination of techniques comprising weighed food records, 24-hour recalls, and food diaries. A Healthy Eating Index (HEI) score was calculated summing the individual scores (0 to 10) assigned to each one of 10 index components. Results Eighty percent of participants had an HEI score ⬍50 (ie, “poor” diet), 0.4% had an HEI score ⬎80 (ie, “good” diet), and the overall mean HEI score was 59. HEI scores were significantly higher among boys, children aged 4 to 5 years, children participating in moderate to vigorous physical activities for more than 3 hours per week, children living in rural or small towns, and those whose mothers were employed and had higher educational status (⬎12 years). HEI score was also found to be strongly associated with several macronutrient and micronutrient intakes. Conclusions Based on HEI scores, the vast majority of Greek preschoolers was found to have a poor diet. Moreover, low HEI scores were associated with low levels of physical activity, low vegetable intake, high saturated fat
Y. Manios is an assistant professor, G. Kourlaba is a biostatistician, K. Kondaki is a public health nutritionist, E. Grammatikaki is a dietitian-public health nutritionist, M. Birbilis is a public health nutritionist, and E. Oikonomou is a dietitian-public health nutritionist, Department of Nutrition and Dietetics, Harokopio University of Athens, Kallithea, Greece. E. Roma-Giannikou is a pediatrician, First Department of Pediatrics, Athens University, Athens, Greece. Address correspondence to: Yannis Manios, PhD, Department of Nutrition and Dietetics, Harokopio University, 70 El.Venizelou Ave, 176 71 Kallithea, Athens, Greece. E-mail: [email protected] Manuscript accepted: October 28, 2008. Copyright © 2009 by the American Dietetic Association. 0002-8223/09/10904-0002$36.00/0 doi: 10.1016/j.jada.2008.12.011
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intake, lower maternal educational level, and unemployment status. J Am Diet Assoc. 2009;109:616-623.
I
t is a well-known fact that nutrition during infancy and childhood is strongly associated with a child’s physical growth and cognitive and emotional development (1,2). Moreover, increased total energy and fat intakes observed among children in developed countries during past decades (3-6) have resulted in an increasing prevalence of risk factors for chronic diseases such as obesity, high blood pressure, and high cholesterol levels in children (7-9). However, it has been proposed that children with obesity may become adults with obesity, putting them at greater risk for developing several chronic diseases (eg, cardiovascular disease, hypertension, cancer, and diabetes) (10,11). Therefore, it is extremely important to monitor diet quality of young children. Assessment of diet quality is complicated because the evaluation of a single nutrient or single day’s food intake cannot be a token of overall diet quality. Several national epidemiologic studies have examined dietary intakes of toddlers and preschoolers and revealed increased consumption of energy, inadequate intakes for certain nutrients (eg, fiber), excessive intakes of other nutrients (eg, total fat, saturated fat, and sugar) (3-5,12,13), and low fruit and vegetable intake (14,15). Despite the fact that these findings indicate inadequacies in some nutrients or foods, they do not reflect overall diet quality. However, during the past decades composite index development has emerged as an alternative way to evaluate not only overall diet quality but also the association between diet and several chronic diseases (16). These indexes are called composite diet quality indexes and they are attractive because they capture the multidimensional nature of people’s diets. To date, several dietary indexes have been proposed in the literature (17-20). The vast majority are inappropriate for preschool children because they were developed based on dietary recommendations proposed for adults (17,18,20). However, the Healthy Eating Index (HEI) was designed to assess diet quality in people aged 2 years and older (19). Although several studies have investigated whether this index is related to nutrient adequacy or particular health outcomes among adults (21-23), similar data are limited among preschoolers (24). Moreover, to the best of our knowledge, no previous work has been conducted to evaluate the overall diet quality of preschoolers in Greece. This work aimed to evaluate the overall diet quality of Greek preschoolers using HEI score and to examine so-
© 2009 by the American Dietetic Association
ciodemographic factors that may be associated with this score. In addition, it was investigated whether HEI score is strongly associated with particular nutrients/foods intake (ie, whether it is valid against nutrients/foods intake) among Greek preschoolers. METHODS Sampling The design and rationale of the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) have been described meticulously in a previous work (25). In brief, 2,518 children aged 1 to 5 years were enrolled in the study between April 2003 and July 2004. This cohort was recruited from a representative sample of randomly selected public and private nurseries as well as daycare centers within municipalities in five counties of Greece. All nurseries invited to participate responded positively. Among the total number of nursery schools studied (n⫽115), 63 were in Attica, 10 were in Thessalonica, 12 were in Halkidiki, 22 were in Aitoloakarnania, and eight were in Helia. The selected counties are widely scattered across the Greek dominion and their overall local population comprises about 70% of the total Greek population (Census 1999). After adjusting for parental age and education level of the population agreeing to participate in the study we observed no significant differences between the overall population characteristics and the study sample within counties, according to data provided by the National Statistical Service of Greece (Census 1999). Thus, the final sample is representative of 70% of the Greek population with proportions of children 12 to 23, 25 to 35, 36 to 47 and 48 to 60 months old being 8.7%, 21.7%, 38.8%, and 31.4%, respectively. Both a letter explaining the aims of the study and a consent form were distributed to each parent with a child in these nurseries. Parents agreeing to participate in the study had to sign the consent form and provide contact details. Approval to conduct the study was granted by the Ethical Committee of Harokopio University of Athens and by all municipalities invited to participate in the study. For this research only children aged 2 years or older were included because the HEI has been proposed for people aged ⱖ2 years (2,287 out of 2,518 children participated in the study). Anthropometric Measurements Anthropometric data (ie, body weight and height) of children were obtained by the use of standard procedures in all study sites (25). Body mass index (BMI) was calculated as kg/m2. Height of all children older than 2 years was measured standing. The Nutstat module of Epi Info (version 3.3.2, 2004, Centers for Disease Control and Prevention Division of Integrated Surveillance Systems and Services, Atlanta, GA) was used to determine children’s age- and sex-specific percentiles for weight, height and BMI. The US Centers for Disease Control and Prevention age- and sex-specific growth charts and relative cutoff points were used for the definition of overweight (26). Specifically, for children older than age 24 months, the BMI-for-age chart was used to classify children ⱖ85th and ⬍95th percentile as at risk of overweight and those ⱖ95th percentile as overweight.
Dietary Assessment Dietary intake data was obtained for 2 consecutive weekdays and 1 weekend day using a combination of techniques comprising the weighed food records (during nursery hours) and 24-hour recall or food diaries (outside nurseries). During the 2 weekdays, and while the child was at the nursery, a team member (ie, a registered dietitian) weighed and recorded all foods consumed by each child. Information on the food consumed outside the nursery for these specific weekdays was obtained during a prearranged meeting with the parent/guardian the following morning, using the procedure of the 24-hour recall. During these two morning interviews parents/guardians were familiarized with portion sizes and the relevant procedures required to successfully complete a food record at home on the forthcoming weekend day, most preferably Sunday. Parents/guardians were advised to return the food diaries at the nursery on Monday mornings, where a team member received and checked the records for potential errors. Food intake data were analyzed using the Nutritionist V diet analysis software (version 2.1, 1999, First Databank, San Bruno, CA), which was extensively amended to include traditional Greek foods and recipes, as described in Food Composition Tables and Composition of Greek Cooked Food and Dishes (18,27). Furthermore, the database was updated with nutrition information of chemically analyzed commercial food items widely consumed by infants and preschoolers in Greece. The ratio of reported energy intake and predicted basal metabolic rate was used to check for underreporting. More details are reported elsewhere (5). Diet Quality Assessment HEI score was used to assess overall diet quality of preschoolers (19). The HEI score is the sum of individual scores for 10 components. The first five components measure the degree of compliance of people’s diet with the US Department of Agriculture Food Guide Pyramid recommendations for grains, vegetables, fruit, dairy, and meat as expressed in servings per day. The next four components of the HEI assess the degree of adherence to Dietary Guidelines for Americans recommendations regarding several nutrients (eg, total fat, saturated fat, cholesterol, and sodium intakes). The final component examines the variety of foods in a person’s diet. Foods that were similar, such as two different forms of white bread, were considered one item as concerns variety. Scores between 0 and 10 were assigned to all components. For example, a score of 10 was assigned to each one of the first five components (ie, food groups) when someone consumed equal to or more than the recommended number of servings, as indicated in Table 1, whereas a score of 0 was assigned when no consumption was reported. Intermediate scores were computed proportionately to the number of servings consumed. As in the past (19), the score for each component was divided into three categories as follows: score⬍5 (poor diet), score between 5 and 8 (diet needs improvement), and score ⬎8 (good diet). In terms of HEI score, the categorization proposed by Kennedy and colleagues (19) was initially used (ie, an HEI score ⬎80 implies a “good” diet, a score between 50 and 80 indicates a diet needs improvement, and a score lower than 50
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Table 1. Components of the Healthy Eating Index and scoring systema as used to assess diet quality in the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287 children)b Component Grain consumption Children, 2-3 y Children, 4-5 y Vegetable consumption Children, 2-3 y Children, 4-5 y Fruit consumption Children, 2-3 y Children, 4-5 y Milk consumption Children, 2-3 y Children, 4-5 y Meat consumption Children, 2-3 y Children, 4-5 y Total fat intake Saturated fat intake Cholesterol intake Sodium intake Variety a
Scoring range
Criteria for minimum score of 0
Criteria for maximum score of 10
0-10
0 servings/d
6.0 servings/d 7.0 servings/d
0-10
0 servings/d
3.0 servings/d 3.3 servings/d
0-10
0 servings/d
2.0 servings/d 2.3 servings/d
0-10
0 servings/d
2.0 servings/d 2.0 servings/d
0-10
0 servings/d
0-10 0-10 0-10 0-10 0-10
ⱖ45% of energy from fat ⱖ15% of energy from saturated fat ⬎450 mg ⬎4,800 mg ⱕ9 different items over 3 d
2.0 servings/d 2.1 servings/d ⱕ30% of energy from fat ⬍10% of energy from saturated fat ⬍300 mg ⬍2,400 mg ⱖ24 different items over 3 d
The scores for intakes between the maximum and the minimum cutoffs were assigned proportionately. Adapted from Kennedy and colleagues (19).
b
indicates a “poor” diet). However, because only 0.4% of participating children had a score ⬎80, further analyses were performed using the quartile of the HEI score. In addition to the HEI, the HEI components as well as total energy intake, carbohydrate and protein intake, and some other selected nutrients such as folate, fiber, iron, vitamin C, magnesium, phosphorous, zinc, and calcium, were used to further assess preschoolers’ diet quality. These nutrients were selected because they are very important for children’s growth and because the risk for deficiencies is increased. Physical Activity Assessment Using a valid, structured questionnaire, information regarding children’s physical activity was obtained by parents during scheduled interviews at the nurseries (25,28). Emphasis was placed on light to vigorous physical activities with intensity higher than 4 metabolic equivalents (METs). More information on the type of activities comprising light to vigorous physical activity is presented elsewhere (25). Based on light to vigorous physical activities, children were divided into those with more than 3 hours of physical activity per week and those with ⬍3 hours/week. Statistical Analysis The Shapiro-Wilk test was used to evaluate the normality of continuous variables (ie, HEI score, HEI components score, energy intake , and several nutrients intake) (29). Continuous variables are presented as mean⫾standard deviation and categorical variables are summarized as
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relative frequencies (%). Correlations between food, macronutrient, or micronutrient intakes and HEI score were evaluated by the Pearson or Spearman correlation coefficient, as appropriate. Moreover, the associations between the HEI components, the overall HEI scores, and binary variables (ie, sex, child’s physical inactivity, maternal employment status, place of residence, and child’s age) were evaluated using Student t test or Mann-Whitney U test when scores had normal or skewed distribution, respectively. The associations between food/nutrient intakes and the groups of the HEI score as well as the associations of the HEI components/overall HEI scores with maternal educational status and children BMI status were examined using one-way analysis of variance after testing for equality of variances (homoscedacity) or Kruskal-Wallis test. However, due to multiple significance comparisons, the Bonferroni correction was used to account for the increase in Type I error. Finally, stepwise linear regression analysis was performed to determine the independently associated factors with the HEI score. Several sociodemographic characteristics (eg, maternal educational status and employment; child’s sex, age, and BMI; and the place of residence) were used as independent variables. A probability value of 0.05 was considered statistically significant. All statistical calculations were performed using the SPSS version 14.0 software (2005, SPSS Inc, Chicago, IL). RESULTS Among 2,287 participants, 22% were 2 years old, 41% were 3 years old, 32% were 4 years old, and the remaining
Table 2. Healthy Eating Index (HEI) component scores among preschoolers in Greece using results from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287 children) % in HEI Component Scores Group Food variable
Components score MeanⴞSDa
“Poor” diet (score<5)
“Needs improvement” diet (score 5.1-8)
“Good” diet (score >8)
Grains Vegetables Fruits Milk Meat Total fat Saturated fat Cholesterol Sodium Variety
4.5⫾1.9 1.2⫾1.5 5.5⫾3.5 9.4⫾1.7 5.5⫾2.9 3.3⫾0.6 1.2⫾2.4 9.8⫾0.9 9.9⫾0.3 8.3⫾2.3
68.9 97.3 51.7 8.2 48.8 99.7 90.3 1.3 0.1 11.0
25.7 2.4 14.2 6.0 28.2 0.3 6.1 2.2 0.1 34.7
5.5 0.3 34.1 85.8 23.0 0.0 3.6 96.5 99.8 54.4
a
SD⫽standard deviation.
5% were 5 years old. The majority of preschoolers had a poor diet as indicated by the fact that 80.5% had an HEI score ⬍50. Only 0.4% of preschoolers had HEI score ⬎80. The overall mean HEI score was 58.7⫾8.2. This implies that the participating preschoolers showed almost 59% (ie, 58.7 out of 100) adherence to the healthful diet that the HEI evaluates. Table 2 presents the mean values of all HEI components. They ranged between 1.2 and 10. The lowest mean values were found in components measuring vegetable and saturated fat intake (1.2⫾1.5 and 1.2⫾2.4, respectively) reflecting extremely low vegetable intake and excessive consumption of saturated fat. On the contrary, the highest mean values were observed in components measuring milk, cholesterol, and sodium intake as well as in the component that reflects the variety of foods consumed daily (9.4, 9.8, 10, and 8.3, respectively). In addition, Table 2 presents the percentage of participants having “poor” diet, diet that “needs improvement,” and “good” diet based on HEI components score. It is observed that almost all preschoolers (⬎90% of participants) had “poor” diet as concerns vegetable and total and saturated fat consumption and “good” diet regarding milk, cholesterol, and sodium consumption. Table 3 presents the mean values of the 10 HEI component scores and selected nutrients by the quartiles of the HEI score. As expected, the consumption of foods (in servings/day) and cholesterol (in milligrams/day) used as HEI components increases with increasing HEI score (ie, higher quartiles of HEI score), whereas total and saturated fat intakes decrease across higher quartiles of the HEI score. Moreover, it was observed that the selected nutrients were strongly correlated with HEI score, indicating that increased HEI score values reflect better diet quality (Table 3). In particular, folate, fiber, iron, vitamin C, magnesium, phosphorous, and zinc intakes were higher in the highest quartile of the total HEI score compared to the lowest quartile. Table 4 summarizes the mean values of HEI component scores and HEI score based on several sociodemographic characteristics. It was observed that HEI score was significantly higher among boys, children aged 4 to 5
years, children with more than 3 hours/week of physical activity, children living in rural or small towns, and those whose mothers had high educational status (⬎12 years) and were employed compared to their counterparts. No significant association was detected between child’s BMI status and HEI score. Although several subgroups were found to have higher average HEI scores compared to others, no subgroup had average score ⬎80 (which implies a “good” diet). Performing multiple linear regression, it was found that sex, age, and place of living as well as maternal educational and employment status were factors significantly associated with the total score (Table 5). DISCUSSION The HEI has been proposed by the US Department of Agriculture’s Center for Nutrition Policy and Promotion as a useful tool to assess the dietary status of Americans. The total score can be used to rank individuals by their diet quality, whereas individual components scores of HEI can be used to determine adequacy or inadequacy for dietary intake of specific food groups and nutrients. Although this index has been developed to assess dietary habits for people aged 2 years and older, there are limited data regarding the success of this index in assessing diet quality among preschoolers. In addition, this index has never been implemented in a Greek population and our work aimed to evaluate the dietary habits of Greek preschoolers through the HEI score and to investigate factors that may influence this score. Our results indicate that the HEI is a good tool to detect diet quality among preschoolers because it was observed that the HEI score was moderate to strongly associated not only with foods and nutrients that are index components but also with other selected nutrients such as folate, vitamin C, iron, potassium, magnesium, and fiber. These findings are in accordance with those reported in a previous work where the HEI score was applied in children aged between 9 and 14 years (30). Regarding Greek preschoolers’ diet quality, our results revealed that there is an increased necessity to improve children’s diet, because the vast majority of participants
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Table 3. Differences in food and nutrient intakes by Healthy Eating Index (HEI) score categories among preschoolers in Greece, based on results from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287 children) HEI Total Score Quartile Variable
1st (HEI <53)
2nd (HEI 53-59)
3rd (HEI 59-65)
4th (HEI >65)
P value
Correlation with HEI
4™™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™™™™3 HEI components Grains (servings/d) Vegetables (servings/d) Fruit (servings/d) Milk (servings/d) Meat (servings/d) Fat (% energy) Saturated fat (% energy) Cholesterol (mg/d) Intake of energy and other nutrients Energy (kcal/d) Carbohydrate (% energy) Protein (% energy) Folate (g/d) Fiber (g/d) Iron (mg/d) Vitamin C (mg/d) Magnesium (mg/d) Phosphorus (mg/d) Zinc (mg/d) Calcium (mg/d)
2.3⫾0.9 0.1⫾0.2 0.5⫾0.5 2.9⫾1.5 0.8⫾0.5 40.4⫾0.8 18.0⫾2.9 188⫾81
2.7⫾1.2 0.3⫾0.4 1.0⫾0.9 3.1⫾1.4 1.1⫾0.7 40.0⫾0.8 16.9⫾2.9 202⫾81
3.0⫾1.2 0.4⫾0.5 1.6⫾0.9 3.1⫾1.3 1.3⫾0.8 39.9⫾0.7 16.4⫾2.9 213⫾82
3.6⫾1.6 0.6⫾0.6 2.3⫾1.2 3.0⫾1.3 1.6⫾0.8 39.6⫾0.8 14.6⫾3.0 219⫾76
⬍0.001 ⬍0.001 ⬍0.001 0.026 ⬍0.001 0.001 ⬍0.001 ⬍0.001
0.37 0.41 0.69 0.04 0.42 ⫺0.34 ⫺0.39 0.18
1,192⫾225 45.3⫾0.8 17.2⫾1.4 115⫾45 8⫾3 9.3⫾6.3 46⫾28 153⫾38 1,032⫾312 7.4⫾2.7 970⫾328
1,366⫾243 45.6⫾0.8 17.1⫾1.7 143⫾50 10⫾3 9.8⫾4.9 65⫾38 181⫾41 1,130⫾349 8.4⫾2.8 1,020⫾311
1,490⫾271 45.7⫾0.7 16.9⫾1.7 171⫾60 12⫾4 10.7⫾4.5 86⫾48 201⫾46 1,235⫾342 8.8⫾2.9 1,065⫾299
1,597⫾286 45.9⫾0.8 16.9⫾1.8 198⫾64 14⫾5 11.4⫾4.7 106⫾53 219⫾50 1,247⫾359 9.2⫾2.9 1,028⫾324
⬍0.001 ⬍0.001 0.04 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
0.56 0.30 ⫺0.05 0.56 0.60 0.25 0.52 0.55 0.27 0.28 0.09
(80.5%) have “poor diet” and almost the rest of participants (19%) have a diet that “needs improvements.” Furthermore, the mean value of the HEI score was almost 59. This value indicates that diet quality of Greek preschoolers is lower compared to that of US preschoolers and children (24,31,32). For instance, in a survey conducted during 1999-2000, Basiotis and colleagues (32) reported that the mean value of the total HEI score was 75.5 and 66.9 for children aged 2 to 3 years and 4 to 6 years, respectively. In addition, a study carried out among US children aged 2 to 5 years to evaluate their diet quality by beverage pattern revealed that the HEI mean score ranged between 70.9 and 79.0 (24). Similar results were found among low-income US children aged 2 to 3 and 4 to 8 years because the HEI mean score was 68.8 and 65.8, respectively, for light eaters and 78.1 and 69.6, respectively, for substituters (31). On the other hand, the mean HEI score in our work was close to that proposed from a similar study conducted in another Mediterranean country (Spain) among children aged 6 to 7 years (mean HEI score 64.6) (33). These results indicate that the diet quality of children from Mediterranean countries is lower compared to that observed in children from the United States. Low diet quality observed both in our work and in the study conducted in Spain could be partially attributed to the increased consumption of total and saturated fat. It is remarkable that the scores of HEI components measuring total and saturated fat intakes were too low in both studies. In particular, the score was 3.3 and 2.9 for total fat and 1.2 and 0.7 for saturated fat intake in our study and the Spanish study (33), respectively, indicating that
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the vast majority of children consumed extremely high quantities of total and saturated fat. In our study, the consumption of total and saturated fat was higher than the recommended even among children in the highest HEI quartiles. The low consumption of vegetables and grains observed in our study may contribute to the low overall diet quality of Greek preschoolers. In particular, it was found that the daily consumption of these foods was lower than recommendations even in children in the highest HEI quartile. These findings are not in accordance with those reported in the study conducted in Spain (33). However, these findings are in agreement with studies reporting that fruits, vegetables, and whole grains consumption could be increased in children from the United States (34,35). Therefore, it was realized that Greek preschoolers’ dietary habits adhere more to a Western diet pattern rather than to a Mediterranean diet as was expected. These findings are consistent with the results of other studies conducted in Greek populations, indicating that dietary habits in Greece have changed dramatically during past decades toward a more Westernized pattern (36). In particular, it has been revealed that fat intake among children and adolescents are much higher than recommended (37,38). Moreover, a recently published study showed that a majority of Greek children consume sugaradded beverages on a daily basis and this is strongly related to low intake of fruit and vegetables (39). Finally, it was detected that children whose mothers had low educational status (ie, ⬎9 years) or were unemployed had lower HEI score compared to those whose mothers’ education lasted more than 9 years or were
Table 4. Healthy Eating Index (HEI) component scores and total HEI score by several characteristics of preschoolers and their mothers in Greece, based on results from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287) HEI Component Characteristic
Grains
Vegetables Fruits
Milk
Meat
Total fat
Saturated fat Cholesterol Sodium
Variety
Overall
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ mean⫾standard deviation ™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3 Sex Male Female Age (y) 2-3 4-5 Child body mass index status Normal weight At risk of being overweight Overweight Physical activity status ⬍3 h/wk ⬎3 h/wk Place of residence Large urban/urban Rural/small towns Maternal employment Unemployed Employed Maternal educational status (y) ⬍9 9-12 ⬎12
4.7⫾1.9* 1.2⫾1.5 4.4⫾1.8 1.2⫾1.6
5.5⫾3.5 5.5⫾3.5
9.5⫾1.5* 5.6⫾2.9 9.3⫾1.9 5.4⫾2.9
4.0⫾1.6* 1.0⫾1.4* 5.6⫾1.9 1.4⫾1.8
5.1⫾3.5* 9.4⫾1.6 6.2⫾3.6 9.3⫾1.8
4.5⫾1.8* 1.2⫾1.6
5.6⫾3.5
4.6⫾1.9 4.9⫾1.9
1.2⫾1.5 1.1⫾1.6
5.4⫾3.4 5.1⫾3.5
4.5⫾1.8 4.7⫾1.8
3.3⫾0.6 3.3⫾0.6
1.2⫾2.4 1.2⫾2.4
9.8⫾1.0 9.8⫾0.9
9.9⫾0.3 8.4⫾2.2* 59.2⫾8.3* 9.9⫾0.1 8.2⫾2.3 58.2⫾8.1
5.9⫾3.0* 3.4⫾0.6* 1.1⫾2.3* 4.6⫾2.5 3.1⫾0.5 1.4⫾2.6
9.9⫾0.6* 9.6⫾1.4
9.9⫾0.3 8.1⫾2.3* 58.2⫾0.2* 9.9⫾0.2 8.7⫾2.0 59.9⫾8.4
9.3⫾1.7
5.5⫾2.9
3.3⫾0.6
1.2⫾2.4
9.8⫾0.9
10.0⫾0.3 8.3⫾2.3
58.8⫾8.2
9.6⫾1.5 9.5⫾1.6
5.5⫾2.9 5.7⫾2.8
3.3⫾0.5 3.3⫾0.6
1.2⫾2.3 1.1⫾2.2
9.9⫾0.7 9.7⫾1.2
10.0⫾0.1 8.3⫾2.2 10.0⫾0.1 8.4⫾2.1
58.9⫾8.0 58.8⫾7.9
1.1⫾1.5* 1.6⫾1.7
5.4⫾3.5* 9.4⫾1.7* 5.5⫾2.9 6.1⫾3.4 9.7⫾1.4 5.5⫾2.8
3.3⫾0.5 3.3⫾0.5
0.8⫾2.1* 1.3⫾2.4
9.8⫾0.9 9.9⫾0.6
10.0⫾0.3 8.2⫾2.3* 58.5⫾8.2* 10.0⫾0.1 8.8⫾2.0 60.4⫾7.3
4.5⫾1.9* 1.1⫾1.5* 4.7⫾1.7 1.4⫾1.6
5.4⫾3.6* 9.3⫾1.8* 5.5⫾2.9 5.8⫾3.4 9.7⫾1.3 5.6⫾2.8
3.2⫾0.5* 0.5⫾1.7* 3.4⫾0.6 1.4⫾2.6
9.8⫾1.0 9.9⫾0.6
10.0⫾0.3 8.2⫾2.3* 58.5⫾8.3* 10.0⫾0.1 8.6⫾2.0 59.4⫾7.7
4.5⫾1.8 4.5⫾1.9
1.0⫾1.5* 1.3⫾1.5
4.7⫾3.6* 9.3⫾1.7 5.8⫾3.5 9.4⫾1.7
5.5⫾2.9 5.5⫾2.9
3.3⫾0.6 3.3⫾0.5
1.2⫾2.4 1.3⫾2.4
9.8⫾0.9 9.8⫾0.9
10.0⫾0.1 7.9⫾2.5* 57.2⫾8.9* 10.0⫾0.3 8.4⫾2.2 59.3⫾7.9
4.6⫾1.9 4.7⫾1.7 4.5⫾1.9
0.8⫾1.4* 1.2⫾1.6 1.3⫾1.6
4.9⫾3.6* 9.4⫾1.7 5.1⫾3.6 9.3⫾1.8 5.8⫾3.4 9.5⫾1.5
5.8⫾2.9 5.4⫾2.9 5.5⫾2.9
3.2⫾0.5 3.3⫾0.5 3.4⫾0.6
0.9⫾2.0 1.1⫾2.3 1.3⫾2.5
9.6⫾1.5* 9.8⫾0.9 9.8⫾0.9
10.0⫾0.1 8.1⫾2.4 10.0⫾0.1 8.2⫾2.3 10.0⫾0.3 8.4⫾2.2
57.7⫾8.0* 58.3⫾8.3 59.4⫾8.1
*P⬍0.05 for comparisons of HEI component values and total HEI score among the several groups of each characteristic (eg, between boys and girls).
employed. This finding implies that children who live in a household with low socioeconomic status have lower diet quality compared to children from households with high socioeconomic status. This result is in agreement with previous studies reporting that socioeconomically disadvantaged groups adopt a dietary profile less consistent with dietary recommendations (40,41). As concerns the relationship between education status and diet quality, the level of knowledge regarding nutrition and its links with health has been proposed as a possible pathway. Several epidemiologic studies conducted among adults have reported that people with low education status have low level of knowledge about healthful dietary practices and their benefits on health (42). It is possible that uneducated or low educated mothers are not familiar with the importance of a healthful diet for their child’s normal development and prevention of several chronic diseases and with the existence of specific dietary recommendations for this age group. Moreover, education level is an important determinant of occupation and consequently this is a determinant of income level. That is, people with low education status are more likely to be unemployed and to have a low income level. Previous work has shown that people with low economic status exhibit food purchasing behavior that is as least as consistent with a
healthful dietary pattern as their higher economic status counterparts. More specifically, it has been detected that the former are more likely to purchase high-fat and highsugar foods and less likely to buy foods rich in fiber compared to the latter (42-45). These choices have partly been attributed to the increased cost of healthful foods (42). Still, there are some potential limitations in this study. The weekday intakes were collected with greater precision than the weekend intakes because 24-hour recall or food diaries were used for preschoolers’ dietary assessment outside nurseries. Therefore, it is possible that there is a bias in the estimation of children’s diet quality through the HEI score (ie, skewed diet scores), because score of 0 was assigned when no consumption was reported. However, the addition of a third weekday, the use of weighted records for 2 of 3 days, cultural tailoring of the dietary data base, parental training by a trained registered dietitian, and the availability of a registered dietitian during the weekday/weekends were used to address these limitations, strengthen the study. Another limitation of this work is that the HEI score was calculated according to the version based on the 2000 Dietary Guidelines for Americans HEI-2000) instead of the updated HEI based on 2005 recommendations (HEI-2005), which have recently been published (46). This limitation
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Table 5. Sociodemographic factors associated with Healthy Eating Index (HEI) total score among preschoolers in Greece, based on results from multiple logistic regression of data from the Growth, Exercise, and Nutrition Epidemiological Study In preSchoolers (GENESIS) (n⫽2,287) Independent variable Sex Male Female Child’s age (y) 2-3 3-4 Place of residence Large urban/urban Rural/small towns Maternal employment Unemployed Employed Maternal educational status (y) ⬍9 9-12 ⬎12 a
 (95% CIa)
P value
Reference category ⫺1.00 (⫺1.75 to ⫺0.25)
— 0.009
Reference category 2.05 (1.23 to 2.87)
— ⬍0.001
Reference category 1.79 (0.89 to 2.69)
— ⬍0.001
Reference category 2.12 (1.14 to 3.10)
— ⬍0.001
Reference category .69 (⫺0.62 to 2.01) 1.45 (0.15 to 2.76)
— 0.303 0.029
CI⫽confidence interval.
is attributed to the lack of records for some dietary data (eg, whole fruits, dark green and orange vegetables, and legumes) that are components of the HEI-2005. However, the use of the total HEI-2000 and HEI-2005 scores in the same population showed that the latter was lower compared to the former (46). That is, the HEI-2005 is stricter in evaluating the diet quality compared to the HEI-2000. Therefore, it is ensured that the main conclusion of our study (ie, a majority of Greek preschoolers follow a poor diet) is not biased by the use of HEI-2000. Moreover, a valid questionnaire to assess the children’s physical activity was used, although it is widely accepted that the use of accelerometry would provide more valid data. HEI was found to be strongly associated with the intake of several essential nutrients that are important for children’s development and health. Therefore, the HEI could be considered a good index to assess diet quality of preschoolers. Moreover, our study provides a snapshot of the diets of Greek preschoolers that indicates that they follow a poor diet that is high in total and saturated fat and inadequate in fruits, vegetables, and grains. These findings highlight the need to draw up and implement policies and programs that raise the awareness of parents regarding their children’s poor diet quality and the potential adverse effects of this on their children’s health and development. These programs should focus especially on parents with low education status or those who are unemployed, as well as those living in large urban areas and underscore the need to enrich their children’s diet with more fruits, vegetables, and grains and reduce total and saturated fat intakes to meet recommendations. The GENESIS study was supported by a Research Grant from Friesland Foods Hellas. Yannis Manios works as a
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part-time scientific consultant for Friesland Foods Hellas. The study sponsor had no interference in the study design, data collection, or writing of the manuscript. The authors thank Vivian Detopoulou, Anastasia Anastasiadou, Christine Kortsalioudaki, Elina Ioannou, Margarita Bartsota, Thodoris Liarigkovinos, Elina Dimitropoulou, Nikoleta Vidra, Theodoros Athanasoulis, Pari Christofidou, Lilia Charila, Sofia Tzitzirika and Christos Vassilopoulos for their contribution to the completion of the study. References 1. Stevenson J. Dietary influences on cognitive development and behaviour in children. Proc Nutr Soc. 2006;65:361-365. 2. Martin HP. Nutrition: Its relationship to children’s physical, mental, and emotional development. Am J Clin Nutr. 1973;26:766-775. 3. Devaney B, Ziegler P, Pac S, Karwe V, Barr SI. Nutrient intakes of infants and toddlers. J Am Diet Assoc. 2004;104(suppl 1):S14-S21. 4. Kranz S, Siega-Riz AM, Herring AH. Changes in diet quality of American preschoolers between 1977 and 1998. Am J Public Health. 2004;94:1525-1530. 5. Manios Y, Grammatikaki E, Papoutsou S, Liarigkovinos T, Kondaki K, Moschonis G. Nutrient intakes of toddlers and preschoolers in Greece: The GENESIS study. J Am Diet Assoc. 2008;108:357-361. 6. Munoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and adolescents compared with recommendations. Pediatrics. 1997;100:323-329. 7. Magkos F, Manios Y, Christakis G, Kafatos AG. Age-dependent changes in body size of Greek boys from 1982 to 2002. Obesity (Silver Spring). 2006;14:289-294. 8. Angelopoulos PD, Milionis HJ, Moschonis G, Manios Y. Relations between obesity and hypertension: Preliminary data from a crosssectional study in primary schoolchildren. Eur J Clin Nutr. 2006;60: 1226-1234. 9. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA. 2004;291: 2107-2113. 10. Hesketh K, Wake M, Waters E, Carlin J, Crawford D. Stability of body mass index in Australian children: A prospective cohort study across the middle childhood years. Public Health Nutr. 2004;7:303-309. 11. Boulton TJ, Magarey AM, Cockington RA. Tracking of serum lipids and dietary energy, fat, and calcium intake from 1 to 15 years. Acta Paediatr. 1995;84:1050-1055. 12. Kranz S, Mitchell DC, Siega-Riz AM, Smiciklas-Wright H. Dietary fiber intake by American preschoolers is associated with more nutrient-dense diets. J Am Diet Assoc. 2005;105:221-225. 13. Kranz S, Smiciklas-Wright H, Siega-Riz AM, Mitchell D. Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pediatr. 2005;146:105-111. 14. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med. 2000;154: 1148-1152. 15. Hampl JS, Taylor CA, Johnston CS. Intakes of vitamin C, vegetables and fruits: Which schoolchildren are at risk? J Am Coll Nutr. 1999; 18:582-590. 16. Hu FB. Dietary pattern analysis: A new direction in nutritional epidemiology. Curr Opin Lipidol. 2002;13:3-9. 17. Huijbregts P, Feskens E, Rasanen L, Fidanza F, Nissinen A, Menotti A, Kromhout D. Dietary pattern and 20-year mortality in elderly men in Finland, Italy, and The Netherlands: Longitudinal cohort study. BMJ. 1997;315:13-17. 18. Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, Gnardellis C, Lagiou P, Polychronopoulos E, Vassilakou T, Lipworth L, Trichopoulos D. Diet and overall survival in elderly people. BMJ. 1995;311:14571460. 19. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: Design and applications. J Am Diet Assoc. 1995;95:1103-1108. 20. Patterson RE, Haines PS, Popkin BM. Diet quality index: Capturing a multidimensional behavior. J Am Diet Assoc. 1994;94:57-64. 21. Fung TT, Hu FB, Barbieri RL, Willett WC, Hankinson SE. Dietary patterns, the Alternate Healthy Eating Index, and plasma sex hormone concentrations in postmenopausal women. Int J Cancer. 2007; 121:803-809. 22. Pick ME, Edwards M, Moreau D, Ryan EA. Assessment of diet quality
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