OBJECTIVES: Childhood obesity is a growing global problem that can be prevented by improving diet quality. Mediterranean diet (MedDiet), historically present in Mediterranean countries, is considered one of the healthiest dietary patterns. This cross-sectional study aimed to determine the MedDiet adherence and anthropometric parameters in 9-year-old children from the central geographic locations of Split-Dalmatia County, Croatia. METHODS: The study analysed data obtained from 158 children aged nine years from central parts of Dalmatia: Split and Hvar. To assess the MedDiet adherence, the parents of the children filled out the Mediterranean Diet Index (KIDMED) questionnaire. Appointed school medicine specialists collected anthropometric data of the children and categorized them into body mass index (BMI) categories according to the Center for Disease Control and Prevention (CDC) criteria. Additionally, we assessed the influence of parents' education degree on children's MedDiet adherence and anthropometric measures. RESULTS: Results showed that more than a quarter of nine-year-olds included in this study were overweight or obese (BMI ≥ 85th percentile for age and sex). One of the main findings was that 72% of children had suboptimal (poor or average) MedDiet adherence. Moreover, children with suboptimal KIDMED results (KI < 8) had significantly higher body weight, waist circumference, hip circumference, and waist-to-height ratio. Also, results showed that mothers' education notably influences children's anthropometry. CONCLUSION: Our study found that childhood obesity is a significant concern among 9-year-olds, with a high prevalence of overweight and obesity. Additionally, our results showed that MedDiet adherence is suboptimal among this age group. These results indicate that children of the Mediterranean are not spared of modern life challenges. This problem should be prioritized in the future to prevent the development of a metabolically compromised adult population.

Healthcare Centre of Split Dalmatia County Split Croatia

School of Medicine University of Split Split Croatia

Teaching Institute for Public Health of Split Dalmatia County Split Croatia

University Department of Health Studies University of Split Split Croatia

See more in PubMed

Lăcătușu CM, Grigorescu ED, Floria M, Onofriescu A, Mihai BM. The Mediterranean diet: from an environment-driven food culture to an emerging medical prescription. Int J Environ Res Public Health. 2019 Mar 15;16(6):942. doi: 10.3390/ijerph16060942. PubMed DOI

Davis C, Bryan J, Hodgson J, Murphy K. Definition of the Mediterranean diet; a literature review. Nutrients. 2015 Nov 5;7(11):9139-53. PubMed DOI

Rees K, Takeda A, Martin N, Ellis L, Wijesekara D, Vepa A, et al. Mediterranean-style diet for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2019 Mar 13;3(3):CD009825. doi: 10.1002/14651858.CD009825.pub3. PubMed DOI

Buzzetti E, Linden A, Best LM, Madden AM, Roberts D, Chase TJG, et al. Lifestyle modifications for nonalcohol-related fatty liver disease: a network meta-analysis. Cochrane Database Syst Rev. 2021 Jun 11;6(6):CD013156. doi: 10.1002/14651858.CD013156.pub2. PubMed DOI

Palmer SC, Maggo JK, Campbell KL, Craig JC, Johnson DW, Sutanto B, et al. Dietary interventions for adults with chronic kidney disease. Cochrane Database Syst Rev. 2017 Apr 23;4(4):CD011998. doi:10.1002/14651858.CD011998.pub2. PubMed DOI

Hagen KB, Byfuglien MG, Falzon L, Olsen SU, Smedslund G. Dietary interventions for rheumatoid arthritis. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006400. doi: 10.1002/14651858.CD006400.pub2. PubMed DOI

Jirout J, LoCasale-Crouch J, Turnbull K, Gu Y, Cubides M, Garzione S, et al. How lifestyle factors affect cognitive and executive function and the ability to learn in children. Nutrients. 2019 Aug 20;11(8):1953. doi: 10.3390/nu11081953. PubMed DOI

Weihrauch-Blüher S, Schwarz P, Klusmann JH. Childhood obesity: increased risk for cardiometabolic disease and cancer in adulthood. Metabolism. 2019 Mar;92:147-52. PubMed DOI

Llewellyn A, Simmonds M, Owen CG, Woolacott N. Childhood obesity as a predictor of morbidity in adulthood: a systematic review and meta-analysis. Obes Rev. 2016 Jan;17(1):56-67. PubMed DOI

World Health Organization. Obesity and overweight [Internet]. Geneva: WHO [cited 2024 Aug 4]. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.

Musić Milanović S, Lang Morović M, Križan H. European Childhood Obesity Initiative, Croatia 2018/2019 (CroCOSI). Zagreb: Croatian Institute of Public Health; 2021.

2021 anthropometry procedures manual: national health and nutrition examination survey [Internet]. CDC; 2021 [cited 2024 Aug 4]. Available from: https://wwwn.cdc.gov/nchs/data/nhanes/2021-2023/manuals/2021-Anthropometry-Procedures-Manual-508.pdf.

U. S. Centers for Disease Control and Prevention. Child and teen BMI calculator widget [Internet]. Atlanta: CDC [cited 2024 Aug 4]. Available from: https://www.cdc.gov/healthyweight/bmi/calculator.html.

U. S. Centeres for Disease Control and Prevention. BMI frequently asked questions. Child and teen BMI questions [Internet]. Atlanta: CDC [cited 2024 Aug 4]. Available from: https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.

Altavilla C, Caballero-Pérez P. An update of the KIDMED questionnaire, a Mediterranean Diet Quality Index in children and adolescents. Public Health Nutr. 2019 Oct;22(14):2543-7. PubMed DOI

Serra-Majem L, Ribas L, Ngo J, Ortega RM, García A, Pérez-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 Oct;7(7):931-5. PubMed DOI

Kolčić I, Relja A, Gelemanović A, Miljković A, Boban K, Hayward C, et al. Mediterranean diet in the southern Croatia - does it still exist? Croat Med J. 2016 Oct 31;57(5):415-24. PubMed DOI

Franić I, Boljat P, Radić Hozo E, Burger A, Matana A. Parental traits associated with adherence to the Mediterranean diet in children and adolescents in Croatia: a cross-sectional study. Nutrients. 2022 Jun 23;14(13):2598. doi: 10.3390/nu14132598. PubMed DOI

García Cabrera S, Herrera Fernández N, Rodríguez Hernández C, Nissensohn M, Román-Viñas B, Serra-Majem L. KIDMED test; prevalence of low adherence to the Mediterranean diet in children and young; a systematic review. Nutr Hosp. 2015 Dec 1;32(6):2390-9.

Obradovic Salcin L, Karin Z, Miljanovic Damjanovic V, Ostojic M, Vrdoljak A, Gilic B, et al. Physical activity, body mass, and adherence to the Mediterranean diet in preschool children: a cross-sectional analysis in the Split-Dalmatia County (Croatia). Int J Environ Res Public Health. 2019 Sep 4;16(18):3237. doi: 10.3390/ijerph16183237. PubMed DOI

de Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies. Eur Heart J. 2007 Apr;28(7):850-6. PubMed DOI

Moore LM, Fals AM, Jennelle PJ, Green JF, Pepe J, Richard T. Analysis of pediatric waist to hip ratio relationship to metabolic syndrome markers. J Pediatr Health Care. 2015 Jul-Aug;29(4):319-24. PubMed DOI

Ruiz M, Goldblatt P, Morrison J, Porta D, Forastiere F, Hryhorczuk D, et al. Impact of low maternal education on early childhood overweight and obesity in Europe. Paediatr Perinat Epidemiol. 2016 May;30(3):274-84. PubMed DOI

Bjelland M, Lien N, Bergh IH, Grydeland M, Anderssen SA, Klepp KI, et al. Overweight and waist circumference among Norwegian 11-year-olds and associations with reported parental overweight and waist circumference: The HEIA study. Scand J Public Health. 2010 Nov;38(5 Suppl):19-27. PubMed DOI

Biehl A, Hovengen R, Grøholt EK, Hjelmesaeth J, Strand BH, Meyer HE. Adiposity among children in Norway by urbanity and maternal education: a nationally representative study. BMC Public Health. 2013 Sep 12;13:842. doi: 10.1186/1471-2458-13-842. PubMed DOI

Klein-Platat C, Wagner A, Haan MC, Arveiler D, Schlienger JL, Simon C. Prevalence and sociodemographic determinants of overweight in young French adolescents. Diabetes Metab Res Rev. 2003 Mar-Apr;19(2):153-8. PubMed DOI

Gnavi R, Spagnoli TD, Galotto C, Pugliese E, Carta A, Cesari L. Socioeconomic status, overweight and obesity in prepuberal children: a study in an area of Northern Italy. Eur J Epidemiol. 2000;16(9):797-803. PubMed DOI

Bacopoulou F, Landis G, Rentoumis A, Tsitsika A, Efthymiou V. Mediterranean diet decreases adolescent waist circumference. Eur J Clin Invest. 2017 Jun;47(6):447-55. PubMed DOI

Mazaraki A, Tsioufis C, Dimitriadis K, Tsiachris D, Stefanadi E, Zampelas A, et al. Adherence to the Mediterranean diet and albuminuria levels in Greek adolescents: data from the Leontio Lyceum ALbuminuria (3L study). Eur J Clin Nutr. 2011 Feb;65(2):219-25. PubMed DOI

Schröder H, Mendez MA, Ribas-Barba L, Covas MI, Serra-Majem L. Mediterranean diet and waist circumference in a representative national sample of young Spaniards. Int J Pediatr Obes. 2010 Dec;5(6):516-9. DOI