Nutrition 30 (2014) 1379–1383

Contents lists available at ScienceDirect

Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

Adherence to Mediterranean diet in a sample of Tuscan

adolescents
Francesca Santomauro Ph.D. a, *, Chiara Lorini Ph.D. a, Tommaso Tanini M.D. b,
Laura Indiani M.D. b, Vieri Lastrucci M.D. b, Nicola Comodo Prof. c,
Guglielmo Bonaccorsi M.D. c
a
Department of Health Science, University of Florence, Florence, Italy
b
School of Specialization in Hygiene and Preventive Medicine, University of Florence, Florence, Italy
c
Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study was to estimate the level of adherence to the Mediterranean diet in
Received 17 July 2013 a group of Italian high school students, in relation to their lifestyles and social and family contexts,
Accepted 4 April 2014 and to compare the nutrition habits of the sample with other similar groups.
Methods: The KIDMED index and an ad hoc questionnaire were administered to 1127 students
Keywords: (mean age 16.8
1.6 y) in the province of Florence. Any significant associations between the level
Mediterranean diet
of adherence to the Mediterranean diet and the aforementioned variables were assessed by the c2
Adolescents
test and by logistic regression analysis.
Nutrition
Nutritional status Results: The adherence to the Mediterranean diet was good in 16.5%, average in 60.5%, and poor in
Italy 23% of the students. The students attending technical high schools, those who played sports less
KIDMED than “almost every day”, those who spent >3 h/d in sedentary activities, those who defined their
school performance as worse than “more than sufficient,” and those who referred to use of a car/
moped as the most frequent mode of transportation, had significantly higher odds of poor rather
than average or good adherence to Mediterranean diet. Moreover, being normal weight or over-
weight/obese, and referring to health workers as source of information on diet, seem to be pro-
tective factors against poor adherence to Mediterranean diet.
Conclusions: Our sample presents a departure from the Mediterranean dietary pattern. It is
certainly necessary to implement public health policies targeting teenagers to promote healthier
lifestyle choices; the nutritional patterns of the Mediterranean diet should be among these choices.
Ó 2014 Elsevier Inc. All rights reserved.

Introduction
The Mediterranean diet, which is considered a model of a
healthy diet, ensures a sufficient intake of calories and nutrients
in proper proportions. This dietary pattern helps prevent car-
diovascular diseases [1], hypertension [2], cancer [3], and dia-
betes [4], and is generally related to a longer life expectancy.
The Mediterranean diet is characterized by a high consump-
tion of vegetables, grains, nuts, olive oil, and legumes; a mod-
erate consumption of poultry, fish, eggs, and dairy products; and
FS, CL, and GB designed the study, analyzed the data, and drafted the manu-
script. TT, LI, and VL administered the questionnaire, entered the data, and
drafted the manuscript. NC contributed to design the study.
* Corresponding author. Tel.: þ39 055 275 1066; fax: þ39 055 275 1093.
E-mail address: francesca.santomauro@unifi.it (F. Santomauro).
a low consumption of red meat and animal fat. It also includes a
good intake of antioxidant vitamins (vitamins E and C), carot-
enoids, and micronutrients [5].
In recent decades, a shift away from this nutritional pattern
toward a high-energy diet pattern that is rich in saturated fats
and low in micronutrients has been seen in Mediterranean
countries. This diet has often replaced traditional foods, espe-
cially in younger generations [6–8].
This gradual transition has led to an alarming increase in
obesity, especially among children in both Mediterranean and
other industrialized countries [9]. Many factors may have con-
tributed to this increased prevalence of obesity (e.g., genetic,
neurologic, endocrine, and environmental). However, although it
is unlikely that changes in the genetic structure could represent
the main factor, it is conceivable that the root of the problem can
be found among environmental factors [10].

0899-9007/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nut.2014.04.008
1380 F. Santomauro et al. / Nutrition 30 (2014) 1379–1383
In fact, the rapid development of the food industry, together
with the sociologic changes and technological developments
that have emerged alongside it, has modified eating habits and
lifestyles. A combination of these factors has spurred many in-
dividuals toward choosing a diet rich in “industrialized” food-
stuffs and, at the same time, adopting an increasingly sedentary
lifestyle [1]; together, these two factors have been determining
the phenomenon of the so-called globesity [11]. The alarming
obesity epidemic has pushed many scientists and public health
professionals to develop health promotion interventions, espe-
cially those addressed to children and teenagers [12].
Food choices are directly related to an individual’s level of
nutritional knowledge [13]. The family, school environment,
peers, coaches of extracurricular sporting activities, and health
professionals can provide this type of knowledge [13]. In the sci-
entific literature, a great deal of evidence exists that the family
environment is particularly important in determining food
choices and lifestyle. In particular, membership in a higher social
class and the possession of higher familiar cultural capital are
associated with a higher-quality diet and, generally, with healthier
lifestyles [14].
Many scientific studies have utilized the KIDMED tool to
evaluate adherence to the Mediterranean diet (as a prototypical
healthy diet) in people between the ages of 2 and 24 y [15,16].
KIDMED was initially used in Spain and was then applied to
studies carried out in other Mediterranean countries [13,17]; it is
the first index aimed at specifically evaluating the adherence to
the Mediterranean diet in children and young people [15].
The aim of this study was to estimate the level of adherence to
the Mediterranean diet in a group of Italian high school students,
in relation to their lifestyles and social and family contexts, and
to compare nutritional habits of the sample with other similar
surveys.
Materials and methods
The survey has been conducted according to the Helsinki Declaration on
human subjects testing. Written consent of students’ parents has been collected.
The survey was carried out in a state high school located in the province of
Florence and that includes different fields of education: Liceo Classico, which
features Latin, Ancient Greek, Italian, history, and philosophy as its most
important subjects; Liceo Scientifico, which is more oriented toward mathe-
matics, physics, chemistry, biology, Earth science; and Istituto Tecnico, which is
more oriented toward practical subjects such as jurisdiction, tourism, metal
working, electronics, chemical industry, biotechnology, visual communication,
and fashion. The sample was selected on convenience criteria: The school was
chosen due to the different fields of education, the number of students that
could be included in the study, and the collaboration of the headmaster and
teachers. Among the students (N ¼ 1380), 40% and 28%, respectively, resided
in the municipalities of Scandicci and Florence, whereas the other students
lived in 20 different municipalities of the provinces of Florence and Prato. The
final sample consisted of 1127 students, representing 100% of the students at
school on the day of the survey and approximately 82% of the registered
students.
The KIDMED and an ad hoc questionnaire were administered to the students
who agreed to join the study. The administration took place over a single day in
February 2012. The questionnaire and the KIDMED test were self-compiled
during the school day after the research team gave a short explanation. The
questionnaires were immediately compiled. The KIDMED is a tool widely used in
the literature [15]. It produces a score measuring the degree of adherence to the
Mediterranean diet (poor, average, or good) in children and adolescents. The
KIDMED was developed to combine in a single index recommendations on the
Mediterranean diet for adults with others for a child’s diet (such as regularly
making breakfast). The scale consists of 16 questions with yes/no answers. A
value of 1 was assigned to the responses reflecting a lack of adherence to the
Mediterranean diet, whereas those responses indicating compliance were
assigned a value of þ1. The final scores ranged from 4 to þ12 and were then
classified into three levels: 8 was considered a good level of adherence; 4 to 7,
an average level of adherence; and <4, a poor level of adherence to Mediterra-
nean diet.
The questionnaire included questions regarding the following items:
 Individual and family characteristics, such as nationality, job, level of edu-
cation, and marital status of the parents;
 Anthropometric data (self-reported height and weight);
 Self-perception regarding one’s own body weight (“Do you think you are
underweight, normal weight, or overweight/obese?”);
 Source of information on proper nutrition (family, teachers, coach, friends,
health workers, TV/internet, no source);
 Sport (type and h/wk), daily hours of sedentary activity, mode of travel
during the day; and
 Potential elements of distress, including quality of relationships with peers,
family, and school performance.
Body mass index (BMI) was calculated using self-reported weights and
heights; underweight, normal weight, and overweight/obesity were defined
using the threshold values for BMI previously derived and as recommended by
the International Obesity Task Force (IOTF) [18,19].
For each student, the jobs and the level of education of the parents were used
to establish the social class and cultural capital attributed to the single parent and
to the family, based on a previously described model [20]. Erikson’s criterion of
dominance [21] was used to combine the parents’ jobs in the variable “familiar
social class” considering the higher level of profession between the two parents.
Similarly, “familiar cultural capital” was determined based on parental achieve-
ment of the higher level of education. The collected data were entered into an ad
hoc access database and analyzed using the statistical software SPSS 19 (IBM
SPSS, Version 19.0. Armonk, NY, USA).
To evaluate significant associations between the level of adherence to the
Mediterranean diet and the variables just cited, a descriptive analysis with c2 test
and a logistic regression analysis were conducted. In particular, the logistic
regression analysis was performed to assess the degree of association, as
measured by odds ratio, between all the variables and the level of adherence to
Mediterranean diet. Because the main objective was to understand the predictive
factors of poor adherence, in the logistic analysis we have considered, as
dichotomous outcome variable, poor or average plus good adherence.
At first, univariate logistic analysis was performed. The variables statistically
associated with the level of adherence to Mediterranean diet (poor versus
average/good) were entered into a multivariate logistic regression model, con-
ducted using the backward stepwise method. The final model includes only the
variables with a statistically significant association with the outcome variable in
the multivariate analysis.
For each analysis, an a level of 0.05 has been considered as significant.
Results
The sample consisted of 1127 students (55.1% boys and 44.9%
girls), between ages 14 and 20 (mean age 16.8
1.6 y). All the
collected questionnaires were, almost partially, completed, and
considered for the statistical analyses. The percentage of missing
values was, for each item, <12%. In the descriptive analysis, the
percentage of each modality of answer was calculated without
considering missing values.
Of these, 8.4% of the students were born abroad, most
frequently in Albania (2.6%) or Romania (2.4%), and 12.8% and 9.4%
of the sample had a mother or father born abroad, respectively.
Considering self-reported anthropometric data, 9.3% were
underweight, whereas the prevalence of overweight/obesity
was 10%.
The sample primarily consisted of students belonging to
families with medium-high or high familial cultural capital
(54.2% and 29.2%, respectively), and the familial social classes
were medium-high (47%) or high (25.4%) in most of the sample.
Fewer than 20% of the mothers and fathers graduated high
school only, whereas 2.2% of mothers and 3.1% of fathers had
only a primary school education. Among the sample, 26.9% of
respondents said they played sports almost every day; 45.2%
played one to three times a week; 17.3% played occasionally; and
10.5% never played. Regarding their usual modes of trans-
portation, 31.7% of the students responded that they traveled
mainly by foot and by bicycle.
 F. Santomauro et al. / Nutrition 30 (2014) 1379–1383 1381

The most common sources from which the students received Table 2
information on how to eat properly were family members (68%), Levels of adherence to the Mediterranean diet stratified by demographic,
anthropometric, and body self-perception characteristics of adolescents (c2 test:
their coach or trainer (23.6%), and their general practitioner P < 0.05)
(18.8%). The percentage of students who said they had not
received information from anyone was very high (14.9%). n (%) Adherence

Furthermore, 13.6% of the students had a low level of school Poor (%) Average (%) Good (%)
performance, and 6.7%, 16.8%, and 3.2% declared that they did not Country of birth
have a good relationship with their peers, families, or either, Italy 989 (91.6) 23.0 60.9 16.2
Albania 28 (2.6) 17.9 60.7 21.4
respectively.
Romania 26 (2.4) 19.2 80.8 0
Table 1 reports the percentage of “yes” for each item on the Other 37 (3.4) 29.7 40.5 29.7
KIDMED. The percentage of students who did not follow the Area of study
daily recommendation of at least five servings of fruits and Istituto tecnico 506 (46.4) 29.8 55.9 14.2
vegetables was very high. A high percentage of participants often Liceo classico and scientifico 584 (53.6) 17.1 64.4 18.5
Body self-perception
skipped breakfast, and consumed sweets and candy several
Underweight 75 (7.0) 30.7 62.6 6.7
times every day. Regarding the consumption of fish and nuts, Normal weight 909 (84.2) 21.6 60.5 17.9
42.6% and 24.5%, respectively consumed these at least two or Overweight/obese 95 (8.8) 29.5 61.1 9.5
three times a week. Have you ever followed a weight loss diet?
The percentage of students who went to a fast food restaurant Yes 204 (19.0) 15.2 60.8 24.0
No 768 (71.5) 24.0 60.5 15.5
more than once a week decreased significantly with increasing No, but I intend to 102 (9.5) 32.4 57.8 9.8
age (14.3% of students in the upper first level, but only 8.2% of BMI classes
students in their last year of high school). Underweight 92 (9.3) 35.9 47.8 16.3
Tables 2 and 3 report the levels of adherence to the Medi- Normal weight 797 (80.9) 20.8 62.4 16.8
Overweight/obese 96 (9.8) 21.9 64.6 13.5
terranean diet for the variables with significant association.
The adherence to the Mediterranean diet was good in 16.5% of BMI, body mass index.
cases, average in 60.5%, and poor in 23%. The prevalence rate of
poor adherence was significantly higher among students used mode of transportation, how they defined their school
attending technical high schools (29.8%), in underweight stu- performance, how they defined their relationship with their
dents (35.9%), in those who were not physically active (41.2%), in parents, familiar social class, and BMI class. These variables were
underachievers (32.4%), and in those reporting a suboptimal entered into the multivariate logistic regression model. The final
relationship with their families (38.5%). Additionally, a higher
prevalence of poor adherence was found among students Table 3
belonging to low- or middle-class families (29.8%) and among Level of adherence to the Mediterranean diet according to sources of information
those whose mothers had low or medium levels of cultural on diet, lifestyles, academic performance, and relationships with parents
capital (28.6%). There were no significant differences between n (%) Adherence
the two sexes based on the results of total KIDMED scores.
Poor (%) Average (%) Good (%)
Table 4 reports the results of multivariate logistic regression
Who provided the information on diet?*
analysis. In the univariate logistic analysis, the variables statis- Familyy 745 (66.1) 0.3 62.4 17.3
tically associated with level of adherence to Mediterranean diet Teachers 52 (4.6) 25.0 59.6 15.4
y
(poor versus average/good) were the following: area of study, Coach/trainer 255 (22.6) 16.9 61.2 22.0
health workers as source of information on diet (no one, family, Friends 42 (3.7) 16.7 66.7 16.7
Health workersy 203 (18.0) 12.3 66.6 21.7
coach/trainer, or health workers), having followed a weight loss
TV/Internet/magazines 105 (9.3) 18.1 61.9 20.0
diet, how many times a week they played a sport, how many Other 26 (2.3) 26.9 53.8 19.2
hours per day spent sedentarily, car or moped as the most often No sourcey 159 (14.1) 42.1 50.3 7.5
y
How many times a week do you play a sport?
Table 1 Every day or almost 290 (26.8) 16.9 58.3 24.8
KIDMED: Percentage of “Yes” answers* 1–3/wk 487 (44.9) 21.4 62.0 16.6
Occasionally 193 (17.8) 24.9 65.3 9.8
KIDMED test Yes (%) Never 114 (10.5) 41.2 52.6 6.1
Takes a fruit or fruit juice every day 78.0 How many hours a day do you spend in sedentary activity?y
Consumes a second fruit every day 40.4 <2 351 (32.3) 19.9 58.4 21.7
Consumes fresh or cooked vegetables regularly 1/d 64.3 2–3 445 (40.9) 20.4 63.4 16.2
Consumes fresh or cooked vegetables >1/d 29.8 >3 291 (26.8) 30.9 58.8 10.3
Consumes fish regularly (at least 2–3/wk) 42.6 Which modes of transportation do you most often use?*
Eats at a fastfood restaurant >1/wk 10.4 Walkingy 329 (29.2) 19.5 60.5 20.1
Bicycle 24 (2.1) 12.5 58.3 29.2
Likes pulses and eats them >1/wk 48.2
Car/mopedy 614 (54.5) 26.1 58.5 15.5
Consumes pasta or rice almost every day (5/wk) 84.3
Public transportation 231 (20.5) 20.3 64.5 15.2
Consumes cereals or grains (bread, etc.) for breakfast 42.9 y
How would you define your school performance?
Consumes nuts regularly (2–3/wk) 24.5
More than sufficient 309 (28.6) 15.9 63.4 20.7
Uses olive oil at home 96.1
Sufficient 624 (57.7) 24.0 60.1 15.9
Skips breakfast 31.4 Not sufficient 148 (13.7) 32.4 57.4 10.1
Consumes a dairy product for breakfast (yogurt, milk, etc.) 66.6 How would you define your relationship with your parents?y
Has commercially baked goods or pastries for breakfast 55.0 Good 901 (83.2) 21.3 60.8 17.9
So-so 169 (15.6) 30.2 59.2 10.7
Consumes 2 yogurts and/or some cheese (40 g) daily 33.2
Not good 13 (1.2) 38.5 53.8 7.7
Consumes sweets and candy several times every day 34.5
* c tests carried out for each category considering the prevalence of an
2

* “Yes” answers in the white rows have a positive score (þ1); “yes” answers in affirmative response compared to a negative response.
y
the grey rows have a negative score (1). P < 0.05 (c2).
1382 F. Santomauro et al. / Nutrition 30 (2014) 1379–1383

Table 4 1956 Spanish adolescents between the ages of 13 and 16 y was

Multivariate logistic regression analysis: Odds ratio of poor vs. average/good reported as poor in 6.7%, average in 50.4%, and good in 42.9% of
adherence to Mediterranean diet
cases [23].
Variables OR P-value 95% CI In the multivariate logistic regression analysis the classifica-
Area of study (ref. ¼ Istituto tecnico) tion in underweight, normal weight, or overweight/obese has
Liceo classico and scientifico 2.01 <0.001 1.44–2.79 shown a significant association with poor level of adherence,
Who provided the information on diet (ref.¼ No source) with a higher risk in underweight adolescents. Other studies on
Health workers 0.44 0.002 0.26–0.73 child and adult populations present conflicting results on the
How many times a week do you play a sport? (ref. ¼ Every day or almost) association between BMI and the level of adherence to the
1–3 1.41 0.117 0.92–2.16 Mediterranean diet: Some studies concluded that this correla-
Occasionally 1.66 0.059 0.98–2.81 tion is inversely proportional [24–28], whereas others showed
Never 3.61 <0.001 2.05–6.35
no correlation between adherence and BMI [29,30], suggesting a
How many hours a day do you spend in sedentary activity? (ref.¼ <2 hours) correlation between overweight and physical inactivity and a
2–3 1.09 0.660 0.73–1.64 high energy intake rather than a link between BMI and the
>3 1.70 0.015 1.11–2.59
quality of the diet alone.
Do you use car/moped as the most frequent mode of transportation? (ref. ¼ No) Moreover, our study shows that students with better school
Yes 1.71 0.002 1.21–2.41 achievement maintain a higher adherence to the Mediterranean
How would you define your school performance? (ref. ¼ More than sufficient) diet; the same has not been observed for students with a better
Sufficient 2.13 <0.001 1.41–3.22 relationship with their parents. These results also were partially
Not sufficient 2.51 0.001 1.45–4.33
confirmed by a previous study that underlined the importance of
BMI class (ref. ¼ Underweight) the parental role in the acquisition of correct lifestyle habits [31].
Normal weight 0.41 <0.001 0.25–0.68 On the other hand, because it has been shown that an effective
Overweight/obese 0.47 0.032 0.24–0.94
education is correlated with better school performance [32], it
BMI, body mass index could be argued that low achievement could be connected with a
Number of observations ¼ 970; LR c2 (12 df) ¼ 102.09; c2 < 0.001; pseudo
difficult family situation in general, but especially during the
R2 ¼ 0.1007
delicate phase of growth that is adolescence.
In our sample, adherence to the Mediterranean diet and the
model includes the following variables: area of study, health
amount of physical activity were closely related to each other.
workers as source of information on diet, how many times per
The rate of adherence to the Mediterranean diet increased with
week they played a sport, how many hours per day they spent in
increased time devoted to sports and, conversely, decreased with
sedentary activities, car or moped as the most often used mode
increasing hours of inactivity and with the use of car or moped as
of transportation, how they defined their school performance,
the most frequent mode of transportation. This association also
and BMI class. Students attending technical high schools, those
has been confirmed by other studies [22,33,34].
who played sports less than or almost every day (the odds in-
There were no significant differences between boys and girls
crease with the decreasing number of times they participated in
in levels of adherence to the Mediterranean diet, as measured
a sport), those who spent more than 3 h/d in sedentary activities,
with the KIDMED test. Considering the individual items of the
those who defined their school performance worse than “more
KIDMED test, we noted that girls had a higher average con-
than sufficient” (the odds increase with the decreasing of school
sumption of fruits and vegetables.
performance), and those who referred to use a car or moped as
The results of our study seem to confirm what emerges in
the most frequent mode of transportation, had significantly
other Mediterranean countries where we witness the passage
higher odds of poor rather than average/good adherence to
from a diet considered healthy to other less healthy food
Mediterranean diet. Moreover, being normal weight or over-
patterns, as also described by other Italian authors [35].
weight/obese, and reporting health workers as source of infor-
The limitations of this study are related to the study design. In
mation on diet, seem to be protective factors against poor
particular, we have considered self-reported anthropometric
adherence to Mediterranean diet.
data to calculate BMI. A recent review has shown that self-
reported data underestimate overweight prevalence and there
Discussion is bias by sex and weight status [36]. Therefore, there could be a
misclassification in the attribution of each participant in under-
The adherence to the Mediterranean diet was good in 16.5%, weight, normal weight, or overweight/obese class.
average in 60.5%, and poor in 23% of the students. According to Another limitation is related to the choice of including only
multivariate logistic regression analysis, poor adherence was one school and to the modality we used to select it (convenience
significantly higher in students who were not physically active, criteria, not random selection). Considering these aspects, the
who underachieved in school, who were underweight, and who results of our study could be considered not representative of a
attended technical high schools. large area or population and should be confirmed by other
The data in the literature regarding adherence to the Medi- surveys.
terranean diet are not uniform, confirming that this dietetic The strengths of the study are related to the choice of the
patterndamong the countries traditionally comprising the KIDMED test, which is a tool validated in the Mediterranean diet,
Mediterranean areadhas been, at least partially, abandoned. and to the sample size.
Studies on 554 Greek adolescents between the ages of 12 and 18
y reported poor adherence in 27%, average in 68.6%, and good in
8.3% of the sample [17,22]. In a study on a population of Spanish Conclusion
adolescents and young adults between the ages of 15 and 24 y,
poor adherence was reported in 5.3%, average in 50.1%, and good This sample presents a move away from the nutritional model
in 44.6% of the sample [15]. Finally, adherence in a sample of of the Mediterranean diet, reflecting the adoption of poor eating
 F. Santomauro et al. / Nutrition 30 (2014) 1379–1383
habits that often are associated with high levels of sedentary
behavior.
It is necessary to implement public health policies targeting
teenagers, especially for those at higher risk, to promote
healthier lifestyle choices; the nutritional patterns of the Medi-
terranean diet should be among these choices.
Acknowledgments
The authors acknowledge Guendalina Allodi, Antonino Sala,
and Giulia Esposto for their substantive contribution to the
study; Pasquale Pepe for assistance with the statistical analysis;
and the headmaster, teachers, and students of the high school
where the study was conducted for the collaboration.
References
[1] Bonaccio ML, Iacoviello L, de Gaetano G, Moli-sani Investigators. The Med-
iterranean diet: the reasons for a success. Thromb Res 2012;129:401–4.
[2] Di Daniele N, Petramala L, Di Renzo L, Sarlo F, Della Rocca DG, Rizzo M, et al.
Body composition changes and cardiometabolic benefits of a balanced
Italian Mediterranean diet in obese patients with metabolic syndrome.
Acta Diabetol 2013;50:409–16.
[3] Martınez-Gonz n-Grima F, De Irala J, Ruız-Canela M, Bes-
alez MA, Guille
Rastrollo M, Beunza JJ, et al. The Mediterranean diet is associated with a
reduction in premature mortality among middle-aged adults. J Nutr 2012;
142:1672–8.
[4] Abiemo EE, Alonso A, Nettleton JA, Steffen LM, Bertoni AG, Jain A, et al.
Relationships of the Mediterranean dietary pattern with insulin resistance
and diabetes incidence in the Multi-Ethnic Study of Atherosclerosis
(MESA). Br J Nutr 2012;30:1–8.
[5] Srinath RK, Katan MB. Diet, nutrition and the prevention of hypertension
and cardiovascular diseases. Public Health Nutr 2004;7:167–86.
[6] Ritchie LD, Spector P, Stevens MJ, Schmidt MM, Schreiber GB, Striegel-
Moore RH, et al. Dietary patterns in adolescence are related to adiposity in
young adulthood in black and white females. J Nutr 2007;137:399–406.
[7] Co rdoba-Caro LG, Luego Perez LM, Garcıa Preciado V. Nutricional adequacy
of students of compulsory secondary education in Badajoz. Nutr Hosp
2012;27:1065–71.
[8] Aounallah-Skhiri H, Traissac P, El Ati J, Eymard-Duvernay S, Landais E,
Achour N, et al. Nutrition transition among adolescents of a south-
Mediterranean country: dietary patterns, association with socio-economic
factors, overweight and blood pressure. A cross-sectional study in Tunisia.
Nutr J 2011;10:38.
[9] Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in
public health. Obes Rev 2004;5:4–85.
[10] Rey-Lo  pez JP, Vicente-Rodrıguez G, Biosca M, Moreno LA. Sedentary
behaviour and obesity development in children and adolescents. Nutr
Metab Cardiovasc Dis 2008;18:242–51.
[11] World Health Organization. Controlling the global obesity epidemic. Avail-
able at: www.who.int/nutrition/topics/obesity/en. Accessed May 28. 2014.
[12] Dattilo AM, Birch L, Krebs NF, Lake A, Taveras EM, Saavedra JM. Need for
early interventions in the prevention of pediatric overweight: A review and
upcoming directions. J Obes 2012;2012:123023.
[13] Sahingoz SA, Sanlier N. Compliance with Mediterranean Diet Quality Index
(KIDMED) and nutrition knowledge levels in adolescents. A case study from
Turkey. Appetite 2011;57:272–7.
[14] Martini LA, Verly E, Marchioni DM, Fisberg RM. Prevalence and correlates
of calcium and vitamin D status adequacy in adolescents, adults, and
elderly from the Health Survey-Sao Paulo. Nutrition 2013;9:845–50.
1383
[15] Serra-Majem L, Ribas L, Ngo J, Ortega RM, Garcıa A, Pe rez-Rodrigo C, et al.
Food, youth and the Mediterranean diet in Spain. Development of KIDMED,
Mediterranean Diet Quality Index in children and adolescents. Public
Health Nutr 2004;7:931–5.
[16] Schroder H, Mendez MA, Gomez SF, Fito M, Ribas L, Aranceta J, et al. Energy
density, diet quality, and central body fat in a nationwide survey of young
Spaniards. Nutrition 2013;29:1350–5.
[17] Kontogianni MD, Farmaki AE, Vidra N, Sofrona S, Magkanari F,
Yannakoulia M. Associations between lifestyle patterns and body mass
index in a sample of Greek children and adolescents. J Am Diet Assoc
2010;110:215–21.
[18] Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition
for child overweight and obesity worldwide: International survey. BMJ
2000;320:1240–3.
[19] Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut offs to
define thinness in children and adolescents: International survey. BMJ
2007;335:194.
[20] Schizzerotto A. Classi sociali e societ a contemporanea. Milano: Angeli;
1988.
[21] Cardano M, Marinacci C. Measuring social position. Epidemiol Prev
2004;28:124–42.
[22] Kontogianni MD, Vidra N, Farmaki AE, Koinaki S, Belogianni K, Sofrona S,
et al. Adherence rates to the Mediterranean diet are low in a representative
sample of Greek children and adolescents. J Nutr 2008;138:1951–6.
[23] Ayechu A, Dur a T. Quality of dietary habits (adherence to a Mediterranean
diet) in pupils of compulsory secondary education. An Sist Sanit Navar
2010;33:35–42.
[24] Panagiotakos DB, Chrysohoou C, Pitsavos C, Stefanadis C. Association be-
tween the prevalence of obesity and adherence to the Mediterranean diet:
the ATTICA study. Nutrition 2006;22:449–56.
[25] Schröder H, Marrugat J, Vila J, Covas MI, Elosua R. Adherence to the
traditional Mediterranean diet is inversely associated with body mass in-
dex and obesity in a Spanish population. J Nutr 2004;134:3355–61.
[26] Jennings A, Welch A, van Sluijs EM, Griffin SJ, Cassidy A. Diet quality is
independently associated with weight status in children aged 9–10 years.
J Nutr 2011;141:453–9.
[27] Dura Trave T, Castroviejo Gandarias A. Adherence to a Mediterranean diet
in a college population. Nutr Hosp 2011;26:602–8.
[28] Romaguera D, Norat T, Mouw T, May AM, Bamia C, Slimani N. Adherence to
the Mediterranean diet is associated with lower abdominal adiposity in
European men and women. J Nutr 2009;139:1728–37.
[29] Trichopoulou A, Naska A, Orfanos P, Trichopoulos D. Mediterranean diet in
relation to body mass index and waist-to-hip ratio: The Greek European
Prospective Investigation into Cancer and Nutrition Study. Am J Clin Nutr
2005;82:935–40.
[30] Farajian P, Risvas G, Karasouli K, Pounis GD, Kastorini CM, Panagiotakos DB,
et al. Very high childhood obesity prevalence and low adherence rates to
the Mediterranean diet in Greek children: the GRECO study. Atheroscle-
rosis 2011;217:525–30.
[31] Lopez-Dicastillo O, Grande G, Callery P. Parents contrasting views on diet
versus activity of children: implications for health promotion and obesity
prevention. Patient Educ Couns 2010;78:117–23.
[32] Martinez Gonzalez AE, Ingles Saura CJ, Piqueras Rodriguez JA, Ramos
Linares V. Importancia de los amigos y los padres en la salud y el rendi-
miento escolar. Rev Electron Investig Psicoeduc Psigopedag 2010;8:111–38.
[33] Martınez E, Llull R, Bibiloni M del M, Pons A, Tur JA. Adherence to the
Mediterranean dietary pattern among Balearic Islands adolescents. Br J
Nutr 2010;103:1657–64.
[34] Schröder H, Mendez MA, Ribas-Barba L, Covas MI, Serra-Majem L. Medi-
terranean diet and waist circumference in a representative national sample
of young Spaniards. Int J Pediatr Obes 2010;5:516–9.
[35] Casini L, Contini C, Marone E, Romano C. Food habits. Changes among
young Italians in the last 10 years. Appetite 2013;68:21–9.
[36] Sherry B, Jefferds ME, Grummer-Strawn LM. Accuracy of adolescent self-
report of height and weight in assessing overweight status: a literature
review. Arch Pediatr Adolesc Med 2007;161:1154–61.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.