Improved Diet

Quality and
Nutrient Adequacy
in Children and
Adolescents with
Abdominal Obesity
after a Lifestyle
Intervention
Ana Ojeda-Rodriquez, Itziar Zazpe, Lydia Morell-
Azanza, Maria J. Chueca, Maria Cristina Azcona-
sanjulian, and Amelia Marti

Presented by Tyhisha Melhado

 Introduction
Childhood and adolescent obesity has reached epidemic
levels in the United States.

Public Health Concern:

Adolescence is a crucial period for establishing healthy
behaviors.
o Many of the habits formed during this developmental
stage will last well into adulthood.

o A variety of research studies have been conducted to

lessening the effect of childhood obesity.

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 Methods
o Participants were recruited from the Pediatric Endocrinology Unit of the Clinic University of Navarra, the Pediatric Department of the

University Hospital Complex of Navarra and Health Centers in Pamplona

o Ages: 7-16 years old (Average: 11.3 years old, 63% Females), with a waist circumference above the 90th percentile

o Exclusion criteria: prevalent pre-diabetes, food intolerance, eating disorders or psychiatric disease, pharmacological treatment, or

special diet treatment

o 126 participants were initially recruited, however, due to outliers, dropouts, and inability to meet inclusion criteria, the final

subsample was 107 children

o Random assignment into two groups: the usual or intensive care group at a ratio of 1:3

o Subjects from usual care (n = 26) and intensive care (n = 81) groups had similar baseline clinical measurements

o Usual group: standard pediatric recommendations on healthy diet

o Intensive care group: moderately hypocaloric Mediterranean diet (fixed full day meal plan)

o The percentage of calorie restriction varied from 10-40% of total energy intake depending on the degree of obesity

presented

o Diet distribution: breakfast (20%), morning snack (5-10%), lunch (30-35%), afternoon snack (10-15%) and dinner (20-25%)

with 55%, 30%, and 15% towards carbohydrates, fat, and protein respectively

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 Methods
o Consisted of an 8-week phase conducted by a multidisciplinary team (registered
dietitians, pediatricians, physical activity experts and nurses)

During the eight-week period:

o The usual care group received a 30-min individual session with the dietitian as well as
five monitoring visits to assess anthropometric parameters
o The intensive care group completed six 30-min individual sessions with the research
team as well as one group session
o Dietitians provided information on healthy lifestyle and how to manage obesity-
related problems to parents and legal guardians
o Children were taught several topics such as controlling healthy lifestyle behavior,
food preparation, portion control, eating behavior, food composition and the
importance of being physically active during leisure time
o Both groups were encouraged to accumulate an extra time of 200 min of physical
activity per week at 60–75% of their maximum heart rate

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 Assessment
Anthropometric measurements were obtained at both the beginning and end of the eight-week period:
o Height - Harpenden’s stadiometer of 1 mm precision (Seca 220, Vogel & Halke, Hamburg,
Germany)

o Body weight - Digital scale (BC-418, TANITA, Tokyo, Japan)

o Body Mass Index (BMI) was calculated and converted into standard deviation scores
(SDS) for sex and age derived from Spanish reference data according to specific cutoff

points for BMI

o Pubertal development was evaluated according to Tanner stages

o Glucose, insulin and total cholesterol were determined by standard autoanalyzer techniques
o Blood pressure was measured using an electronic sphygmomanometer (OMRON M6,
Hoofddorp, The Netherlands) on the right arm after the children had rested quietly for 15 min

o Venous blood samples were obtained by nurses at the hospital after an overnight fast

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 Assessment
Dietary intake data was gathered at baseline and after the eight-week period:
o 136-item Food-Frequency Questionnaire (FFQ)
o Diet Quality Index (DQI):

o Composed of the sum of three categories: Variety, Adequacy, Moderation, Balance

o Evaluated the consumption of (1) bread and cereals, (2) potatoes and grains, (3)
vegetables, (4) fruits, (5) milk products, (6) cheese, (7) meat, fish and substitutes, (8) fats

and oils
o Healthy Lifestyle Index Diet Index (HLDI):
o Frequency of consumption of fruit, vegetables, fish and seafood, sweets, refined grains,

dairy products, meat and meat products

o The other components indicate the level of physical activity through measuring the
time spent on moderate to vigorous physical activity versus looking at screens

o Mediterranean Diet Quality Index (KIDMED Questionnaire):

o Evaluated the adequacy of the Mediterranean dietary pattern in children and adolescents

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 Assessment

Micronutrient adequacy (Ca, Fe, I, Mg, Zn, Na, K, P, Se, and vitamins B1, B2, B3, B6, B12, C, A, D,
E and folic acid) was assessed utilizing the Dietary Reference Intakes (DRIs) and methods
endorsed by the Institute of Medicine:
o Estimated Average Requirement (EAR)
o Adequate Intake (AI) - if the EAR values were not available
o Tolerable Upper Intake Level (UL)

Macronutrient adequacy was assessed utilizing the Acceptable Macronutrient Distribution

Ranges (AMDR)

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 Results
o Both groups showed a significant decrease in body weight, BMI, glucose and total cholesterol levels.
o Total energy intake: (-) 766 kcal for the usual care subjects and (-) 731 kcal for the intensive care subjects
o Fat: (-) 3.0% for the usual care subjects vs. (-) 5.8% for the intensive care subjects
o Protein: 3.1% for the usual care subjects vs. 3.8% for the intensive care subjects
o Carbohydrates: (-) 0.1% for the usual care subjects vs. 2.0% for the intensive care subjects
o After the intervention, participants in the usual group consumed more whole grains and less refined grains than
the intensive care group. In addition, the usual group had a slight increase in the consumption of nuts and
slightly lower consumption of sweets in comparison to the intensive care group
o The intensive care group significantly reduced blood pressure and meat intake, and increased consumption of
fruits, vegetables, and fish in comparison with usual care group. There was also increased moderate-to-vigorous
physical activity time after the intervention for this group

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Results
Key points:
o The intensive care group showed a decrease in
inadequacy for calcium, magnesium, vitamin A, and
vitamin D while the usual care group showed an increase
in inadequacy for those vitamins and minerals
o Both groups experienced a significant drop in sodium
intake, with a larger proportion seen in participants
within the intensive care group
o There was a significant increase in inadequacy of
potassium for the usual group as well as an increase in
vitamin E inadequacy for both groups

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Results

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 Results
o The intensive care group presented a significant change in total DQI (Diet Quality Index), and
HLD-I (Healthy Lifestyle Index) compared to the usual care group

Data showed the following:

o Total DQI: 12.1 (in comparison to 6.8 in the usual care group)
o HLD-I: 4.1 (in comparison to 1.4 in the usual care group)
o KIDMED: 3.0 (in comparison to 2.0 in the usual care group)

o Participants were able to reduce their BMI (−0.5 units) and improve their diet quality scores
therefore getting closer to the nutritional recommendations and thus decrease in overall
cardiovascular risk.

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 Discussion
There is a link with the Mediterranean diet and its effectiveness on obesity:

o “High adherence to a Mediterranean diet at age 4 reduces overweight, obesity, and abdominal obesity incidence in children at the age of 8”

o “Mediterranean Diet and Obesity-related Disorders: What is the Evidence?” – “MD proves to be the healthiest dietary pattern available to

tackle obesity and prevent several non-communicable diseases, including cardiovascular disease and type 2 diabetes.”2

Participants were able to reduce their BMI (−0.5 units) and improve their diet quality scores therefore getting closer to the nutritional recommendations

and thus decrease in overall cardiovascular risk.

o Limitations: failure to provide a thorough analysis of the diet recall during the 8-week period which would allow for a better assessment of

the impact of the diet on obesity

o Clarification is also needed regarding the slight decrease in consumption of whole grains and nuts as well as a slight increase in vitamin E

inadequacy for the intensive care group

Socio-economic status should also be assessed to tie the likelihood of adhering to and maintaining the change and determine the specific reasons for

the adoption of unhealthy eating habits

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 References
1 Muscogiuri, G., Verde, L., Sulu, C., Katsiki, N., Hassapidou, M., Frias-Toral, E., Cucalón, G., Pazderska, A., Yumuk, V. D., Colao, A., & Barrea, L.

(2022, December). Mediterranean diet and obesity-related disorders: What is the evidence?. Current obesity reports.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9729142/

2 Notario-Barandiaran, L., Valera-Gran, D., Gonzalez-Palacios, S., Garcia-de-la-Hera, M., Fernández-Barrés, S., Pereda-Pereda, E., Fernández-

Somoano, A., Guxens, M., Iñiguez, C., Romaguera, D., Vrijheid, M., Tardón, A., Santa-Marina, L., Vioque, J., &

Navarrete-Muñoz, E. M. (2020, March 9). High adherence to a Mediterranean diet at age 4 reduces overweight, obesity and

abdominal obesity incidence in children at the age of 8. Nature News. https://www.nature.com/articles/s41366-020-0557-z#citeas

3 Ojeda-Rodríguez, A., Zazpe, I., Morell-Azanza, L., Chueca, M. J., Azcona-Sanjulian, M. C., & Marti, A. (2018, October 13). Improved diet

quality and nutrient adequacy in children and adolescents with abdominal obesity after a lifestyle intervention. Nutrients.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213517/

4 Sanyaolu, A., Okorie, C., Qi, X., Locke, J., & Rehman, S. (2019, December 1). Childhood and adolescent obesity in the United

States: A public health concern. Global pediatric health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887808/

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