Pediatric Weight Management

PWM: Foods and Nutrients (2006)

Rodriguez-Artalejo F, Garces C, Gorgojo L, Lopez Garcia E, Martin-Moreno JM, Benavente M, del Barrio JL, Rubio R, Ortega H, Fernandez O, de Oya M. Dietary patterns among children aged 6-7 y in four Spanish cities with widely differing cardiovascular mortality. European Journal of Clinical Nutrition 2002; 56: 141-149.
Study Design:
Cross-sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
  • To examine a number of anthropometric variables and the consumption of principal foods and nutrients among children aged 6-7 y, living in four Spanish cities with a substantial variation in IHD mortality.
  • To examine children’s diet, measured directly, in relation to the geographic variation in adult coronary mortality in a Mediterranean country.
Inclusion Criteria:

Children attending public & private schools in Cadiz & Murcia (cities with relatively high IHD mortality & Madrid and Orense (cities with relatively low IHD mortality).

Exclusion Criteria:

Children reported by their parents to suffer from cardiovascular or nephrological diseases were excluded.

Description of Study Protocol:

The study units were four Spanish cities with widely varying adult IHD mortality. Children were selected through random cluster-sampling of schools, stratified by sex & socio-economic level. A total of 6 schools were selected in each city & in each school all 6-7 y old children were invited to take part. Data were collected over a 6 week period.

Data Collection Summary:

Dependent:  Ponderal index, BMI, Overweight (BMI > 17.6 kg/m2), Obesity (BMI > 20.1 kg/m2) BMI cut-offs based on international studies - ht & wt measured following standardized procedures.

Independent:  Total energy, % of total energy from protein, total-carbohydrate, complex-carbohydrate, simple-carbohydrate energy, lipid energy, saturated-fat energy, monounsaturated fat energy, polyunsaturated fat energy, Protein (g/day), Carbohydrates (g/day): Complex, simple, Total lipids (g/day), Saturated fats, Monounsaturated Fats, Polyunsaturated fats, Oleic acid, Linoleic acid, cholesterol, total cholesterol, Fiber, Micronutrients (FFQ completed by children’s mothers)

Control Variables:  Birthweight

Statistical Analysis:  Spearman correlation coefficient

Description of Actual Data Sample:

Original Sample:  not specified

Withdrawals/Drop-Outs:  not specified.

Final Sample: 1112 children, 557 boys & 555 girls.

Location:  4 Spanish cities

Race/Ethnicity:  representative sample.

SES:  representative sample.

Age:  6-7 years

Summary of Results:

Anthropometric measurements:

  • Children in the two cities with high IHD mortality showed higher BMI, PI & prevalence of obesity then those in the two cities with low IHD mortality.
  • There was a positive correlation between these 3 anthropometric variables & IHD mortality across the four cities.

Dietary intake:

  • Compared with Madrid and Orense, the children of Cadiz and Murcia reported higher intakes of energy, protein (g/day), carbohydrates (g/day combine complex & simple), Simple carbohydrates (g/day), total lipids (g/day combine sat, monunsat, polyunsat, oleic acid, linoleic acid, cholesterol), saturated fats (g/day), polyunsaturated fats (g/day), linoleic acid (g/day) & cholesterol (mg/1000 cal/day).
  • No significant correlation noted when macronutrients examined at % of total energy. No sig. correlation noted with fiber (g/day).

Author Conclusion:

Intake of fats, especially saturated fats, and cholesterol should be reduced among Spanish children. It could contribute to a needed reduction of the high prevalence of overweight and obesity in children.

If the differences in anthropometric variables and diet between children from the cities with high and low coronary mortality are maintained in future or continue into adulthood, this could contribute to consolidate or even increase the IHD mortality gradient across cities.

The findings that differences in anthropometric variables are independent of birthweight suggests that the childhood, rather than intrauterine environment, is involved in the development of such differences.

Funding Source:
Government: Comunidad Autonoma de Madrid
International Olive Oil Board (Consejo Olei´cola Internacional)
Commodity Group:
Foundation associated with industry:
Reviewer Comments:


Widest geographical coverage of all the studies undertaken over the last two decades in Spain on food & nutrition among school children.


Cross-sectional study design.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? ???
  2.2. Were criteria applied equally to all study groups? ???
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? ???
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? No
  4.1. Were follow-up methods described and the same for all groups? No
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? N/A
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? N/A
  7.1. Were primary and secondary endpoints described and relevant to the question? N/A
  7.2. Were nutrition measures appropriate to question and outcomes of concern? N/A
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? N/A
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? N/A
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? N/A
  8.1. Were statistical analyses adequately described and the results reported appropriately? N/A
  8.2. Were correct statistical tests used and assumptions of test not violated? N/A
  8.3. Were statistics reported with levels of significance and/or confidence intervals? N/A
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? N/A
  9.1. Is there a discussion of findings? N/A
  9.2. Are biases and study limitations identified and discussed? N/A
10. Is bias due to study's funding or sponsorship unlikely? N/A
  10.1. Were sources of funding and investigators' affiliations described? N/A
  10.2. Was the study free from apparent conflict of interest? N/A