Healthy and Sustainable Dietary Patterns in Children and Adolescents: A Systematic Review

Adherence to Mediterranean Diet and Health Outcomes in Adolescents: An Umbrella Review

CONTEXT

Proper nutrition represents 1 of the domains of adolescents' well-being. In this context, the Mediterranean diet (MD), as a healthy, traditional, and sustainable dietary pattern, plays a crucial role in promoting adequate growth and preventing chronic noncommunicable diseases.

OBJECTIVE

The currently available evidence on the effects of adherence to the MD (AMD) in association with several physical health outcomes in adolescence is summarized in this review.

DATA SOURCES

Five electronic databases were searched.

STUDY SELECTION

Systematic reviews with or without meta-analysis of observational studies and randomized clinical trials, published in English during 2013-2022, and that assessed the health impact of AMD among adolescents were eligible.

DATA EXTRACTION

Details on study design, methods, population, assessment of dietary patterns, health outcomes, and main results were extracted.

RESULTS

The search yielded 59 references after removal of duplicates. Applying PICOS criteria, 4 systematic reviews and 3 meta-analyses ultimately were included in this review. The AMD was evaluated in association with overweight/obesity and adiposity in 2 studies, musculoskeletal health in another 2, inflammation in 1 study, and cardiometabolic health in 1 study. The seventh review examined all mentioned health outcomes (overweight and obesity, musculoskeletal health, inflammation, and cardiometabolic health) in relation to AMD.

CONCLUSIONS

Overall, this umbrella review showed limited evidence and a lack of consistency about the relation between AMD and health outcomes of interest in adolescence, indicating the need for more studies to better understand it.

SYSTEMIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023428712.

Association between early dietary patterns and cardiometabolic health at age 8: a confirmatory analysis of the European Childhood Obesity Project

BACKGROUND & AIM

Metabolic and cardiovascular health outcomes are strongly influenced by diet. Dietary habits established in early childhood may persist into adulthood. This study aimed to examine the association between dietary patterns at both 2 and 8 years of age, explaining the maximum variability of high- and low-quality fats, sugars, and fibre, and cardiometabolic markers at age 8 years.

METHODS

This was a secondary analysis of the European Childhood Obesity Project, formerly a randomized clinical trial across five European countries performed in healthy term newborns. Children in the study were categorized at ages 2 and 8 years into two groups based on cluster analysis of dietary patterns (DP) derived from Reduction Rank Regression (RRR). A cross-sectional and prospective analysis was conducted to evaluate the associations between these DPs and cardiometabolic outcomes, including body mass index (BMI), blood pressure (BP), and biochemical markers. Triglycerides, HDL cholesterol and insulin resistance index (HOMA-IR) were also categorized as altered versus normal values. Asociations between dietary patterns and health outcomes were assessed using linear and logistic regression models, adjusting for covariates based on a step-wise approach.

RESULTS

A total of 336 children were classified based on quality of nutrient intakes into either a "Poor-Quality dietary pattern" (PQ-DP) (48% and 66% of infants at 2 and 8 years, respectively) or the "Health-Conscious dietary pattern" (HC-DP) (52% and 34% of infants at 2 and 8 years, respectively). Following a PQ-DP at both ages 2 and 8 was associated with higher triglycerides (β = 0.061, p = 0.049), systolic and diastolic BP (β = 13.019, p < 0.001 & β = 7.612, p = 0.014, respectively) and altered levels of HOMA-IR (OR = 3.1, p = 0.037, 95% CI = 1.1-9.1) at 8 years, compared to children with an HC-DP at both ages, after adjusting for confounders.

CONCLUSION

Adherence to a dietary pattern with a poorer nutritional profile in early childhood and school age is associated with worse cardiometabolic risk markers at 8 years old.

Are the EAT-Lancet dietary recommendations associated with future cardiometabolic health? - Insights from the Generation XXI cohort from childhood into early adolescence

BACKGROUND

The prospective effect of healthy and planetary diets on cardiometabolic health at young ages remains unclear.

OBJECTIVES

This study aims to investigate the prospective associations between adherence to the EAT-Lancet dietary recommendations at age 7 and the prevalence of obesity and Metabolic Syndrome (MetS) at 7, 10, and 13 y old.

METHODS

Participants are children from the Generation XXI birth cohort who completed 3-d food diaries at age 7, with complete data in variables of interest (n = 3564). Adherence to the EAT-Lancet dietary recommendations was evaluated using the World Index for Sustainability and Health (WISH); a higher score indicates a healthier and environmentally sustainable diet. At 7, 10, and 13 y, anthropometrics (weight, height, and waist circumference), blood pressure, serum-fasting triglycerides, high-density lipoprotein cholesterol, and glucose were measured. Obesity and MetS prevalence were determined by the World Health Organization and the International Diabetes Federation criteria, respectively. Adjusted custom binomial log-linear models were used to calculate prevalence ratios (PR) and the respective 95% confidence intervals (95% CI) (covariates: mother's age, education, prepregnancy body mass index (BMI), gestational diabetes, child's sex, age, Tanner stage, sports practice and total grams of the remaining food).

RESULTS

From 7 to 13 y, obesity decreased from 14.1% to 9.3% and MetS increased from 1.0% to 5.1%. Higher WISH scores at 7 y were associated with a lower prevalence of obesity, measured by both BMI (≥97th percentile: PR = 0.912; 95% CI: 0.839, 0.991; PR = 0.882; 95% CI: 0.79, 0.938, respectively at 10 and 13 y) and waist circumference (≥90th percentile: PR = 0.899; 95% CI: 0.830, 0.974; PR = 0.858; 95% CI: 0.782, 0.942, respectively at 10 and 13 y). For each 10-point increase in the WISH, a reduction of 16% in MetS prevalence at 13 y was observed (PR = 0.837; 95% CI: 0.732, 0.957). No significant effects were found at younger ages.

CONCLUSIONS

Adherence to the EAT-Lancet diet from an early age may help reduce cardiometabolic risk in early adolescence.

Exploring dietary patterns and their association with environmental sustainability and body mass index in children and adolescents: Insights from the National Food, Nutrition and Physical Activity Survey 2015-2016

OBJECTIVE

To adapt four dietary patterns for children and adolescents, and study their associations with sustainability (greenhouse-gas emissions-GHGE and land use-LU), and health (body mass index-BMI) indicators.

RESEARCH METHODS & PROCEDURES

Dietary intake of children (3-9y) and adolescents (10-17y) from the National Food, Nutrition and Physical Activity Survey 2015-2016, Portugal (n = 1153) was assessed through two non-consecutive interviews: one-day food diaries (children), and 24-h recalls (adolescents), using an automated multiple-pass method, including a picture book for portion sizes estimation. Adherence to the Eat-Lancet and World Health Organization (WHO) recommendations, Mediterranean and Atlantic diets were evaluated using adapted versions for pediatrics of the World Index for Sustainability and Health (WISH), Diet Quality Index (DQI), Mediterranean Diet Score (MDS) and Southern-European Atlantic Diet (SEAD), respectively. Diet-related GHGE and LU were estimated using the SHARP-Indicators database. BMI (measured) z-scores were classified according to WHO criteria. A standardized weighted health-sustainability composite index was created (BMI + 0.5*GHGE+0.5*LU). Adjusted linear regression models were computed.

RESULTS

WISH, DQI, MDS, and SEAD had weighted mean scores (range) of 50 (0-130), 24 (9-36), 20 (8-32), and 17 (8-32), respectively. All dietary patterns were associated with lower environmental impact, particularly in children, but not with BMI. Only MDS explained both health and sustainability indicators in childhood (composite index: sd.β = -0·223,95%CI:-0·347,-0·072,R2 = 25.1 %), and adolescence (composite index: sd.β = -0·159,95%CI:-0·315,-0·003,R2 = 31.3 %).

CONCLUSION

The Mediterranean diet was the most related to (higher) environmental sustainability and (lower) BMI. However, in children (not adolescents), the WISH, DQI, and SEAD showed then same associations.

Dietary patterns and association with Iron deficiency among children and adolescents aged 9-17 years in rural Guangzhou, China: a cross-sectional study

Background

Iron deficiency and iron deficiency anemia cause a huge disease burden worldwide. Diet is an important factor affecting the iron levels. This study aims to explore the dietary patterns of school-aged children in rural areas of Guangzhou and their association with iron deficiency.

Methods

Data on dietary surveys, lifestyle, demographic and laboratory tests were gathered from rural school-age children in Guangzhou. Factor analysis was applied to derive dietary patterns. Robust Poisson regression and subgroup analysis were used to analyze the association between dietary patterns and iron deficiency.

Results

A total of 2,530 children and adolescents aged 9-17 years were enrolled. The prevalence of iron deficiency was 13.36%. Four dietary patterns were identified including snack and fast-food pattern, fruit and vegetable pattern, cereal and tuber pattern and meat and offal pattern. Both children and adolescents in the Q4 group (the highest propensity) of snack and fast-food pattern and cereal and tuber pattern had a higher risk of iron deficiency than the Q1 group (the lowest propensity). Both children and adolescents in the Q4 group of meat and offal pattern and fruit and vegetable pattern had a lower risk of iron deficiency than the Q1 group. The results of stratified analysis showed the negative effect of snack and fast-food pattern and the protective benefits of meat and offal pattern are more obvious for boys, and the negative effect of cereal and tuber pattern were obvious for girls. The negative effect or protective benefits of the four dietary patterns were obvious for children aged 9-13.

Conclusion

Females, older children, and those with shorter sleep duration are at higher risk of iron deficiency. Snack and fast-food pattern and cereal and tuber pattern are risk factors for iron deficiency, and fruit and vegetable pattern and meat and offal pattern are protective factors for iron deficiency. The impact of diet on body iron levels is more obvious in boys and younger children. The findings of this study can provide evidence for formulating prevention and control measures on children and adolescents iron deficiency and iron deficiency anemia.

The influence of physical activity, adherence to Mediterranean diet, and weight status on the psychological well-being of adolescents

The mental health of adolescents is a determining factor for their adequate development, but is influenced by factors such as physical activity, nutrition, gender, and weight status. However, previous research has not analysed differences in psychological status, mainly in basic psychological needs and life satisfaction, among male and female adolescents with different levels of physical activity, weight status and adherence to the Mediterranean diet (AMD). For this reason, the objectives of the present investigation were to establish whether the differences between active and inactive adolescents in basic psychological needs and life satisfaction depend on gender; and to determine the differences in basic psychological needs and life satisfaction of active and inactive adolescents with different weight status and AMD. A total of 791 adolescents aged between twelve and sixteen years old participated in the study. All the participants were measured for basic psychological needs, life satisfaction, and level of physical activity, AMD, and height and body mass. The results showed a higher score in basic psychological needs and life satisfaction for active adolescents in both the males' and females' groups. No differences were found in the psychological variables when comparing adolescents with different weight status. Adolescents with a higher AMD showed higher scores in satisfaction of basic psychological needs and satisfaction with life than adolescents with a worse AMD. Therefore, it can be concluded that the level of physical activity and AMD are factors to be considered for the mental health of adolescents, but the relevance of weight status will have to be confirmed in future research.

The Planetary Health Diet and Its Association with Asthma and Airway Inflammation in School-Aged Children

Poor dietary choices have been rising concurrently with an increase in asthma prevalence, especially in children. Dietary indexes that simultaneously measure the healthiness and sustainability of dietary patterns have emerged to address the dual concerns of human and planetary health. Accordingly, we aimed to evaluate adherence to a sustainable dietary pattern and its impact on airway inflammation and asthma. In this study, 660 school-aged children (49.1% females, 7-12 years) were considered. A cross-sectional analysis was performed to assess the association between diet and asthma and airway inflammation according to overweight/obesity. Diet was evaluated through the Planetary Health Diet Index (PHDI). Higher scores represent a healthier and more sustainable diet. Three definitions of asthma were considered based on a self-reported medical diagnosis, symptoms, asthma medication, measured lung function, and airway reversibility. Airway inflammation was assessed by exhaled fractional nitric oxide (eNO). We considered two categories of body mass index: non-overweight/non-obese and overweight/obese. The associations between diet with asthma and airway inflammation were estimated using adjusted binary logistic regressions. The odds of having airway inflammation decreased with the increase in PHDI score. Moreover, children in the non-overweight/non-obesity group in the fourth quartile of the PHDI had lower odds of having airway inflammation compared to children in the first quartile. Our study indicates that a healthier and sustainable diet is associated with lower levels of eNO, but only among children without overweight/obesity.

Adolescents' Perceptions About Healthy and Sustainable Diets: A Qualitative School-Based Study in Portugal

In this qualitative study, we explored Portuguese adolescents' perceptions of diet, sustainability, and health through six focus group discussions (FGDs). Fifty-five adolescents (10-18 years) participated. FGDs focused on sustainability in food choices and its health impact, with our primary interest in their perceptions. Results showed a limited comprehension of "sustainable/sustainability," especially among younger participants. Those aware of sustainability recognized its diverse aspects, including health, economic, and ecological domains. Some adolescents recognized the link between health and sustainability in their diets, emphasizing the need for food literacy. These findings emphasize the importance of public health and sustainable policies among Portuguese adolescents.

Analysis of the influence of educational level on the nutritional status and lifestyle habits of the young Spanish population

Aim

This study aims to analyze some nutrition and health habits of young people and the impact of educational attainment on health.

Methods

An observational, descriptive, and cross-sectional study was carried out using surveys. Using non-probabilistic snowball sampling, a previously validated questionnaire was disseminated through networks, collecting a sample of 9,681 people between 18 and 30  years old. Comparative analyses between groups were obtained by clustering and the corresponding statistical tests.

Results

The results showed how young people with higher education generally have a lower BMI, a higher healthy nutrition index, less frequent consumption of sugary drinks, and less smoking than their peers with basic education. These healthier habits are reflected in the higher self-perceived health status of the higher-educated group. While for all the educational levels analyzed, the minutes of physical activity practice are above the 150 min recommended by the WHO.

Conclusion

Our findings suggest that young people's education level is of fundamental importance for health, particularly for nutritional habits. In general, the lifestyle habits of the young Spanish population are healthy, but there is a need for improvement in those aspects related to nutrition and food.

Adherence to the Mediterranean Diet in Children and Adolescents and Association with Multiple Outcomes: An Umbrella Review

The Mediterranean Diet (MD) has been linked to numerous health benefits. This umbrella review aims to synthesize evidence from systematic reviews on the MD's impact on children and adolescents aged 6 to 19 years. Following Joanna Briggs Institute guidelines, we included 11 systematic reviews focusing on the MD's effects on health outcomes, such as asthma, anthropometric measures, physical fitness, and inflammatory markers. The results indicate a protective role of the MD against childhood asthma due to its antioxidant-rich components. However, evidence for its impact on allergic conditions like rhinitis and eczema is inconclusive. Findings regarding anthropometric outcomes, particularly BMI, are limited and inconsistent. A positive correlation was observed between MD adherence and increased physical activity, improved physical fitness, quality of life, and reduced sedentary behavior. Additionally, the MD showed an inverse relationship with pro-inflammatory biomarkers, suggesting anti-inflammatory benefits. The inconsistency in BMI findings and the potential anti-inflammatory properties of the MD warrant further longitudinal research. Future studies should explore the MD's impact on cognitive functions, academic performance, and mental health in this age group, highlighting the significance of establishing healthy eating habits early in life.

Mixed-method study on the association between inclusion to conditional cash transfer program and the multiple faces of malnutrition in children and adolescents aged 3 to 19 years: a school-based evidence from Caraga Region, the Philippines

BACKGROUND

This study aimed to investigate the association between inclusion to Pantawid Pamilyang Pilipino Program (4Ps), a CCT program in the Philippines, and malnutrition in children and adolescents and examine the perceptions and experiences of parents and other stakeholders on how 4Ps influenced child nutrition.

METHODS

A concurrent mixed-method study was conducted in the Caraga Region, Philippines. Quantitative data from 5541 children and adolescents aged 3 to 19 were analyzed using multilevel mixed-effect logistic models. To allow in-depth understanding of the programmatic components that support the findings from the quantitative study, eight focused group discussions (FGDs) were concurrently conducted, cumulating 33 participants, including 4Ps parents, school coordinators/teachers, and school nurses. A constructivist grounded theory approach was used for analysis, and joint displays were employed to integrate quantitative and qualitative results.

RESULTS

Quantitative findings revealed high rates of malnutrition, with significant rates of stunting (12.0%), wasting/thinness (9.4%), and overweight/obesity (16.4%) among children and adolescents. 4Ps beneficiaries had higher odds of stunting and overweight/obesity compared to non-4Ps beneficiaries (AOR = 1.43, 95%CI: 1.08-1.91; AOR = 1.21, 95%CI: 1.01-1.45, respectively). However, no significant association was observed between inclusion to 4Ps and concurrent stunting and wasting/thinness or overweight/obesity (AOR = 1.05, 95%CI: 0.72-1.55). Geographic variations were observed, with 4Ps children in Agusan del Sur having lower odds of stunting than those in Agusan del Norte (AOR = 0.41, 95%CI: 0.23-0.71). Age and gender also showed significant associations with malnutrition. The qualitative analysis provided insights into the challenges contributing to malnutrition, including child labor, sickness, long distances to school, limited access to healthy food, and larger families. Unintended consequences such as cash card mismanagement, inappropriate cash grant allocation, and falsification of school attendance were identified. However, teachers and parents demonstrated resilience by implementing adaptive approaches to enhance child nutrition.

CONCLUSIONS

While 4Ps beneficiaries exhibit higher odds of stunting and overweight/obesity, the program's association with malnutrition was significantly influenced by geographic variations. It is crucial for social protection programs to prioritize comprehensive support strategies that effectively counter unintended consequences and challenges faced by beneficiaries and other stakeholders and address malnutrition in children and adolescents.

Dietary Patterns and Association with Anemia in Children Aged 9-16 Years in Guangzhou, China: A Cross-Sectional Study

Anemia affects 1.8 billion people worldwide, and diet is one of the key modifiable factors for treating anemia in children. The dietary pattern has changed rapidly in recent decades, but its effect on childhood anemia has not been reported. This study aimed to identify dietary patterns among children in rural areas of Guangzhou, China, and explore their association with anemia. A total of 1476 children aged 9-16 years old were included in this study. Demographics, lifestyle, and anthropometric and dietary information were collected. Factor analysis was used to identify dietary patterns, and anemia was diagnosed based on hemoglobin levels. Robust Poisson regression and subgroup analysis were used to analyze the association between dietary patterns and anemia. The prevalence of anemia in children was 10.4%, with 6.1% in boys and 15.4% in girls. Four dietary patterns were identified, including a fast food pattern, a vegetarian pattern, a meat and egg pattern, and a rice and wheat pattern. A high score in the fast food pattern was positively associated with risk of anemia in children entering puberty (PR = 1.767, 95% CI: 1.026~3.043, p = 0.039), especially in girls after menarche, with marginal significance (PR = 1.740, 95% CI: 0.977~3.097, p = 0.059). A high score in the meat and egg pattern was negatively associated with risk of anemia in children entering puberty (PR = 0.498, 95% CI: 0.286~0.866, p = 0.013), especially in boys after spermatorrhea (PR = 0.237, 95% CI: 0.031~0.590, p = 0.007). The fast food pattern was a risk factor for anemia in children, and the meat and egg pattern was a protective factor for anemia in children entering puberty. The findings of this study could be used to guide the strategies of evidence-based preventive nutrition interventions to curb anemia in children.

The effect of nutritional and lifestyle education intervention program on nutrition knowledge, diet quality, lifestyle, and nutritional status of Croatian school children

Introduction

Nutrition education during adolescence has proven effective in increasing knowledge, attitudes, and practices in the diet. The Mediterranean diet has proven health benefits and is proposed as a model of a sustainable diet that is beneficial for health and the environment. Its promotion with the educational program can have a significant effect on improvements in nutrition knowledge, diet quality, and nutritive status of adolescents for their healthy adulthood.

Objective

This study aimed to investigate the effect of the educational program on the nutrition knowledge, diet quality, lifestyle, and nutritional status of school children from the littoral part of Croatia.

Methods

An education-based intervention study was carried out on 2,709 schoolchildren aged 10–12 years (educated/control group: 2617/92). The questionnaire about sociodemographic, anthropometric, dietary, physical activity, screen time, sleep habits, and nutrition knowledge was assessed at the baseline and after a 6- to 9-month follow-up for the medium-term effect of education. Nutrition knowledge was provided after 3 weeks for the short-term education effect assessment.

Results

Educated schoolchildren achieved a significant increase in nutrition knowledge (+75.5%), expressed as a short-term effect of the education and maintained at the 6- to 9-month follow-up (+66.8%, p &lt; 0.001). Follow-up of children significantly improved their nutritional status (underweight −56.6%, normal weight 24.8%, overweight −22.1%, and obesity −57.5%) and physical activity engagement (+13.2%). The proportion of children with a diet highly adhering to the Mediterranean diet significantly doubled (+105.0). Those children with the highest nutrition knowledge at the follow-up significantly improved their nutritional status (+218.9%), participated in organized sports (+204.7%), and had a diet that highly adhered to the MD (+291.8%).

Conclusion

A significantly good medium-term effect of education-based nutrition and lifestyle intervention program on nutrition knowledge, diet quality, lifestyle, and nutritional status of schoolchildren aged 10–12 years was shown. The educational program promoted a Mediterranean diet and lifestyle as a healthy and sustainable way of living, important for children's future health and wellbeing. New research-based approaches are needed for making children more aware and capable of handling the complexity of sustainable living.

Measuring sustainable consumer food purchasing and behavior

Consumer food purchasing and willingness to adopt a sustainable healthy diet (SHD) is a key factor affecting the sustainability of the entire food system. Studies have developed scales to measure consumer preferences for particular consumption patterns, while others have sought to empirically define the multiple dimensions of a sustainable food system (environmental, social, economic, etc.). This paper builds on these literatures by tracking consumers' SHD behaviors using a large-scale, longitudinal survey of adults in the United States and mapping them onto multiple systems-level indicators. We wanted to know whether consumers interact with the sustainability of their food along the same principles developed by experts. Our study defines 18 food purchasing behaviors that support the sustainability goals of leading scientific institutions, uses factor analysis to identify the unobserved drivers behind these behaviors, and creates SHD scores to investigate their correlations with other consumer characteristics and behaviors. Factor analysis results show consumer food purchasing is motivated by three underlying sustainability dimensions-Economic Security, Socio-Environment, and Nutrition-which are fewer constructs than often defined by academic researchers. SHD scores reveal higher adoption of behaviors that fall under Economic Security relative to the other two dimensions. All three sustainability constructs are impacted by socio-economic and demographic characteristics.

The Nutritional Quality of Kids’ Menus from Cafés and Restaurants: An Australian Cross-Sectional Study

Australian families increasingly rely on eating foods from outside the home, which increases intake of energy-dense nutrient-poor foods. ‘Kids’ Menus’ are designed to appeal to families and typically lack healthy options. However, the nutritional quality of Kids’ Menus from cafes and full-service restaurants (as opposed to fast-food outlets) has not been investigated in Australia. The aim of this study was to evaluate the nutritional quality of Kids’ Menus in restaurants and cafés in metropolitan Perth, Western Australia. All 787 cafes and restaurants located within the East Metropolitan Health Service area were contacted and 33% had a separate Kids’ Menu. The validated Kids’ Menu Healthy Score (KIMEHS) was used to assess the nutritional quality of the Kids’ Menus. Almost all Kids’ Menus (99%) were rated ‘unhealthy’ using KIMEHS. The mean KIMEHS score for all restaurants and cafés was −8.5 (range −14.5 to +3.5) which was lower (i.e., more unhealthy) than the mean KIMEHS score for the top 10 most frequented chain fast-food outlets (mean −3.5, range −6.5 to +3). The findings highlight the need for additional supports to make improvements in the nutritional quality of Kids’ Menus. Local Government Public Health Plans provide an opportunity for policy interventions, using locally relevant tools to guide decision making.

Mediterranean Diet in Developmental Age: A Narrative Review of Current Evidences and Research Gaps

Numerous studies in recent decades have shown that Mediterranean diet (MD) can reduce the risk of developing obesity in pediatric patients. The current narrative review summarizes recent evidence regarding the impact of MD across the different stages of child development, starting from fetal development, analyzing breastfeeding and weaning, through childhood up to adolescence, highlighting the gaps in knowledge for each age group. A literature search covering evidence published between 1 January 2000 and 1 March 2022 and concerning children only was conducted using multiple keywords and standardized terminology in PubMed database. A lack of scientific evidence about MD adherence concerns the age group undergoing weaning, thus between 6 months and one year of life. In the other age groups, adherence to MD and its beneficial effects in terms of obesity prevention has been extensively investigated, however, there are still few studies that correlate this dietary style with the incidence of non-communicable diseases. Furthermore, research on multi-intervention strategy should be implemented, especially regarding the role of education of children and families in taking up this healthy dietary style.