compliance with mediterranean diet

8/11/2019 Compliance With Mediterranean Diet

1/6

Research report

Compliance with Mediterranean Diet Quality Index (KIDMED) and nutritionknowledge levels in adolescents. A case study from Turkey

Semra Akar Sahingoz a,*, Nevin Sanlier b

a Gazi University Industrial Arts Education Faculty, Department of Family and Consumer Sciences Education, Food and Nutrition Technology Division, 06830 Golbas, Ankara, Turkeyb Gazi University Faculty of Health Sciences, Department of Nutrition and Dietetics, 06500, Besevler, Ankara, Turkey

Introduction

Rapid developments in the food industry,as well as sociological

and technological developments, have changed nutritional habits;

many people are more likely to eat convenience (i.e. processed)

foods (Horinger & Imoberdof, 2000; Serra-Majem et al., 2004).

Eating patterns can have a significant positive effect on healthy

growth and development during childhood and adolescence

(Loewen & Pliner, 1999; Kroke et al., 2004) and on of health

issues in later life (Garemo, Arvidsson Lenner, Karlge Nilsson,

Borres, & Strandvik, 2007; Neumark-Sztainer, Wall, Perry, & Story,

2003).

There are many factors that contribute to obesity, including

over-eating malnutrition and lack of physical activity. Additionally,

other factors related to obesity are genetic, environmental,

neurological, physiological, biochemical, socio-cultural and psy-

chological. The overall global rise in obesity, particularly inchildhood obesity, is too high to be explained by changes in

genetic structure; prevailing beliefs are that environmental factors

have a major role in obesity (Cowley, 2006; Dietz, 2004; Phips,

Burton, Leithbridge, & Osberg, 2004; Rolls, 2009). The current

prevalence of childhood obesity is 10 times higher than during the

1970s. In a country-wide study the prevalence of adolescent

obesity (1219 years old) was found to be between 5 and 17.6% in

the USA (Ogden, Carroll, & Flegal, 2008); 1520% in England

(Lopstein, James, & Cole, 2003) and 12.6% in China (Luo & Hu,

2002). Health Behavior in School-aged Children Survey (HBSC), a

large-scale study conducted in 20012002, of children aged 11, 13

and 15, from 41 countries showed that 24% of the girls and 34% of

the boys in the 13-year old group and 31% of the girls and 28% of

the boys in the 15-year oldage group were overweight. In addition,

5% of the girls and 9% of the boys in the 1315 year old age group

were obese (HBSC, 1998). Data from the study Have Healthy Diets

Protect Your Heart (conductedby the Ministry of Healthof Turkey

on 15,468 individuals over 30 years old) obesity prevalence was21% for males and 41.5% for females; and childhood obesity had

increased from 67% to 1516% in the previous two decades ( The

Ministry of Health of Turkey, 2009). Obesity causes health

problems: it has a negative impact on many of the bodys systems

(endocrine system, cardiovascular system, gastrointestinal system,

skin, genitourinary system, and muscle-skeleton system) and on

psycho-social status. Childhood obesity also leads to an increase in

Type-2 diabetes and heart diseases (Dietz, 2004).

Providing nutritional information to children when they are

young, and introducing good nutritional habits are important for

optimal, healthy nutritional preferences (Fuhr & Barclay, 1998).

Appetite 57 (2011) 272277

A R T I C L E I N F O

Article history:

Received 14 May 2010Received in revised form 12 May 2011

Accepted 13 May 2011

Available online 20 May 2011

Keywords:

Adolescent

KIDMED

Nutrition knowledge

Nutrition habit

Nutrition education

A B S T R A C T

Adopting an eating patterncomplyingwith the Mediterranean diet not only decreases body fatmass and

obesity risk, but also reduces development of various health problems. This study investigated thenutritional awareness and diet quality Mediterranean Diet Quality Index (KIDMED) of Turkish

adolescents. Thestudy was conducted with890 voluntary participants (464boys and 426girls)aged 10

14 years. A questionnaire form was used to learn demographic characteristics of the participants.

Participants nutritional awareness was determined through a 20-item knowledge form and their

nutritional habits through a 16-item Mediterranean Diet Quality Index (KIDMED). The average

nutritional knowledge score wasX= 82.22 0.42.Resultsindicated that17.9% of the participantshad a lowquality diet (3 points), 59.2% had a mid-quality/needs-improvement diet (47 points) and 22.9% had an

optimal quality diet (8 points). The study results showed that the subjects diet quality was low and that

their nutrition knowledge levels were related to their nutritional habits. 2011 Elsevier Ltd. All rights reserved.

The authors would like to thank the adolescents who participated in the

study; the school managers and teachers, who gave consent for the

administration of the questionnaire; and the graduate students who adminis-

tered the study questionnaire. The essay was finalized after arrangements were

completed in accordance with the opinions and suggestions of the referees. We

are grateful to the journal editors and referees for their invaluable opinions and

contributions.

* Corresponding author.

E-mail address: [email protected] (S.A. Sahingoz).

Contents lists available at ScienceDirect

Appetite

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a p p e t

0195-6663/$ see front matter 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.appet.2011.05.307
http://dx.doi.org/10.1016/j.appet.2011.05.307mailto:[email protected]://www.sciencedirect.com/science/journal/01956663http://dx.doi.org/10.1016/j.appet.2011.05.307http://dx.doi.org/10.1016/j.appet.2011.05.307http://www.sciencedirect.com/science/journal/01956663mailto:[email protected]://dx.doi.org/10.1016/j.appet.2011.05.307


2/6

The nutritional choices made by an individual are directly

related to the nutritional knowledge they possess (Manios,

Moschandreas, Hatzis, & Kafatos, 1999; Pirouznia, 2001; Powers,

Struempler, Guarino, & Parme, 2007).

Nutritional preferences and health problems vary from society

to society; but population groups who adopt a Mediterranean diet

are reported to experience lower rates of chronic diseases,

myocardial infarction, arthritis, various tumors (such as breast,

colon and prostate cancer), diabetes, other pathologies related to

oxidative stress, childhood asthma and rhinitis (Barclay, 2008;

Benetou et al., 2008; Martnez-Gonzalez et al., 2008; Munoz, Fto,

Marrugat, Covas, & Schroder, 2009; Panagiotakos et al., 2009;

Serra-Majem, 2001; Serra-Majem, Roman, & Estruch, 2006). This

diet has a preventive role in the development of Alzheimers

disease and infections (Feart et al., 2009). A Mediterranean diet

includes a high proportion of fruits, vegetables, unrefined natural

cereals, legumes, dried nuts, poultry, eggs (3 times per week), fish,

low-fat dairy products and a small quantity of red meat. This diet

has positive effects on health. The fish and fruit in the

Mediterranean diet provide antioxidant vitamins (E, C) and

carotenes, and prevent insufficient micronutrient intake (Anony-

mous, 2000; Serra-Majem, Ribas, Garca, Perez-Rodrigo, & Ara-

nceta, 2003).

The Mediterranean eating pattern warrants attention because ithas been repeatedly associated with protection against several

chronic degenerative diseases and disorders. Although it is not yet

clear which components of the diet provide the greatest health

benefits, it is likely that certain components, eaten together,

provide a dietary pattern that is highly protective. Several possible

explanations and biological mechanisms have been proposed for

these foods, against the pathogenesis of chronic disease (Brill,

2009).

Obesity has gradually become a public health problem,

resulting in initiatives throughout the entire world to reduce it.

In Turkey, nutritional education is not effective because there are

not enough practical cooking classes and limited curriculum time

devoted to this subject. The nutritional knowledge, attitudes and

behaviors of students cannot be changed efficiently and perma-nently. This study was designed and conducted to determine the

level of nutritional knowledge amongst adolescents living in

Turkey, a country with borders on the Mediterranean Sea, and to

detect the extent to which their diet complies with the

Mediterranean Diet Quality Index (KIDMED).

Methods

Subject and procedures

The study was conducted in Ankara, the capital of Turkey,

between January and May 2009. Turkey is partially European and

nutritional habits from both the Mediterranean and Eastern worldare represented here. While Mediterranean eating patterns prevail

in the coastal regions of Turkey, central and southeastern regional

eating patterns are based mainly on cereals, pastry and red meat,

rather than fruit and vegetables.

This study, conducted to evaluate the nutritional status of

children and adolescents, used KIDMED, which is a rapid and valid

evaluation methodology. The required papers on the objective, the

subjects and the method of the study; about the schools where the

study would be conducted; and confidentiality for study partici-

pants were submitted to the Ministry of National Education and

permission was obtained before starting the study. Students and

their parents were informed and only voluntary participants were

included in this study. The study group included 464 boys and 426

girls in the 1214 age range (mean = 13 0.82 years) (n= 890).

Instruments

The development of the KIDMED index is based on the

principles of Mediterranean dietary patterns as well as the factors

that undermine it. The index rangedfrom 0 to 12,and wasbased on

a 16 questions test that could be self-administered or conducted

via an interview (pediatrician, dietitian, etc.). Questions denoting a

negative connotation with respect to the Mediterranean diet were

assigned a value of 1, and those with a positive aspect were

scored +1 (seeAppendix A)(Serra-Majem et al., 2004).

According to the KIDMED index (16 questions):

8 points shows optimal diet quality.

47 points average (improvement needed).

3 points very low (diet quality).

In addition to the KIDMED index, a nutritional knowledge test

developed by the researchers was used to determine the

nutritional knowledge of participants. The nutritional knowledge

test included 20 questions. Writers were asked to submit a

questionnaire form with questions on nutritional knowledge.

These questions were scored according to a 5-point Likert-type

scale: very important = 5 points; considerably important = 4points; important to some extent = 3; minimal importance =2

points; not important = 1 point. Potential scores ranged from 20 to

100 points. The validity of the nutritional knowledge questions

was tested, and found to have a Cronbachs alpha score of 0.844.

Data collection

Questionnaires were administered face-to-face during course

hours. First, participants were given information on the study and

thenthe questionnaires were given to volunteer participants. Eight

interviewers collected the study data, and then they distributed

112 questionnaires. Interviewers were trained postgraduates

students who visited selected primary schools in Ankara, Turkey.

The objective of the study was briefly explained to the girls andboys by interviewers. To guarantee anonymity of responses and

easy identification of the questionnaires by individuals. Items in

the questionnaire were explained when necessary and adminis-

tered at one sitting as far as possible. Administering the

questionnaire took between 10 and 15 min. Researchers collected

them immediately upon completion.

Data analysis

The questionnaire responses were analyzed using SPSS version

16.0 (SPSS Chicago, IL, USA). The evaluation of the demographic

characteristics of the participants was based on numbers and

percentages. The means and SDs of each question on nutritional

knowledge were measured. The t-test was used to evaluatenutritional knowledge habits (KIDMED index) and total scores

according to gender One way ANOVA Analysis were used to

evaluate factors including parents educational status, whether

meals were skipped, and the number of meals on the basis of

KIDMED and knowledge scores. Tukeys test was used to determine

the difference between the groups. In all analyses, a 5% and 1%

significance level was used.

Results

Demographic characteristics

Demographic characteristics of the adolescents are presented in

Table 1.

S.A. Sahingoz, N. Sanlier / Appetite 57 (2011) 272277 273


3/6

Amongst the adolescents who participated in the study; 52.1%were boys, and 47.9% were girls; 21.0% were 12 years old, 38.5%

were 13 years old and 40.5% were 14 years old. With regard to the

educational level of participants mothers, the results showed that

4.8% were illiterate, 65.8% were primary education graduates,

20.0% were high school graduates and 9.4% were university

graduates. For participants fathers, these levels were 1.4, 50.4,

31.3, 16.9% respectively.

Data on skipped meals showedthat23.7%of adolescentsdid not

skip any meal, while 18% always skipped meals and 58%

occasionally skipped meals. Students who skipped meals included

33.8% who skipped breakfast, 21.6% who skipped lunch and 23.1%

the evening meal. Adolescents who skipped meals offered the

following reasons: no inclination to eat a meal (49.1%); no time for

a meal (23.1%); planning to lose weight (10.9%); and the difficultyof preparing a meal/non-necessity of having a meal (remaining

adolescents).

Nutritional knowledge and KIDMED scores of adolescents

Themeans andstandarddeviations (SD) of the answers foreach

of the questions about nutrition knowledge according to genders

are presented inTable 2.

Girls scored high on these questions: should consume fruits

(4.43) and vegetables (4.24); should not consume food late at

night (3.76); should not eat too much (3.99); and should

consume low-fat food (4.19). Boys scored higher on these

questions: should enjoy eating (3.92); it is beneficial to

consume food cooked with fish (3.75), with chicken (3.72),

with veal (3.60) and with mutton (3.26). The difference

between the genders is statistically meaningful (p < 0.05,

p < 0.01).

A gender-based breakdown of the KIDMED (Mediterranean Diet

Quality Index), used to detect the nutrition habits of the

adolescents, and is shown inTable 3.

The table shows that 17.9% of the adolescents had a very poor

diet, 59.2% had a diet that needed improvement and 22.9%

followed a diet of optimal quality (Table 3).

The KIDMED score for boys was 5.57 2.24, compared to

5.72 2.47 for girls. This difference was not found to be statisticallysignificant (t= 0.907,p > 0.05) and no statistically significant gender-

based difference was observed between the nutritional knowledgescores of boys and girls (boys = 82.15 12.68; girls = 82.32 12.80)

(t= 0.197,p > 0.05).

A comparison of KIDMED scores and nutritional knowledge

scores according to the parents educational status, meal skipping

and number of meals is presented in Table 4.

There was a difference in the KIDMED scores of the children

according to their mothers educational status. As the mothers

educational status rises, so do KIDMED scores (p< 0.05) and

nutritional knowledge scores. A difference was detected amongst

both the KIDMED scores (p < 0.01) and the nutritional knowledge

scores (p < 0.05) of the children who skipped meals. The scores of

the children who do not skip meal arehigh. There is also a difference

betweenthe KIDMEDscores andthe nutritional knowledgescoresof

thechildrenwho eattwo meals perday andthosewho eatthree/fourmealsperday (p < 0.01).As the numberof mealsincreases, sodo the

KIDMED scores and nutrition knowledge scores.

Table 2

The distribution of the nutrition knowledge scores of adolescents according to their genders ( n = 890).

BoysXSD Girls XSD ttest p

Should have balanced nutrition 4.630.71 4.62= 0.72 0.377 0.706

Should have adequate nutrition 4.590.79 4.630.70 0.832 0.406

Should consume fruits 4.251.04 4.430.89 2.689 0.007**

Should consume vegetables 4.021.11 4.241.00 2.975 0.003**

Should not consume food late at night 3.421.54 3.761.48 3.295 0.001**

Should not overeat 3.661.36 3.991.26 3.657 0.000**

Should consume low-fat food 3.941.22 4.191.08 3.162 0.002**

Should chew the food properly 4.271.07 4.300.99 0.536 0.592Should adopt nutrition habits according to age and health status 4.37 .94 4.361.02 0.115 0.908

Should avoid compound processed food 4.221.09 4.291.07 0.931 0.352

Should avoid unnecessary calorie intake 3.991.18 4.071.13 1.095 0.274

Should maintain ideal weight 4.161.12 4.301.05 1.866 0.062

Should avoid overly salty food 4.151.07 4.211.07 0.860 0.390

Should avoid sugary food 4.101.10 4.131.14 0.389 0.698Should have three main meals a day 4.211.06 4.111.14 1.338 0.181

Should enjoy eating 3.921.26 3.701.25 2.568 0.010*

It is beneficial to consume fish 3.751.24 3.491.23 3.109 0.002**

It is beneficial to consume chicken 3.721.25 3.391.23 3.926 0.000**

It is beneficial to consume veal 3.601.33 3.101.32 5.574 0.000**

It is beneficial to consume mutton 3.261.45 2.721.40 5.517 0.000**

Should consume pulpy fibrous products 3.201.50 3.411.42 2.070 0.039*

Total nutritional knowledge score Boys= 82.1512.68 Girls = 82.3212.80, t= 0.197,p>0.05.* p


4/6

Discussion

Currently in Turkish primary schools (1st8th grade), nutri-

tional programs are still implemented with contributions from and

the support of the students families, without any government

support. Food-hour is the time when students eat grab-a-bite food

(fruit, fruit juice, milk, ayran, sandwich, etc.) during the 15-min

break (Sanlier & Arikan, 2002). While students are eating, they are

questioned about food.

If an individual uses his/her knowledge to make behavioral

changes, it means that such knowledge is promoting positive

behaviors and habits. This study determined the level of nutritional

knowledge amongst adolescents, and the extent to which theirnutritional habits are in accordance with the Mediterranean Diet

Quality Index.

Previous studies have shown that children do not have regular

eating habits, and that skipping meals is common (Akar Sahingoz,

2009; Berkey, Rockett, Gillman, Field, & Colditz, 2003; Kelder,

McPherson, & Montgomery, 2003; Unusan, Sanlier, & Danisik,

2006). These findings are supported by the present study. In a

previous study on adolescent and nutritional and eating habits,

girls were found to eat mainlyvegetables and fruits, and boys were

found to eat more sugary products (Kelder, McPherson, &

Montgomery, 2003; Worsley & Worsley, 1992). In a study he

conducted on adolescents in the 14th grade. Roos (2002)

emphasized that girls and boys in this age group are not interested

in healthy nutrition.Akhtar Khan, Ahmet, and Baig (2008)found

that 62% of high school students had inadequate knowledge of

health protection, ate few vegetables and had high fat and calorie

intakes. The results of the present study also showed that students

had low knowledge scores about vegetable and fruit consumption,

optimal eating times/portions; about low-fat food consumption.

Girls were found to know more than boys about the benefits of

eating vegetables, and boys were shown to know more girls about

fish,chicken, veal, and mutton consumption(Table 2). This gender-

baseddifference may be thatTurkish males generally dislike eating

vegetables and prefer meat and meat-based food. The Nin@s en

movimiento program, developed for obese children between 6

and 13 years of age in Spain, applied the Mediterranean diet

(KIDMED) methodology; at the end of the study, participatingchildren showed a reduction in body-mass index (BMI) and

consumption of cakes, and an increase in vegetable and fruit

consumption (Gussinyer et al., 2008).

In this study were found to obtain good KIDMED scores for

adolescent diets (22.9%) (Table 3). Another study conducted in

Turkey, in 2008, by Samur et al. included 84 elementary school

students between the ages of 10 and 12. Of those, 76.2% had

optimal KIDMED index scores; statistically, there were no

differences according to gender. In another study, conducted in

2008 by Koksal et al., 25.6% of the voluntary participants aged

between 7 and 18 had optimal KIDMED index scores, and no

meaningful difference according to gender. This studys results are

similar to the Koksals findings (Koksal, Tek, & Pekcan, 2008). The

results of these twostudies maydiffer from Samur, Gunebak Sahin,

Table 4

Comparison of KIDMED scores and knowledge scores according to the variables.

KIDMED score Nutrition knowledge score

Variables MeanSD F p MeanSD F P

Mothers educational status

1. Illiterate 5.022.11 79.9011.51

2 . P rimary school gradua te 5.552.31 2.836 0.037* 81.7512.19 1.555 0.1993. High school graduate 5.982.46 83.5214.42

4. University graduate 5.922.47 (13) 83.3812.57

Fathers educational status

1. Illiterate 5.912.77 81.0810.97

2 . P rimary school gradua te 5 .502.39 1.123 0.339 81.9712.52 0.566 0.638

3. High school graduate 5.722.25 81.9113.05

4. University graduate 5.872.44 83.4312.89

Meal skipping

1. Skip 4.402.23 33.935 0.000** 80.0915.01 3.964 0.019**

2. Never skip 6.352.47 (12), (13), 83.8313.49

3. Sometimes skip 5.722.18 (23) 82.3111.38 (12)

Number of meals

1 3.832.31 72.8315.252 4.862.34 5.057 0.000** 79.2715.50 3.309 0.011**

3 5.752.38 (23), (34) 83.4911.78

4 5.782.18 82.5212.17 (23)

5 6.262.16 83.5211.06

F: one way ANOVA.* p


5/6

Donmez, and Besler (2008)because of different sample sizes. Two

studies conducted in Spain, using the KIDMED index, produced

results similar to each other. A 2004 study conducted by Serra-

Majem et al. (2004)included a total of 3850 people between 2 and

24 years of age; 46.4% had high KIDMED scores. In another study by

Mariscal-Arcas et al. (2009), 3190people between 8 and 16years of

age were included 46.9% of them had a good KIDMED index. In

another study conducted in Spain, with 229 people between 8 and

18 years of age, the high KIDMED index was calculated at 11.9%

(Montero, 2005). A study by Perez-Gallardo, BayonaMarzo, and

Benito de Miguel (2007) of the nutrition habits of university

students (aged 1824 years) in five European cities found that

31.7% of the students had good quality diets (KIDMED 8). In a

study of 1140 children (10.7 0.98 year) in Cyprus, 37% of theparticipants had low KIDMED scores and it the studys authorsrecommended educating children about the benefits of a Mediterra-nean diet, in order to improve their diets (Lazarou, Panagiotakos, &

Malatas, 2008). In a study of the KIDMED index scores of children(ages 113) living in Greece (n= 13 boys and 11 girls) and Sweden(n= 13 boys and 10 girls), there appeared to be no significantdifference between the two countries (KIDMED index of the Greek

childrenwas 5.71 and 5.91 in Sweden) (Karlen, Lowert, Chatziarsenis,& Falth-Magnusson, 2008). Another study byLazarou and Kalavana

(2009) showed that only a small number of children had highKIDMED index scores; that there were differences between rural

(n= 442) and urban (n= 442) areas; and that children living in ruralareas had higher scores (urban 5.4%, rural 8.4%). Kontogianni et al.(2008) studied 1305 individuals in Greece, aged 318 years, andfound that 11.3% of the children and 8.3% of the adolescents achieved

optimal KIDMED scores (8). Serra-Majem et al. (2003)suggested that children with an optimal diet are already fulfillingtheir nutritional needs and do not need vitamin or mineralsupplements.

A study by Montero (2005), and previous studies in Turkey

(Koksal et al., 2008; Samur et al., 2008) have shown no

statistically significant difference between the KIDMED scores

of boys and girls (p > 0.05). The results in this study correspond

to those earlier studies in this regard (p > 0.05). The results ofthe present study are similar to the results reported by Gibson,

Wardle and Watts (1998) and point to a relationship between

how much children know about nutrition and their eating

habits. Manios, Moschandreas, Hatzis and Kafatos (1999)

emphasized that a nutrition training program aimed at primary

school students would have limited effectiveness, and that

continuous training programs are necessary to ensure that this

knowledge generates long-term behaviors. Luisi, Pietrobelli,

Lova and Gensini (2005) found that 24% of children had

inadequate knowledge how to implement basic health protec-

tion principles before the study; their post-study knowledge

increased by 74%.

In this study, the educational status of mothers and both

KIDMED scores of their children are related (p < 0.01) (Table 4).Other studies show that the children of mothers with a high

educational level also had a high quality diet (KIDMED scores 8),

and that a mothers educational level and nutritional knowledge

could have positive effects on their offsprings nutritional

knowledge levels and eating habits (USDA, 2009).

In later studies there were additional findings: that the number

of meals/meal skipping not taken into consideration in the

previous studies on KIDMED and nutrition knowledge affects

KIDMED scores and the nutrition knowledge scores of adolescents

(p < 0.01,p < 0.05) (Table 4).

Comparable to the rest of the world, quality of life in Turkey is

affected by factors like obese families, obese children, cardiovas-

cular diseases, Type-2 diabetes, hypertension, psycho-social

problems and cancer. The entire population can benefit from a

Mediterranean diet and information and education about this diet

should be distributed and publicized.

For instance, the curriculums of educational institutions,

including kindergartens, should highlight the importance of

consuming olive oil, fruits, vegetables and wholegrain cereals;

balanced and sufficient nutrition; and of physical activity The

health benefits of a Mediterranean diet are profound enough to

warrant inclusion and promotion, for the adoption of healthy

eating habits by children.

Governments at the regional, national and European level

should take prioritize raising, producing, transporting and

commercializing the foods that constitute the Mediterranean diet:

olive oil, fruits and vegetables, fish, cheese and yoghurt, nuts,

cereals. Families, also, should take responsibility for making the

healthiest choices when purchasing food for the home, or at a

restaurant (Serra-Majem et al., 2004).

Including children in shopping activities and showing them

how to choose healthy foods is also important. Governments

should support the food industry in producing healthy food, and

the state, family, schools and related sectors should cooperate in

improving health.

Limitations

Based on theresults of thepresent study,the KIDMED indexcan

also be successfully applied in Turkey in evaluating the Mediter-

ranean diet and healthy nutritional practices. Because variables

like regional habits, income level and sample size can affect the

index scores, it is beneficial to use a food-consumption based

method, anthropometrical measurements and biochemical mea-

surements in evaluating thenutritional status of childrenat risk. In

addition, further studies should be conducted on larger sample

groups with wider age ranges, living in larger geographical areas.

The limited agerange, regionand number of samples of thepresent

study cannot be generalized to the whole of Turkey.

References

Anonymous. (2000). Diyette kullanlan yaglar, Akdeniz Diyeti ve omur boyu saglk.Uluslararas Akdeniz Diyeti Konferans. Londra, Ingiltere: Kraliyet Fizikciler Univer-sitesi.

Akar Sahingoz, S. (2009). The education about breakfast and its importance given tochild-to-mother and its results. Pakistan Journal of Nutrition, 8, 419424.

Akhtar Khan, R. M., Ahmet, E., & Baig, M. Z. (2008). Identification of the risk factors ofobesity among high school children. Medical Forum Monthly, 19, 810.

Barclay, L. (2008). Mediterranean diet may protect against childhood asthma-like symp-toms and rhinitis. Medscape. Available from: http://cme.medscape.com/viewarti-cle/554819 (accessed 21.07.09).

Benetou, V., Trichopoulou, A.,Orfanos, P., Naska, A., Lagiou,P., Boffetta,P., et al. (2008).Greek EPIC cohort. Conformity to traditional Mediterranean diet and cancerincidence. the Greek EPIC cohort.British Journal of Cancer, 99, 191195.

Berkey, C. S., Rockett, H. R. H., Gillman, M. W., Field, A. E., & Colditz, G. A. (2003).Longitudinal study of skipping breakfast and weight change in adolescents.International Journal of Obesity, 27, 12581266.

Brill, J. B. (2009). The Mediterranean diet and your health.American Journal of LifestyleMedicine, 3, 4456.

Cowley, J. (2006).Markets and childhood obesity policy. TheFutureof Children,16, 6988.Dietz, W. H. (2004). Overweight in childhood andadolescence. The New England Journal

of Medicine, 350, 855857.Feart, C., Samieri, C., Rondeau, V., Amieva, H., Portet, F., Dartigues, J. F., et al. (2009).

Adherence to a Mediterranean diet,cognitive decline,and riskof dementia.Journalof the American Medical Association, 302, 638648.

Fuhr, J. E.,& Barclay,K. H. (1998).The importance of appropriatenutrition andnutritioneducation. Young Children, January: 7480.

Garemo, M., Arvidsson Lenner, R., Karlge Nilsson, E., Borres, M. P., & Strandvik, B.(2007).Foodchoice, socio-economic characteristics andhealth in4-yearoldsin awell-educated urban Swedish community.Journal of Clinical Nutrition, 26 , 133140.

Gibson, E. L, Wardle, J., & Watts, C. F. (1998). Fruit and vegetable consumption,nutritional knowledge and belief in mother and children. Appetite, 31, 205228.

Gussinyer, S., Garca-Reyna, N. I., Carrascosa, A., Gussinyer, M., Yetse, D., Clemente, M.,et al. (2008). Antropometric, dietetic and psychological Nin@s en movimientoprogram in childhood obesity. Medicina Clinica, 131, 245249.

Health Behavior in School-AgedChildren Survey (HBSC) (1998). Available from: http://

www.ruhbc.ed.ac.uk/hbsc/download/respro98.pdf (accessed 22.07.10).

S.A. Sahingoz, N. Sanlier / Appetite 57 (2011) 272277276
http://cme.medscape.com/viewarticle/554819http://cme.medscape.com/viewarticle/554819http://www.ruhbc.ed.ac.uk/hbsc/download/respro98.pdfhttp://www.ruhbc.ed.ac.uk/hbsc/download/respro98.pdfhttp://www.ruhbc.ed.ac.uk/hbsc/download/respro98.pdfhttp://www.ruhbc.ed.ac.uk/hbsc/download/respro98.pdfhttp://cme.medscape.com/viewarticle/554819http://cme.medscape.com/viewarticle/554819


6/6

compliance with mediterranean diet

Documents