KIDMEN TEST, Mediterranean diet.pdf

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Nutr Hosp. 2015;32(6):2390-2399ISSN 0212-1611 CODEN NUHOEQ

S.V.R. 318

Revisin

KIDMED test; prevalence of low adherence to the Mediterranean Diet in

children and young; a systematic reviewS. Garca Cabrera1, N. Herrera Fernndez1, C. Rodrguez Hernndez1, M. Nissensohn1,2,3,B. Romn-Vias3,4,5y L. Serra-Majem1,2,3,4

1Universidad de Las Palmas de Gran Canaria, Facultad de Ciencias de la Salud, Las Palmas de Gran Canaria. 2Institutode Investigacin Biomdica y Sanitaria (IUIBS), Grupo de Investigacin de Nutricin, Universidad de Las Palmas de GranCanaria, Las Palmas de Gran Canaria. 3Ciber Fisiopatologa Obesidad y Nutricin (CIBEROBN, CB06/03), Instituto de SaludCarlos III, Madrid. 4Fundacin de Investigacin de Nutricin, Barcelona. 5Departamento de Ciencias del Deporte, Facultad dePsicologa, Ciencias de la Educacin y el Deporte Blanquerna, Universidad Ramon Llull, Barcelona. Espaa.

Abstract

Introduction: during the last decades, a quick and

important modification of the dietary habits has beenobserved in the Mediterranean countries, especiallyamong young people. Several authors have evaluated thepattern of adherence to the Mediterranean Diet in thisgroup of population, by using the KIDMED test.

Objectives: the purpose of this study was to evaluatethe adherence to the Mediterranean Diet among childrenand adolescents by using the KIDMED test through asystematic review and meta-analysis.

Methods: PubMed database was accessed untilJanuary 2014. Only cross-sectional studies evaluatingchildren and young people were included. A randomeffects model was considered.

Results:eighteen cross-sectional studies were included.The population age ranged from 2 to 25 years. The totalsample included 24 067 people. The overall percentageof high adherence to the Mediterranean Diet was 10%(95% CI 0.07-0.13), while the low adhesion was 21%(IC 95% 0.14 to 0.27). In the low adherence group,further analyses were performed by defined subgroups,finding differences for the age of the population and thegeographical area.

Conclusion: the results obtained showed importantdifferences between high and low adherence to theMediterranean Diet levels, although successive subgroupanalyzes were performed. There is a clear trend towardsthe abandonment of the Mediterranean lifestyle.

(Nutr Hosp. 2015;32:2390-2399)

DOI:10.3305/nh.2015.32.6.9828Key words: Kidmed. Mediterranean Diet. Adherence.Meta-analysis.

TEST KIDMED; PREVALENCIA DE LA BAJAADHESIN A LA DIETA MEDITERRNEAEN NIOS Y ADOLESCENTES; REVISIN

SISTEMTICA

Resumen

Introduccin:en las ltimas dcadas se ha observadouna modificacin rpida e importante de los hbitos die-tticos en los pases mediterrneos, especialmente entrelos jvenes. Varios autores han evaluado el patrn de ad-hesin a la Dieta Mediterrnea en este grupo de pobla-cin, mediante el uso de la prueba KIDMED.

Objetivos:el objetivo de este estudio fue evaluar la ad-hesin a la Dieta Mediterrnea entre los nios y adoles-centes mediante el uso de la prueba KIDMED a travs deuna revisin sistemtica y un metaanlisis.

Mtodos: la base de datos PubMed fue revisada has-ta enero de 2014. Los estudios incluidos solo fueron lostransversales que evaluaron a nios y a jvenes. Se consi-der un modelo de efectos aleatorios.

Resultados: se incluyeron dieciocho estudios trans-versales. La edad de la poblacin vari de 2 a 25 aos.La muestra total incluy 24.067 personas. El porcentajeglobal de alta adhesin a la Dieta Mediterrnea fue del10% (IC del 95%: 0,07 a 0,13), mientras que la baja ad-hesin fue del 21% (IC 95%: 0,14 a 0,27). Nuevos anlisispor subgrupos definidos fueron realizados en el grupo debaja adhesin, encontrando diferencias para la edad dela poblacin y para la zona geogrfica.

Conclusin: los resultados obtenidos mostraron dife-rencias importantes entre alta y baja adhesin a la Dieta

Mediterrnea, a pesar de los sucesivos anlisis de sub-grupos que se realizaron. Existe una clara tendencia ha-cia el abandono del estilo de vida mediterrneo.

(Nutr Hosp. 2015;32:2390-2399)

DOI:10.3305/nh.2015.32.6.9828

Palabras clave:KIDMED. Dieta mediterrnea. Adhesin.Metaanlisis.

Correspondence:Nissensohn MarielaDepartmento de Ciencias Clnicas,Universidad de Las Palmas de Gran Canaria,Las Palmas de Gran Canaria, Espaa.E-mail: [email protected]

Recibido: 27-VIII-2015.Aceptado: 9-IX-2015.


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2391Nutr Hosp. 2015;32(6):2390-2399KIDMED test; Prevalence of lowadherence to the Mediterranean Diet in

children and young; A systematic review

Introduction

The Mediterranean Diet (DM) includes not only anacknowledged food pattern but also several social andgastronomical aspects that characterize a certain life-style. It combines ingredients of the local agriculture,recipes and the traditional cooking methods of each geo-graphical area within the Mediterranean basin, togetherwith a regular and moderate physical activity practice1.It is an overall lifestyle that the modern science and thecurrent recommendations invite us to adopt to improveour health. The MD is characterized by the intake of agreat amount of vegetables, fruits, bread and other formsof cereal, rice, beans and nuts. It also includes virgin ol-ive oil as the principal source of fat, moderate amountsof dairy products (basically cheese and yogurt), moder-ate amounts of fish, red meat in low amounts, and wineconsumed in little quantities, normally accompanyingmeals. The importance of this dietary pattern is relatedto being a balanced and varied diet and providing mostof the recommended macronutrients in their right pro-

portion. It is characterized by a low content of saturatedfatty acids and a high content in monounsaturated fat-ty acids, as well as high amounts of fiber and complexcarbohydrates, and important amounts of antioxidants1.All of them play an important role in the prevention ofcardiovascular and cerebrovascular diseases, diabetes,obesity, neurodegenerative illnesses and cancer, thathave been attributed to the MD2,3. The MD was ascribedto the list of Intangible Cultural Heritage of UNESCOin November 2010, as a cultural monument of Greece,Italy, Spain and Morocco (decision 5.COM 6.41)4.

In the last forty years, a quick and important modi-fication of the dietary habits has been observed in the

Mediterranean countries, especially among young peo-ple5. Several factors have contributed to those changes,such as less time and attention devoted to food acqui-sition and preparation, resulting in an increase in theconsumption of processed foods, inadequate levels ofconsumption of products of animal origin, speciallymeat and meat products, an excessive intake of refinedsugars, and a substantial increase of saturated fats andcholesterol in the diet6,7.

The aim of this study was to conduct a systematic re-view and a meta-analysis to evaluate the adherence to theMD among children and adolescents using the results ofcross sectional studies that have used the KIDMED test.

Materials and methods

The PubMed database was accessed using the termKIDMED to identify the most relevant studies. Onlycross-sectional studies carried out in children and youngpeople (between 2 and 25 years old) and published fromJanuary 2004 to January 2014 were included. In addition,the reference list of the retrieved articles was searched tofind other relevant articles. Papers were considered eli-gible for inclusion if they a) were cross-sectional studies,

b) used the KIDMED test as a tool to evaluate the adher-ence to the MD in children and youths, c) evaluated theadherence to the MD, d) were conducted during the lastdecade. The exclusion criteria applied were: a) studieswhich used different categories to express the results ofthe KIDMED test, b) studies which did not include theresults of the test KIDMED and c) studies which analyz-ed the same population group (repeated results).

After the selection process, data were extractedfrom each study and organized using a standard form.The data selected were the following: name of first au-thor, country and year of publication, place where thestudy was conducted, data collection year, sample sizeand age range of the participants for each study. Fur-thermore, percentages of adherence to the MD wereassess for each study.

KIDMED test: The KIDMED test (MediterraneanDiet Quality Index for children and teenagers) is a tool toevaluate the adherence to the MD for children and youths.It was developed and validated by Serra-Majem et al.7.

The index ranges from 0 to 12 and is based on a

16-questions test that can be self-administered orconducted by interview (pediatrician, dietitian, etc.).Questions denoting a negative connotation with re-spect to the MD are assigned a value of -1, and thosewith a positive aspect +1 (Table I). The sums of thevalues from the administered test are classified intothree levels: 1) >8, optimal Mediterranean Diet; 2)47, improvement needed to adjust intake to Mediter-ranean patterns; 3) 3, very low diet quality8.

Statistical analysis

The adherence to the MD, obtained with the KID-MED index, was assessed. The method used to sys-tematically review the results was a formal meta-anal-ysis9. A random effects model was considered to bemore appropriate than a fixed-effect model.

First we conducted a meta-analysis using the studieswith the percentages with high adherence to the MDand after a meta-analysis using those with low ad-herence. With the information of the percentages, wecalculated the pooled effect as the average of the highadherence and the low adherence to the MD.

We used the DerSimonian & Lairds model10to poolthe adherence values across the studies. The formula

we used to estimate the weighted average was:

w= X

w= wX

w

Where wis the weighted average of a series of data:

X= {x1,x

2,x

3,..x

n} X is the repeated value, which

correspond the weights: W= {w1,w

2,w

3,..w

n} W is

the number of times that X occurs, the weight. So,the weighted average (

w) is the sum of each studys

product and their weight, divided all the studies weight.


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2392 Nutr Hosp. 2015;32(6):2390-2399 S. Garca Cabrera et al.

The formula to estimate the weight (wi) of eachstudy was: wi = 1 / Vi + , where Vi is the variance ofeach study and is the inter-study variance.

Besides, we calculated a 95% confidence interval(CI) for the pooled estimated of the effect size:

95% CI =pooled effect (1.96 x SE pooled)

where the lower limit was:

p - Z

p(1 p)

n

and the higher limit was:

p + Zp(1 p)

n

Where, the value of Z was 1.96, p was the per-centage of people with low adherence to the MD andn was the sample size.

A test of heterogeneity was calculated, estimat-ing Q statistics, which follows a chi- square distri-bution with degree of freedom n-1, being n thenumber of studies included in the analysis. The Iindex measures the extent of the heterogeneity. Thecut-off point to detect the heterogeneity was placedin 10% (p=0.1). A lower p-value than 0.1 for thisstatistic indicates the presence of heterogeneitysomewhat compromises the validity of the pooledestimates11.

Because significant heterogeneity was clearly ev-

ident in the pooled analysis estimated for all studiescombined, possible sources of heterogeneity were con-sidered through a subset analysis carried out only inthe low adherence group. We considered gender (maleand female), age (less than 12 years and over 12 yearsold), group of countries (Western countries: Spain12-18

and Chile19and Eastern countries: Greece20-24, Italy25,26,Cyprus27,28and Turkey29) and the representativeness ofthe sample.

The 3.1.0 version (R Development Core Team,2014) of the statistical package R-meta was used toconduct the statistical analyses.

Table IKIDMED test to assess the Mediterranean Diet adhesion8

KIDMED test Scoring

Takes a fruit or fruit juice every day +1

Has a second fruit every day +1

Has fresh or cooked vegetables regularly once a day +1

Has fresh or cooked vegetables more than once a day +1

Consumes fish regularly (at least 23/week) +1

Goes >1/ week to a fast food restaurant (hamburger) -1

Likes pulses and eats them >1/week +1

Consumes pasta or rice almost every day (5 or more per week) +1

Has cereals or grains (bread, etc) for breakfast +1

Consumes nuts regularly (at least 23/week) +1

Uses olive oil at home +1

Skips breakfast -1

Has a dairy product for breakfast (yoghurt, milk, etc) +1Has commercially baked goods or pastries for breakfast -1

Takes two yoghurts and/or some cheese (40 g) daily +1

Takes sweets and candy several times every day -1

KIDMED Index Adherence to Med Diet

Score 3 points Poor

Score 4-7 points Medium

Score 8 points High8Adapted from:Serra-Majem, L.; Ribas, L.; Garca, A.; Prez-Rodrigo, C.; Aranceta, J. Nutrient adequacy and Mediterranean Diet in Spanishschool children and adolescents.Eur J Clin Nutr.2003; 57, 359.


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children and young; A systematic review

Results

Thirty-eight articles were identified in the initialsearch strategy. After applying the inclusion and ex-clusion criteria, eighteen cross-sectional studies wereselected for the meta-analysis (Roccaldo et al. 201425;Vassiloudis et al. 201420; Grosso et al. 201326; GraoCruces et al. 201313; Rodrguez R et al. 201319; Cos-tarelli et al. 201321; Prado C et al. 201114; Prez et al.201115; Dur et al. 201112; Sahingoz et al. 201129 ; Fa-rajian et al. 201122 ; Arvaniti et al. 201123; Mazaraki etal. 201124; Lazarou et al. 2010 27; Daz A. et al. 201016;Lazarou et al. 201028; Mariscal-Arcas et al. 200917andSerra-Majem et al. 200418).

Descriptive characteristics of the included stud-ies are presented in the Table II. The population in-cluded children and teenagers with ages between twoand twenty-five years. The eighteen studies included24.067 participants with individual study sizes rangingfrom 81 in the study by Lazarou et al.27to 4786 in thestudy by Farajian et al.22. Two of the included studies

were conducted in Italy, five in Greece, seven in Spain,one in Chile, one in Turkey and two in Cyprus.

Figure 1 shows the adherence to the MD by catego-ries of the KIDMED index in the included studies. Thepercentages of adherence ranged from 2.9% as lowadherence, 48.6% as medium adherence and 48.5%as high adherence in the study by Mariscal et al.17to

46.8% of low adherence, 48.9% of medium adherenceand 4.3% of high adherence in the study by Farajianet al.22. The Lazarou et al.27 study shows the results ofmedium and high adherence together.

In order to summarize the results, we performed thepooled analysis shown in figure 2 and 3. On average,the pooled estimation of the percentage of high ad-herence to the MD was 10% (CI 95% 0.07-0.13). Thepooled estimation of the percentage of low adherencewas 21% (CI 95% 0.14-0.27). However, substantialheterogeneity was present in both analysis (I2 = 99.7%,p


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High adherence to MD

Medium adherence to MD

Low adherence to MD

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Maris

cal-A

rcasetal

.(200

9)

Serra

-Maje

metal

.(200

4)

Vassi

loudiset

al.(2

014)

Ayech

uetal

.(201

0)

Duret

al.(2

011)

Pradoet

al.(2

011)

Grao

Cruc

esetal

.(201

3)

Costa

rellietal

.(20

13)

Prezet

al.(2

011)

Sahin

gozetal

.(201

1)

Gros

soetal

.(201

3)

Rodr

guezet

al.(2

013)

Arva

nitietal

.(20

11)

Rocca

ldoetal

.(201

4)

Lazar

ouetal

.(201

0)

Lazar

ouetal

.(201

4)

Maza

rakietal

.(20

11)

Faraj

ianetal

.(201

1)

Fig. 1.Adherence to the Mediterranean Diet assess by the KIDMED index in the studies included in the analysis.

12 years was 19% (CI 95% 0.12-0.26). However,substantial heterogeneity was found in both groupsrespectively: I2 = 99.6%, p


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Fig. 5.Effect size of the per-centages of low adherence tothe Mediterranean Diet in the13 studies among females.

Fig. 6.Effect size of the per-centages of low adherence tothe Mediterranean Diet in the6 studies with children agedunder 12 years old.

Fig. 7.Effect size of the per-centages of low adherence tothe Mediterranean Diet in the8 studies with children over12 years old.

Fig. 8.Effect size of thepercentages of low adheren-ce to the Mediterranean Dietin the 10 studies carried outin: Greece, Cyprus, Italy andTurkey.


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population considered ranged between 2 and 25 years.This is a large age range including children, adolescentand young adults, which could increase the possibilityof finding unreliable results.

All these factors might have contributed to the het-erogeneity found, that persisted despite various sub-groups analyzes, which somewhat compromised thevalidity of the pooled estimates. Studies conducted indifferent geographical areas and with different timeframe on different populations lead to different results.The studies included were based on population sam-ples from six different countries: Chile, Cyprus, Spain,Greece, Italy and Turkey. All of them are Mediterra-nean countries (except Chile, which follows a similardietary pattern to the MD). However, there were otherimportant issues that might have explain to considerpossible differences between the more traditional con-texts; such is the case of the Sicily Island whose diethabits includes a high consumption of fried dishes orLas Palmas de Gran Canaria, where there is a signif-icant consumption of stews and roasted maize meal.

Conclusion

The results obtained showed important differencesbetween high and low adherence to the MD, althoughsuccessive subgroup analyzes were performed. Thelow adherence was 21%, which indicates that there isa trend towards the abandonment of the Mediterraneanlifestyle that could unfortunately result into the occur-rence of adverse health events.

Given the effectiveness of the MD dietary patternon its well-known health benefits33,it is necessary to

promote its consumption not only in non-Mediterra-nean countries but also in the Mediterranean countriesthemselves where adherence has been decreasing inthe last decades34, taking special attention on childrenand young people where there are a clear trend to therapidly abandoning of the MD35-37.

Finally, it is important to note that this work is a de-scriptive analysis. Then, the determinants of adherenceto the MD should be interpreted with caution.

Conflicts of interest

The authors declare that they have no conflict of in-terest.

Acknowledgments

We would like to thank to all the people that havecollaborated in carrying out this work. Special thanksto Prof. Pedro Saavedra Santana from the Departmentof Mathematics of the University of Palmas de GranCanaria, Spain for the support provided in assistancein the analyses.

Contributions

SG, NH and CR contributed to the design of thestrategy for the literature search. LSM prepared themain outline of the manuscript. SG, NH, CR and MNselected the data and writing the manuscript. BR con-tributed to the selection of studies and data extraction.All authors contributed to the preparation of the finalmanuscript.

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KIDMEN TEST, Mediterranean diet.pdf