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Research report

Compliance with Mediterranean Diet Quality Index (KIDMED) and nutrition


knowledge 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, Turkey
b
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 signicant 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 andlack 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 in
childhood 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 old age 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 fromthe study Have Healthy Diets
Protect Your Heart (conducted by the Ministry of Health of Turkey
on 15,468 individuals over 30 years old) obesity prevalence was
21% 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 2010
Received 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 pattern complying with the Mediterranean diet not only decreases body fat mass and
obesity risk, but also reduces development of various health problems. This study investigated the
nutritional awareness and diet quality Mediterranean Diet Quality Index (KIDMED) of Turkish
adolescents. The study was conducted with 890 voluntary participants (464 boys and 426 girls) 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 was X = 82.22 0.42. Results indicated that 17.9%of the participants had a low
quality 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 nalized 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: semras@gazi.edu.tr (S.A. Sahingoz).
Contents lists available at ScienceDirect
Appetite
j our nal homepage: www. el sevi er . com/ l ocat e/ appet
0195-6663/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appet.2011.05.307
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, & Schro der, 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 (Fe art et al., 2009). A Mediterranean diet
includes a high proportion of fruits, vegetables, unrened natural
cereals, legumes, dried nuts, poultry, eggs (3 times per week), sh,
low-fat dairy products and a small quantity of red meat. This diet
has positive effects on health. The sh and fruit in the
Mediterranean diet provide antioxidant vitamins (E, C) and
carotenes, and prevent insufcient micronutrient intake (Anony-
mous, 2000; Serra-Majem, Ribas, Garca, Pe rez-Rodrigo, & Ara-
nceta, 2003).
The Mediterranean eating pattern warrants attention because it
has 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
benets, 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 efciently 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 world
are 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 condentiality 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 ranged from0 to 12, and was based 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 (see Appendix 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 = 4
points; 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
then the 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 briey explained to the girls and
boys by interviewers. To guarantee anonymity of responses and
easy identication 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 evaluate
nutritional 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
KIDMEDand knowledge scores. Tukeys test was used to determine
the difference between the groups. In all analyses, a 5% and 1%
signicance 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
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 showed that 23.7%of adolescents did 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 difculty
of preparing a meal/non-necessity of having a meal (remaining
adolescents).
Nutritional knowledge and KIDMED scores of adolescents
The means and standard deviations (SD) of the answers for each
of the questions about nutrition knowledge according to genders
are presented in Table 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 benecial to
consume food cooked with sh (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).
Agender-based breakdown of the KIDMED(Mediterranean Diet
Quality Index), used to detect the nutrition habits of the
adolescents, and is shown in Table 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 statistically
signicant (t = 0.907, p > 0.05) and no statistically signicant gender-
based difference was observed between the nutritional knowledge
scores 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 childrenwho do not skipmeal are high. There is also a difference
betweenthe KIDMEDscores andthe nutritional knowledge scores of
thechildrenwhoeat twomeals per dayandthosewhoeat three/four
meals per day(p < 0.01). As the number of meals increases, sodothe
KIDMED scores and nutrition knowledge scores.
Table 2
The distribution of the nutrition knowledge scores of adolescents according to their genders (n=890).
Boys XSD Girls XSD t test 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 0.592
Should 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 0.698
Should 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 benecial to consume sh 3.751.24 3.491.23 3.109 0.002
**
It is benecial to consume chicken 3.721.25 3.391.23 3.926 0.000
**
It is benecial to consume veal 3.601.33 3.101.32 5.574 0.000
**
It is benecial to consume mutton 3.261.45 2.721.40 5.517 0.000
**
Should consume pulpy brous 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<0.05.
**
p<0.01.
Table 1
Demographic characteristics (n=890).
n %
Gender
Boy 464 52.1
Girl 426 47.9
Age (year)
12 187 21.0
13 343 38.5
14 360 40.5
Grade
6e 188 21.1
7e 378 42.5
8e 324 36.4
Mothers educational status
Illiterate 40 4.8
Primary school graduate 576 65.8
High school graduate 178 20.0
University graduate 80 9.4
Fathers educational status
Illiterate 12 1.4
Primary school graduate 448 50.4
High school graduate 279 31.3
University graduate 151 16.9
S.A. Sahingoz, N. Sanlier / Appetite 57 (2011) 272277 274
Discussion
Currently in Turkish primary schools (1st8th grade), nutri-
tional programs are still implemented with contributions fromand
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 their
nutritional 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 ndings are supported by the present study. In a
previous study on adolescent and nutritional and eating habits,
girls were found to eat mainly vegetables 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 benets of
eating vegetables, and boys were shown to know more girls about
sh, chicken, veal, and mutton consumption (Table 2). This gender-
based difference may be that Turkish 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, participating
children 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 ndings (Koksal, Tek, & Pekcan, 2008). The
results of these two studies may differ fromSamur, Gu nebak 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. Primary school graduate 5.552.31 2.836 0.037
*
81.7512.19 1.555 0.199
3. 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. Primary school graduate 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 72.8315.25
2 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<0.05.
**
p<0.01.
Table 3
Gender-based breakdown of diet quality according to KIDMED index.
Boys (n=465) Girls (n=425) Total (n=890)
n % n % n %
Very poor diet: 3 81 17.4 78 18.4 159 17.9
Diet needs improvement: 47 286 61.5 241 56.7 527 59.2
Optimal Mediterranean diet: 8 98 21.1 106 24.9 204 22.9
KIDMED score: boys =5.572.24, girls = 5.722.47, t =0.907, p >0.05.
S.A. Sahingoz, N. Sanlier / Appetite 57 (2011) 272277 275
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 KIDMEDscores. In another study by
Mariscal-Arcas et al. (2009), 3190 people between 8 and 16 years 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 Pe rez-Gallardo, BayonaMarzo, and
Benito de Miguel (2007) of the nutrition habits of university
students (aged 1824 years) in ve 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 the
participants had low KIDMED scores and it the studys authors
recommended educating children about the benets 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 signicant
difference between the two countries (KIDMED index of the Greek
children was 5.71 and 5.91 in Sweden) (Karle n, Lowert, Chatziarsenis,
& Fa lth-Magnusson, 2008). Another study by Lazarou and Kalavana
(2009) showed that only a small number of children had high
KIDMED index scores; that there were differences between rural
(n = 442) and urban (n = 442) areas; and that children living in rural
areas had higher scores (urban 5.4%, rural 8.4%). Kontogianni et al.
(2008) studied 1305 individuals in Greece, aged 318 years, and
found 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 fullling
their nutritional needs and do not need vitamin or mineral
supplements.
A study by Montero (2005), and previous studies in Turkey
(Koksal et al., 2008; Samur et al., 2008) have shown no
statistically signicant 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 of
the 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 ndings: 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 benet 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 sufcient nutrition; and of physical activity The
health benets 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, sh, 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 the results of the present study, the KIDMEDindex can
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 benecial to use a food-consumption based
method, anthropometrical measurements and biochemical mea-
surements in evaluating the nutritional status of children at risk. In
addition, further studies should be conducted on larger sample
groups with wider age ranges, living in larger geographical areas.
The limited age range, region and number of samples of the present
study cannot be generalized to the whole of Turkey.
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Appendix A. KIDMED test to assess Mediterranean diet quality
and statements and answers given in this study (%)
KIDMED
evaluation
Statements Answers to the
statements (%)
+1 Eats one fruit or has fruit juice every day 84.0
+1 Eats a second fruit every day 70.9
+1 Has fresh or cooked vegetables regularly
once a day
47.6
+1 Has fresh or cooked vegetables more than
once a day
35.4
+1 Consumes sh regularly (at least 2 or
3 times a week)
44.7
1 Goes more than once a week to a fast-food
(hamburger) restaurant
33.8
+1 Likes pulses and eats them more than
once a week
60.8
+1 Consumes pasta or rice almost every day
(5 or more times per week)
44.1
+1 Has cereals or grains (bread, etc.) for breakfast 80.4
+1 Consumes nuts regularly (at least 23 times
per week)
70.2
+1 Uses olive oil at home 84.4
1 Skips breakfast 38.6
+1 Has a dairy product for breakfast
(milk, yoghurt, etc.)
68.8
1 Has commercially baked goods or
pastries for breakfast
52.1
+1 Eats two yoghurts and/or some
cheese (40 g) daily
62.2
1 Eats sweets and candy several
times every day
61.9
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