Assessment of diet quality, nutrient intake, and dietary behaviours in obese children compared to healthy children

Introduction

Obesity has been recognised by the World Health Organisation as the most common chronic disease in the world and is known as the epidemic of the 21st century. In just the last three decades, the proportion of obese people has doubled, and forecasts indicate further growth [1]. The problem of excess weight, according to WHO data from 2016, concerned about 41 million children under five years of age in the world, and it is estimated that the number will rise to 70 million by 2025 [2]. According to a PITNUTS study, overweight concerned 14.5% and obesity 13% of Polish children aged 13 to 36 months [3]. Almost one-third (30.7%) of eight-year-old children examined by the Childhood Obesity Surveillance Initiative (COSI) had excessive body mass [4]. In contrast, data from the Health Be-haviour in School-aged Children (HBSC) study indicate that the proportion of adolescents aged 11 to 15 years with abnormal body mass in Poland was 21.3% (16.6% for overweight and 4.7% for obesity, respectively) [5]. Obesity in children leads to many health consequences such as dyslipidaemia, hypertension, insulin resistance or impaired glucose metabolism, non-alcoholic fatty liver disease, increased risk of non-communicable diseases such as type 2 diabetes, and cardiovascular disease. Unfortunately, excessive body weight is often underestimated by parents, perceived as a temporary problem that the child will grow out of; however, about 55% of children with excessive body weight in preschool age will become obese teenagers. The prevalence of obesity between 15 and 17 years of age is associated with a 17.5-fold higher risk of obesity in adulthood [6]. Obesity is the consequence of a chronic imbalance between energy intake and energy expenditure, which is a result of incorrect diet and inadequate physical activity.

Aim of the study

The aim of this study was to compare dietary behaviours, the quality of diet, and the implementation of nutritional standards in a group of obese children compared to children with normal body weight.

Material and methods

Participation in the study was voluntary and anonymous. Informed consent was signed by parents or legal caregivers of children. This study was reported according to the Strengthening the Reporting of Observational Studies in Nutritional Epidemiology (STROBE-nut) checklist [7]. The study was conducted according to the ethical principles for medical research stated in the Helsinki Declaration and was approved by the authors’ Institutional Review Board [8]. The study was carried out between December 2018 and February 2019.
A total of 105 children aged between seven and 15 years were surveyed. The studied group consisted of 52 patients from a Dietary Clinic in the Children’s University Hospital in Cracow, with obesity but without metabolic complications of obesity (hypertension or diabetes mellitus) except for abnormal lipid values, based on the information contained in the medical card. The control group was chosen in terms of gender and age. The group consisted of 53 patients with normal weight, recruited from the Primary Health Care Clinic. Inclusion criteria for the study were the absence of chronic diseases and, in the case of obesity group – BMI value above the 95th percentile, and in the case of the control group – BMI between the 10th and 85th percentile. The BMI value was calculated (ac-cording to the formula body mass [kg]/height [m2]) for adolescents under 18 years of age following the OLAF project (growth referen-ces for Polish school-aged children and adolescents); values exceeding the 95th percentile were classified as obesity, and values between the 85th and 95th percentiles were classified as overweight [9]. Body weight and height were obtained from medical cards.

Dietary assessment

Children’s nutritional behaviours and diet were assessed with a questionnaire and a 24-hour recall, which included a detailed de-scription of the foods and beverages consumed, their amounts (portion size), brand (if relevant), and preparation (e.g. cooking method, addition of fat, recipe, ingredients, etc.). The interview was conducted by a qualified dietician by using a photo album of all food pro-ducts. Parents of children also filled in a nutrition questionnaire, which concerned the following: food and beverage consumption frequ-ency; number and frequency of meals; snacking in-between meals; regularity of meals; consumption of fast-foods; and use of dietary supplements. The Food Frequency Questionnaire-FFQ (70 items), which was used to capture habitual dietary intake, was similar to the validated Polish Questionnaire prepared by the Behavioural Conditions of Nutrition Team, Committee of Human Nutrition Science, Polish Academy of Science [10]. The frequency of consumption was determined in relation to the day, week, or month. The survey did not include open-ended questions. For the assessment of the frequency of consumption of selected products, food, and beverages, a seven-point scale was used. In the rest, the responses were assigned integer values, using selected scales, e.g. a two-point scale (1 = no, 2 = yes). Diet quality was also examined using the Healthy Diet Indicator (HDI). The HDI was categorised into low, interme-diate, and high (0–2, 3, 4–7, respectively) [11]. This score includes six nutrients (saturated fatty acids, polyunsaturated fatty acids, cho-lesterol, protein, dietary fibre, and free sugars) and one food group (fruits and vegetables). Intake within the recommended range was assigned a score of 1. The final HDI score was the sum of all components, ranging from 0 (minimal adherence) to 7 (maximal adheren-ce).

Data analysis

A Dietetyk-Pro calculator was used to evaluate the implementation of nutrition standards. The Software used for the nutrient analy-sis of the food records included the Polish National Institute of Food and Food Science database. Dietary supplements were not inclu-ded in the nutrient calculations. The values of macro and micronutrients were referred to the Polish norms according to the age and sex of the child. To evaluate the prevalence of nutrient adequacy the Estimated Average Requirement (EAR) or Adequate Intake (AI) was used. All the collected data were analysed statistically with the use of the PS IMAGO PRO 5 (IBM SPSS Statistics 25). Chi-square test or U Mann–Whitney test was used to compare the differences in the studied groups, assuming in a significance level of  <0.05.

Results

A total of 105 children aged 7–15 years were recruited, and the average age of children was 11.83 years (SD = 2.61). The group of obese children consisted of 52 children (49.5%), and the control group comprised 53 children (50.5%). Due to the selection of the con-trol group relative to the gender, the distribution of this variable was equal in both groups. Anthropometric data are defined in Table I, while socio-economic and family characteristics of the participants with reference to the analysed groups (Obesity and Control) are pre-sented in Table II.
The children who took part in the research differed in the frequency of consumption of all food products analysed, except for groats, poultry meat, fish, and cheese, in respect of which no significant differences in the frequency of intake were observed. The grea-test differences in the frequency of consumption were observed in the range of dietary products such as whole grains, natural dairy pro-ducts, vegetables and fruits, legumes, milk and natural dairy products, and oils, which were consumed significantly less frequently in the group of obese children (Table III). In the group of obese children one out of three consumed different types of sweets daily (32.5% vs. 15.25%, p < 0.05). The differences were also evident in the amount of fluid intake: one out of three of obese children drank fruit nectars and sweetened beverages daily (once a day or several times a day). Flavoured water was consumed daily by 23% of obese children. With regard to the fluids consumed by obese children, tea sweetened with sugar was the predominating drink (Table III).
A higher incidence of incorrect eating behaviours was observed in the obesity group. A significantly smaller proportion of obese children compared to children from control group ate breakfast every day (57.0% vs. 79.2%, p < 0.01); a duplicate main dish was consumed daily by 15.3% of obese children and by 7.7% of children from the control group (p < 0.01). Fast food products were con-sumed several times a month by 59.6% of obese children and by 26.4% of children with normal weight (p < 0.01). It was also observed that obese children statistically significantly more often than children with normal weight bought candy bars (44.23% vs. 18.87%, p < 0.01), buns and donuts (48.08% vs. 22.64%, p < 0.01), and biscuits and wafers (34.62% vs. 16.98%, p < 0.01) in school shops every day. In contrast, there was an inverse situation in the case of fruit: children with normal body weight bought fruit at school shops statistically significantly more often than obese children (20.75% vs. 3.85%, p < 0.01) (Table IV).
The analysis of the research group in reference to macronutrients showed significant differences in the implementation of dieta-ry standards. Obese children consumed on average 73.42 ±19.60 kcal per body weight (3171 ±876 kcal per day) whereas normal-weight children consumed 49.89 ±12.25 kcal per body weight (2087 ±373 kcal per day), p < 0.01. The macronutrient composition of the obese children’s diet differed from the normal-weight children’s diet by its increased proportions of all macronutrients and the per-centage content of energy. Obese children consumed more energy from fat than from carbohydrates – the intake of saturated (SFA) and monounsaturated (MUFA) fat was twice as high as for children from the control group. What it more, in the case of obese children, significantly higher consumption of cholesterol as well as polyunsaturated fatty acids (PUFA) was observed. Carbohydrate intake was also greater in the group of obese children, who consumed on average 150 g more carbohydrates than children with normal body we-ight, and almost half more sucrose and significantly less dietary fibre (Table V).
Most micronutrient intakes were adequate when compared with the recommendations; the exceptions were low intakes of cal-cium, iodine, and iron. In both groups, an overdose of the recommended sodium intake was observed; however, in the group of obese children, sodium intake was half higher than that of the nutrition standards (Table VI). When comparing food intake of vitamins between both groups, it was observed that obese children obtained from their diet statistically significantly less vitamin A and folic acid than their healthy peers. Regardless of the group, the children’s consumption of vitamin D did not meet the requirements of the recommended daily intake of this vitamin. The calculated HDI indicated that nearly 40% of obese children and 17% of children from the control group had poor quality diets (Fig. 1).

Discussion

The aim of this study was to compare dietary behaviours, diet quality, and daily intake level of nutrients in the groups of obese chil-dren and those with normal weight. The results of the study show a number of nutritional errors among obese children that lower the quality of their diet and affect the further accumulation of body fat.
First of all, obese children consumed too much energy in relation to their proper weight. The differences between the group of obese and children with normal weight amounted an average of 1000 kcal, which is 30% more calories than they required, taking into consideration their proper weight age and gender. The results of other studies also show an excess of energy in the diets of obese chil-dren [12–14]. The analysis of the individual components being the source of the energy excess in obese children showed that fats are in first place, with carbohydrates in second. Obese children consumed an average of twice as much fat as did their peers with normal body weight, which is consistent with the results of other studies in the population of Polish children [12, 15]. What is interesting, also in the population of obese children from Spain it was observed that, respectively, 45% and 38% of the studied obese children had fat and carbohydrate intake levels above the norms (Acceptable Macronutrient Distribution Range AMDR) [14]. Similar results were observed in overweight Greek children, who consumed less energy from carbohydrates and more from fat, according to AMDR [15–17]. Given the fact that fat is the most calorific nutrient (9 kcal per 1 g), it constitutes the main source of excess energy in the diet of children. The children differed statistically significantly not only in terms of the amount of delivered fat but also its type. Obese children consumed an average of almost twice as much saturated and monounsaturated fatty acids, which come mostly from sweets, salted snacks, and meat products, and which were eaten more frequently in the group of obese children than by children with normal body weight. Obese chil-dren had a diet with an average of 70 mg of cholesterol more than their peers with normal weight. The results of another study show the negative effect on the lipid profile of excessive amounts of saturated fatty acids in the diet [18]. Advice to reduce saturated fat intake among children results in a significant reduction in total and LDL-cholesterol levels, as well as diastolic blood pressure, without adverse effects. The results of this review suggest that the greatest effect on blood cholesterol occurred when SFA was replaced with PUFA or a mixture of PUFA/MUF, which was found in the current WHO recommendations [19]. In our study group of obese children, ex-cessive protein intake was observed; the standard for the body weight was exceeded by an average of 7%, whereas the healthy children did not exceed the daily standard. As far as sugars are concerned, attention should be paid to the amount of sucrose consumed by the research group. Obese children consumed on average twice as much sucrose as the children with normal weight. Apart from using sugar to sweeten meals and drinks, another source of sucrose in the obese children’s diet were sweets. These results coincide with the results of other Polish studies, which confirm the high intake of sucrose among obese children [20, 21]. Another source of simple sugars in the diet of children was sweetened drinks and flavoured water. A meta-analysis of consumption of sweetened beverages in the paediatric population revealed that more than 80% of teenagers consume such drinks every day [22]. The results of other meta-analyses unanimo-usly observe that excessive consumption of sweetened beverages increases the risk of overweight and obesity as well as tooth decay among children and may result in the development of insulin resistance [23, 24]. Such dependencies were not observed in case of 100% fruit juices. Concerns that 100% fruit juice may be associated with childhood weight gain or metabolic consequences have not been supported by most systematic reviews and meta-analyses [25]. Juice consumption in an isocaloric diet may be particularly important for its quality. Studies show that children who drink fruit juices also consume more fruit and vegetables, and their diet is of higher quality [26].
More than half (57.7%) of children with obesity did not obtain the standard amount of fibre in their diet (AI), whereas in the group of children with normal weight the percentage was almost two times smaller (30.2%). Similar results were observed in the group of obese children from Kozachstan [27]. Dietary fibre intake from vegetables, fruit, and whole cereal grains reduces the risk of obesity and enriches the diet with high-nutrient and low-energy products [28, 29]. It has also been shown that there are many other benefits associated with the appropriate amount of dietary fibre in children’s diets; for example, lower risk of developing cardiovascular diseases, hypertension, insulin resistance, and diabetes mellitus [30].
In both groups (study and control) children had a visible shortage of nutrients such as calcium, iron, and iodine. This confirms the fact that obese children’s diet does not translate into a higher quality diet. Obese children, because of their excessive body mass, have a greater need for some nutrients, which in the case of a low-quality diet can lead to nutritional deficiencies. The main source of calcium in the diet are dairy products. Data from the 24-h interviews suggest that obese children consumed similar quantities of dairy products as did children with normal body weight, but the types of chosen product were different. Obese children were significantly more likely to consume sweetened dairy products than natural ones. In one study, it was observed that flavoured milk consumers (children 10–11 ye-ars old) had a higher average intake of energy, fat, and carbohydrate but also protein and calcium, compared with non-consumers [31]. Sweetened dairy drinks provided an average of 150 kcal extra energy intake per day, some studies provide evidence that overwe-ight/obese children may benefit from avoiding flavoured milk drinks; however, generally data do not suggest that the consumption of dairy foods is positively associated with weight and body composition [32]. Moreover, a number of different plausible mechanisms by which dairy products may affect energy balance and consequently body weight have been suggested. The most frequently cited is the mechanism relating to the effects of intracellular ionised Ca on adipocyte metabolism [32]. Another study refers to specific components of dairy food, and mainly whey and casein proteins were associated with increased satiety through delayed gastric emptying and regula-tion of the concentration of plasma amino acid and gastrointestinal hormones such as cholecystokinin, peptide YY, and gastrin [33]. Given the above as well as the fact that dairy products are a good source of calcium, iodine, and vitamin K and B12, with low intake of these constituents in paediatric populations, it appears that the elimination of these products from the diet can bring more damage than benefits. Another ingredient, the intake of which was lower than the recommended norm in the children’s diet, was iron. A number of studies show that obese children have, despite of lower iron intake, higher levels of serum ferritin; however, high levels of serum ferrite may not reflect increased iron stores but rather inflammation, that is way obese children and adolescents are exposed to iron deficiency [34, 35]. Despite iodine playing a key role in psychomotor growth during puberty, its deficiency is common in the general Polish pae-diatric population [36]. Obese children consumed a diet containing statistically significantly more sodium than that of their peers with normal weight. The results concerning excessive consumption of salt coincide with the results of other Polish and foreign authors [37, 38]. Excessive intake of sodium results from using too much salt, but also from high consumption of highly processed foods rich in sodium, such as chips, crisps, and other salty snacks, as well as bread. High sodium intake increases the risk of hypertension, which itself is already a complication of obesity [39]. The WHO recommends that people consume less than 5 g of salt (2 g of sodium) per day, to keep blood pressure at normal levels [40].
Vitamin A is a fat-soluble vitamin that originates from plants as provitamin A carotenoids or from animals as retinol. In order to determine the intake of vitamin A, it takes into account the amount of ingested retinol as well as this vitamin formed from the carotenoids and expressed in the form of retinol equivalent (RE). In the study group the level of vitamin A (RE) intake was higher than the reference value. A higher level of vitamin A was observed in group normal-weight children than in the group of obese children, which might be a result of lower intake of fruit and vegetables in obese children. Concentrations of serum retinol were positively associated with BMI, visceral fat mass, and total body fat mass, whereas the opposite was found for serum -carotene, trans--carotene, and cis--carotene. In one study, higher retinol quartile was associated with a 2- to 3-fold greater probability of overweight and obesity, and the highest quartile of carotenoids was associated with reduced probability of obesity [41]. Low consumption of vegetables and fruit also translates into low levels of folic acid in the group of obese children. As expected, in our study, children from both groups had a low intake of a vitamin D in their diet. Deficits of this vitamin are very common, and the recommendations of major scientific organisations including the Polish Society of Paediatric Endocrinology and Diabetes unanimously recommend vitamin D supplementation for children and ado-lescents aged 1–18 years in the amount of 600 UI per day, and in obese children 1000 UI or more, depending on the concentration of this vitamin in serum [42]. Not only the wrong choice of products but also portion size and bad eating habits, such as skipping breakfast and eating irregular meals, influence the development of obesity, which was confirmed in our study as well as in the results of other authors [43–46]. In one systematic review in a group of over 300 thousand teenagers from 33 countries, it was shown that omitting breakfast concerns between 10 and 30% of young people, and this trend was growing with the age of the respondents. Omitting bre-akfast by girls was associated with a higher risk of obesity, worse lipid profile, higher arterial pressure, insulin resistance, and metabolic syndrome [46]. The HDI indicator, according to the assumptions, showed that obese children are more likely to have low-quality diets. Unfortunately, also a high proportion of healthy children presented low quality diets. HDI is associated with measures of children’s weight status independently of energy density, physical activity, and other important covariates associated with obesity in children. This indicates that besides energy balance, dietary profiles may also contribute to the prevention of obesity in children [47].
Limitations of the study: The nutrition data were from only one 24-h recall, which may limit this study.

Conclusions

The diet of the studied obese children was rich in highly processed and high-fat products, and poor in vegetables, fruit, and whole-grain products, which fits into the definition of the Western-style diet [48]. In the diets of obese children an excess of energy intake mo-stly from fat was observed. Obese children were exposed to deficiencies of vitamin D, folic acid, iodine, iron, and calcium, which was a result of its low consumption or increased demand. Dietary treatment of obese children should concentrate not only on the reduction of calories from food products but also on choices of high-nutrient-density products rich in vitamins and minerals and on developing he-althy eating behaviours. Nutritional education should also be directed to healthy children and their parents, as part of widespread preven-tion of obesity and its complications.

References

1. Bluher M. Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol 2019; 15: 288–298.
2. Lobstein T, Jackson-Leach R, Moodie ML, et al. Child and adolescent obesity: part of a bigger picture. Lancet 2015; 385: 2510–2025. doi: 10.1016/S0140-6736(14)61746-3.
3. Weker H, Barańska M, Riahi A, et al. Dietary patterns in toddlers with excess weight. The 2016 PITNUTS study. Dev Period Med 2017; 21: 272–285.
4. http://www.euro.who.int/en/countries/poland/news/news/2017/06/who-supports- poland-in-fighting-childhood-obesity;(accessed on 14 August 2019 r.)
5. Instytut Matki i Dziecka. Nadwaga i otyłość u polskich 8-latków w świetle uwarunkowań biologicznych, behawioralnych i społecznych. Raport z międzynarodowych badan WHO European Childhood Obesity Surveillance Initiative (COSI), Warsza-wa 2017.
6. Gawlik A, Zachurzok-Buczyńska A, Małecka-Tendera E. Powikłania otyłości u dzieci i młodzieży. Endokrynol Otył Zab Przem Mat 2009; 5 (1).
7. Lachat C, Hawwash D, Ocké MC, et al. Strengthening the reporting of observational studies in epidemiology-nutritional epi-demiology (STROBE-nut): An extension of the STROBE statement. PLoS Med 2016; 13: e1002036. doi: 10.1371/journal.pmed.1002036
8. Puri KS, Suresh KR, Gogtay NJ, Thatte UM. Declaration of Helsinki, 2008: Implications for stakeholders in research. J Post-grad Med 2009; 55: 131–134. doi: 10.4103/0022-3859.52846
9. Kułaga Z, Litwin M, Tkaczyk M. Polish 2010 growth references for school-aged children and adolescents. Eur J Pediatr 2011; 170: 599–609.
10. Jeżewska-Zychowicz M, Gawęcki J, Wądołowska L, et al. Beliefs and Eating Habits Questionnaire; Behavioral Conditions of Nutrition Team, Committee of Human Nutrition Science. Polish Academy of Sciences, Warszawa 2014; 3–20.
11. Heidi P, Beulens FJW, May AM, et al. Dietary patterns in relation to quality-adjusted life years in the EPIC-NL cohort. Prev Med 2015; 77: 119–124. doi: 10.1016/j.ypmed.2015.05.014
12. Falkowska A, Stefańska E, Ostrowska L, Ocena sposobu żywienia dzieci w wieku 10–12 lat o zróżnicowanym stopniu odżywienia. Endokrynol Otył Zab Przem Mat 2011; 7 (4).
13. Sharmanov TS, Salkhanova AB, Datkhabayeva GK. A comparative analysis of actual nutrition of children aged 9-10 years. Vopr Pitan 2018; 87: 28–41. doi: 10.24411/0042-8833-2018-10064
14. Ojeda-Rodríguez A, ZazpeI, Morell-Azanza L, et al. Improved Diet Quality and Nutrient Adequacy in Children and Adole-scents with Abdominal Obesity after a Lifestyle Intervention. Nutrients 2018; 10: pii: E1500. doi: 10.3390/nu10101500
15. López-Sobaler AM, Aparicio A, González-Rodríguez LG, et al. Adequacy of usual vitamin and mineral intake in Spanish chil-dren and adolescents: ENALIA study. Nutrients 2017; 9: pii: E131. doi: 10.3390/nu9020131
16. López-Sobaler A M, Aparicio A, Rubio J, et al. Adequacy of usual macronutrient intake and macronutrient distribution in chil-dren and adolescents in Spain: A national dietary survey on the child and adolescent population, ENALIA 2013–2014. Eur J Nutr 2019; 58: 705–719. doi: 10.1007/s00394-018-1676-3
17. Manios Y, Grammatikaki E, Papoutsou S, et al. Nutrient intakes of toddlers and preschoolers in Greece: The GENESIS Study. J Am Diet Assoc 2008; 108: 357–361. doi: 10.1016/j.jada.2007.10.042
18. Te Morenga L, Montez JM. Health effects of saturated and trans-fatty acid intake in children and adolescents: Systematic review and meta-analysis. PLoS One 2017; 12: e0186672. doi: 10.1371/journal.pone.0186672
19. https://www.who.int/dietphysicalactivity/childhood_what_can_be_done/en/;(accessed on 3 June 2019)
20. Kolarzyk E, Janik A, Kwiatkowski J. Ocena ryzyka zespołu metabolicznego u dzieci z nadwagą i otyłością. Część II. Żywieniowe czynniki ryzyka zespołu metabolicznego. Probl Hig Epidemiol 2011; 92: 747–752.
21. Dyląg H, Weker H, Barańska M, et al. Interwencja żywieniowa w grupie otyłych dzieci w wieku przedpokwitaniowym. Probl Hig Epidemiol 2011; 92: 569–572.
22. Dereń K, Weghuber D, Caroli M, et al. Consumption of Sugar-Sweetened Beverages in Paediatric Age: A Position Paper of the European Academy of Paediatrics and the European Childhood Obesity Group. Ann Nutr Metab 2019; 74: 296–302. doi: https://doi.org/10.1159/000499828.
23. Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children’s health: an update of the literatu-re. BMC Obesity 2018; 5: 6. doi: https://doi.org/10.1186/s40608-017-0178-9
24. Malik VS, Pan A, Willett WC, et al. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr 2013; 98: 1084–1102. doi: 10.3945/ajcn.113.058362.
25. Murray RD. 100% fruit juice in child and adolescent dietary patterns. Journal of the American College of Nutrition, 2019. doi: 10.1080/07315724.2019.1615013
26. O’Neil CE, Nicklas TA, Rampersaud GC, et al. One hundred percent orange juice consumption is associated with better diet quality, improved nutrient adequacy, and no increased risk for overweight/obesity in children. Nutr Res 2011; 31: 673–682. doi: 10.1016/j.nutres.2011.09.002.
27. Sharmanov TS, Salkhanova AB, Datkhabayeva GK. A comparative analysis of actual nutrition of children aged 9-10 years. Vopr Pitan 2018; 87: 28–41. doi: 10.24411/0042-8833-2018-10064
28. Kranz S, Brauchla M, Slavin JL, et al. What Do We Know about Dietary Fiber Intake in Children and Health? The Effects of Fiber Intake on Constipation, Obesity, and Diabetes in Children. Adv Nutr 2012; 3: 47–53. doi: 10.3945/an.111.001362.
29. Poole SA, Hart CN, Jelalian E, et al. Relationship between dietary energy density and dietary quality in overweight young chil-dren: a cross-sectional analysis. Pediatr Obes 2016; 11: 128–135. doi: 10.1111/ijpo.12034.
30. Anderson JW, Baird P, Davis Jr R H, et al. Health benefits of dietary fiber. Nutr Rev 2009; 67: 188–205. doi: 10.1111/j.1753-4887.2009.00189.x
31. Emmett PM, Jones LR. Diet, growth, and obesity development throughout childhood in the Avon Longitudinal Study of Pa-rents and Children. Nutr Rev 2015; 73 (Suppl 3): 175–206. doi: 10.1093/nutrit/nuv054
32. Noel S, Ness A, Northstone K, et al. Associations between flavored milk consumption and changes in weight and body com-position over time: differences among normal and overweight children. Eur J Clin Nutr 2013; 67: 295–300. doi: 10.1038/ejcn.2012.123.
33. Dougkas A, Barr S, Reddy S, et al. A critical review of the role of milk and other dairy products in the development of obesity in children and adolescents. Nutr Res Rev 2019; 32: 106–127. doi: 10.1017/S0954422418000227
34. Manios Y, Moschonis G, Chrousos GP, et al. The double burden of obesity and iron deficiency on children and adolescents in Greece: the Healthy Growth Study. J Hum Nutr Diet 2013; 26: 470–478. doi: 10.1111/jhn.12025.
35. Aeberli I, Hurrell RF, Zimmermann MB. Overweight children have higher circulating hepcidin concentrations and lower iron status but have dietary iron intakes and bioavailability comparable with normal weight children. Int J Obes (Lond) 2009; 33: 1111–1117. doi: 10.1038/ijo.2009.146.
36. Merkiel-Pawłowska S, Chalcarz W. Gender differences and typical nutrition concerns of the diets of preschool children – the results of the first stage of an intervention study. BMC Pediatrics 2017; 17: 207. doi: 10.1186/s12887-017-0962-1.
37. Florkiewicz A, Grzych-Tuleja E, Cieślik E, et al. Ocena pobrania z dietą wybranych składników mineralnych przez młodzież w wieku 13–15 lat w zależności od płci oraz miejsca zamieszkania. Zdr Publ Zarządz 2013; 11: 260–266.
38. Yang Q, Zhang Z, Kuklina EV, et al. Sodium intake and blood pressure among US children and adolescents. Pediatrics 2012; 130: 611–619. doi: 10.1542/peds.2011-3870.
39. Buendia JR, Bradlee ML, Daniels SR, et al. Longitudinal effects of dietary sodium and potassium on blood pressure in adole-scent girls. JAMA Pediatr 2015; 169: 560–568. doi: 10.1001/jamapediatrics.2015.0411.
40. WHO, Guideline: Sodium intake for adults and children, 2012, WHO Library Cataloguing-in-Publication https://www.who.int/nutrition/publications/guidelines/sodium_intake/en/ (Accesses on 24 October 2019).
41. Gunanti IR, Marks GC, Al-Mamun A, et al. Low serum concentrations of carotenoids and vitamin E are associated with high adiposity in Mexican-American children. J Nutr 2014; 144: 489–495. doi: 10.3945/jn.113.183137.
42. Rusińska A, Płudowski P, Walczak M, et al. Vitamin D Supplementation Guidelines for General Population and Groups at Risk of Vitamin D Deficiency in Poland-Recommendations of the Polish Society of Pediatric Endocrinology and Diabetes and the Expert Panel With Participation of National Specialist Consultants and Representatives of Scientific Societies – 2018 Update. Front Endocrinol (Lausanne) 2018; 9: 246. doi: 10.3389/fendo.2018.00246.
43. Chew WF, Leong PP, Yap SF, et al. Risk factors associated with abdominal obesity in suburban adolescents from a Malaysian district. Singapore Med J 2018; 59: 104–111. doi: 10.11622/smedj.2017013
44. Mihrshahi S, Drayton BA, Bauman AE, et al. Associations between childhood overweight, obesity, abdominal obesity and obesogenic behaviors and practices in Australian homes. BMC Public Health 2017; 18: 44. doi: 10.1186/s12889-017-4595-y
45. Nurul-Fadhilah A, Teo PS, Huybrechts, et al. Infrequent breakfast consumption is associated with higher body adiposity and abdominal obesity in Malaysian school-aged adolescents. PLoS One 2013; 8: e59297. doi: 10.1371/journal.pone.0059297
46. Monzani A, Ricotti R, Caputo M, et al. Systematic Review of the Association of Skipping Breakfast with Weight and Cardiome-tabolic Risk Factors in Children and Adolescents. What Should We Better Investigate in the Future? Nutrients 2019; 11: pii: E387. doi: 10.3390/nu11020387
47. Jennings A, Welch A, van Sluijs EMF, et al. Diet quality is independently associated with weight status in children aged 9–10 years. J Nutr 2011; 141: 453–459. doi: 10.3945/jn.110.131441
48. Muhammad AN, Varani J. The western-style diet, calcium deficiency and chronic disease. J Nutr Food Sci 2016; 6: 3. doi: 10.4172/2155-9600.1000496